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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

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A public health nurse to population ratio l.jpg

A Public Health Nurse to Population Ratio

Linda Olson Keller, DNP, RN, FAAN

American Public Health Association

San Diego, California

October 26, 2008


Objectives l.jpg
Objectives

  • Overview of PHN Ratio History

  • Overview of Public Health Nurse Task Analysis

  • Recommendations & Next Steps


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“One good

community nurse

will save a

dozen

policeman.”

Herbert Hoover

1929


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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


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PHN Census History Harriet Fulmer at the International Congress of Nurses in Buffalo, New York1916 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).


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1927 Harriet Fulmer at the International Congress of Nurses in Buffalo, New York

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


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Planning Harriet Fulmer at the International Congress of Nurses in Buffalo, New York

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


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1932 Commonwealth Fund Harriet Fulmer at the International Congress of Nurses in Buffalo, New YorkCommittee 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)


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1932 Commonwealth Fund Harriet Fulmer at the International Congress of Nurses in Buffalo, New YorkCommittee on Administrative Practice of APHA

Hiscock recommended “one nurse to 2,000 population, or 50 nurses in a city of 100,000 population”


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1936 Milbank Memorial Fund Harriet Fulmer at the International Congress of Nurses in Buffalo, New York

PHN task analysis:

  • number of home visits made

  • number of clinic visits by patients

  • number of examinations given to school children


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1936 Milbank Memorial Fund Harriet Fulmer at the International Congress of Nurses in Buffalo, New York

“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.


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1943 Harriet Fulmer at the International Congress of Nurses in Buffalo, New York

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


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Functions of a local health department 1943 Harriet Fulmer at the International Congress of Nurses in Buffalo, New York

  • 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


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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)


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1937-1972 persons“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


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1937-1972 persons“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


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1951 persons

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


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1951 persons

“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.)


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1954 persons

“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.


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1965 persons

"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


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1968 persons

  • 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.


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Ratio of Local Agency persons

Nurses to Population


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" personsPublic health nurses do what

nobody else is doing.

And what every

community deserves."

Georges Benjamin, MD, FACP

Executive Director,

American Public Health Association (APHA)


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Alaska persons

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


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n=60 persons


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n=60 persons


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n=60 persons


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n=60 persons


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Job Responsibilities persons

n=60

(*Participants selected all categories that applied)


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PHN Task Analysis persons

  • By population

  • By practice/program area


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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


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PHN Role in the Community 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


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“How much time do I have to answer this? the community

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 l.jpg
PHN Role in Emergency Preparedness the community

  • 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.


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PHN Role in Emergency Preparedness the community

  • 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


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" the communityFrom 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


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93% PHNs the community 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%)


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Percentage of PHNs who the community

work in clinics


Types of public health clinics l.jpg

Immunization (93%) the community

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


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Percentage of PHNs who perform the community

case management

11.7%

88.3%


Types of phn case management n 60 l.jpg

Individuals TB (52%) the community

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


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PHN Role with Vulnerable Populations the community

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


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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



Types frequency of home visits l.jpg

Health Promotion (74%) no PHN services?

Case Management (72%)

DOT (68%)

Contact Investigation (68%)

Newborn (66%)

Abuse and Neglect (64%)

Parenting (62%)

Prenatal (58%)

Child G & D (58%)

Post partum (56%)

Special Needs Child (54%)

Lead (50%)

SIDS follow-up (40%)

Court ordered (34%)

PH nuisance (28%)

Homecare (20%)

Types & Frequency of Home Visits


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What would be the impact on the health of the community if no PHN services?

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.

PHN Task Analysis Participant


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Immunization status (94%) no PHN services?

Mantoux (68%)

Hypertension/Blood Pressure (68%)

Infant/Child Growth and Development (66%)

Lice (62%)

Nutrition (62%)

Anemia (57%)

Abuse & Neglect (49%)

BMI (49%)

Lead (45%)

Vision (45%)

Hearing (45%)

Dental (43%)

Interpersonal

violence (43%)

78% conduct health screeningsn=60


Phn role in disease prevention control l.jpg
PHN Role in Disease Prevention & Control no PHN services?

78% PHNs investigate disease and other health threats


Phn role in tb prevention control l.jpg
PHN Role in no PHN services?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


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PHN Role in no PHN services?TB Prevention & Control

  • 68% of PHNs conduct Directly Observed Therapy (DOT) home visits

  • 68% of PHNs investigate TB contacts


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Recommendation One no PHN services?

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


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Nationally accepted standard: no PHN services?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)


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Recommendation Two no PHN services?

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


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Ratio of 1 supervisor to no more than 8 PHNs no PHN services?

  • 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


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Recommendation Three no PHN services?

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


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Baccalaureate preparation for PHNs no PHN services?

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


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Recommendation Four no PHN services?

Collaborate with other public health disciplines to consider recommended population ratios for all public health professionals


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Next Steps no PHN services?

  • Implement a national survey to identify existing PHN ratios, supervisor ratios, and educational preparation of PHNs in US

  • Convene a task force to recommend a set of community criteria that would require a PHN to population ratio less than 1:5,000

  • Engage stakeholders in discussion on potential strategies for utilizing the recommended PHN to population ratio.


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Next Steps no PHN services?

  • Explore strategies for promoting and enforcing the baccalaureate educational requirement as the credential for PHN nursing practice.

  • Convene partners to discuss recommended population ratios for all public health professionals.


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Acknowledgements no PHN services?

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.


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Acknowledgements no PHN services?

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.”