Position Statement: Vision for Nursing in Public Health
Recent experience such as SARS and the Walkerton water tragedy focused public, political and media attention on public health services across Ontario. Both federal and provincial governments have responded to these public health emergencies with commissions, reports and new visions for public health. While the response of government has included commitments for additional resources for public health, the new vision focuses almost exclusively on expanding and strengthening the disease control responsibilities of the public health system. As a result, there are very real concerns that the role of public health nurses to implement strategies that promote health and build capacity in individuals, families and communities has been and will continue to be diminished.
The introduction of the Health Protection and Promotion Act and the establishment of the Mandatory Health Programs and Services Guidelines in the 1980’s, and more recently, the downloading of funding of public health to municipalities, resulted in significant changes to public health units. For public health nurses (the largest group of public health professionals) the changes were dramatic and included :
- Reorganization from discipline based structures to program based units resulting in loss of positions. The outcome was a significant decrease in the number of public health nurses with estimates of up to 32% decrease in the public health nurse to population ratio.
- Loss of senior nursing positions. As a result, there were few, if any, nursing voices at senior decision making tables.
- Reduction or elimination of traditional public health services for individuals and families across the lifespan. As a result, access to these services shifted from the public health nurse to family physicians and reliance on a biomedical model of service delivery rather than a social determinants approach.
- Decreased ability to fulfill scope of practice as a result of downloading/transfer of funding responsibility for public health to municipalities. Many public health units restricted practice to the core functions required by the Mandatory Health Programs and Services Guidelines, limiting access to services for the vulnerable and at risk individuals (i.e., mental health patients, high school students, etc).
When faced with SARS, a public health emergency like no other, public health nurses demonstrated unique and specialized skills in policy development, advocacy, risk communication, health assessment, health teaching, counseling and contact follow-up case management.ii While public health nurses were able to face the challenges, the experience was stressful and nurses
identified serious concerns about service delivery and workload.
- As a result of fewer public health nurses in the system, during SARS virtually all of these nurses were redeployed. Health promotion, prevention and protection services ceased at many health units, leaving the most vulnerable and at-risk populations isolated and without access to necessary services and supports.
- Public health nurses were confounded by the myriad of directives that changed decision making processes, reporting and working relationships and data collection strategies on an almost daily basis and at various points during the crisis. Public health nurses looked for nursing leadership at both the local and provincial level which did not exist.
- Because of the lack of surge capacity in public health and service reductions, there were significant effects on communities and individuals. Facing the backlog when services resumed was a massive undertaking, with many vulnerable clients being lost to the system, while others were traumatized by the loss of contact. Re-establishing therapeutic relationships was a difficult, complex and time consuming task.
The New Priority for Public Health
Three key reports provide analysis and recommendations to shift the priority activities in public health at both the federal and provincial levels.
- The Walkerton Inquiry recommended expanded roles and responsibilities for public health units in ensuring safe water supply in communities.
- The Naylor Report on SARS proposed a strengthened role for the federal government in public health with a specific focus on infectious disease monitoring and control.
- Justice Campbell’s interim report on SARS focused exclusively on the capacity of public health units to monitor and respond to infectious diseases. In response, the Ontario government committed $273M to fight infectious disease and promised to increase the provincial share of public health costs to 75% by 2007.
These reports and recommendations were the result of very real public health crises that exposed significant weaknesses in the public health system. While it is important that these issues are addressed to monitor and control infectious diseases more effectively, it is imperative that we also consider the broader role of public health and ensure that efforts to strengthen this system balance the health promotion and protection role with the disease control function.
A Comprehensive Vision for Public Health
Ontarians need and deserve a strong and effective public health system. Such a system must have a renewed and revitalized
approach that balances health promotion and disease prevention with the responsibilities of preventing and responding to public health threats.
Canada has a long and very proud history of advocating for a social determinants approach and advancing health promotion
and it is ironic that we have not been able to truly embrace and adopt health promotion as the framework in our own health care system.
As Ontario moves forward to rebuild our public health system, it is essential that we consider how the system will react to new
threats but also that we focus on health promotion in the broadest sense – diminishing poverty and homelessness, fostering health schools, closing the gap between rich and poor through income distribution, increasing access to education, ensuring clean
environments, improving literacy, promoting healthy growth and development, creating supportive communities, building community capacity and taking measures to ensure a clean safe environment.
RNAO’s Vision for Nursing in the New Public Health Environment
Public health nurses must continue to have dual responsibilities. In their practice, they should consider communities at large to address issues in population health while also working on strategies to improve individual and family health. They link the health of the community with the health of individuals and groups who live and work in the community.
Public health nurses practice in practice in a “setting without walls.”iii Their clients self-refer and come from diverse settings including schools, health facilities, work places, the street and community settings. One of the hallmarks of public health nursing is the trust that individuals and communities place in them.
Public health nurses bring a broad range of skills to their practice: counseling, teaching, advocacy and community development. This skill set allows them to make a difference to individuals, families and groups and to effect change at the community level. To move forward on a health promotion agenda, public health nurses must expand the scope of services provided beyond the limitations currently imposed by the Mandatory Health Programs and Services Guidelines.
Examples of public health nursing activities that should be accessible across Ontario include:
- Promoting the health of young families from preconception through postnatal to support for parenting.
- Facilitating comprehensive school health programs working with students, staff, and families.
- Evaluating health trends and identifying populations at risk and identifying populations as priorities for intervention.
- Promoting the health of populations at-risk (e.g., homeless, immigrants, etc.).
- Promoting the health of elders through collaboration with community programs and facilities.
- Acting as case managers for vulnerable populations.
- Providing nursing expertise and health information.
- Collaborating with communities to empower communities to address health issues.
- Providing support to individuals that allows them to maintain control of their lives and health.
RNAO Calls for Action to Sustain a Vibrant Public Health Nursing Workforce
There are three critical factors that must be addressed to maintain and sustain a vibrant public health nursing workforce: positions, education, and leadership.
- Support for a vibrant public health nursing workforce begins with adequate, long term, stable funding to build and sustain a strong and balanced public health system.
- Capacity must be created in public health units to support the full scope of health promotion practice. This will require funding to support new positions and changes to regulation and policy to support full scope of practice. Funders and policy makers must ensure that there is sufficient surge capacity to enable public health units to respond to new public health emergencies with minimal disruption to existing programs.
- Although existing education programs include comprehensive public health curricula, additional clinical placements must be established to allow nursing students to consolidate theory with practice. Increased access to clinical placements will encourage students to consider public health nursing as career choices.
- Nursing leadership is essential to every nursing work environment. Health Units must re-establish nursing leadership positions, accountable to the Chief Executive Officer, to promote moral support, retention and ensure nursing voices are part of decision making processes.
Please see the PDF version of this document for footnotes and references.