Public Health Nursing
Audrey Danaher, RN, MSc, Carol Yandreski, RN, BScNm, Katie Dilworth, RN, MHSc-HP, CCHN(C), Karen Ellis-Scharfenberg RN, BScN, MBA, Jennifer Bouwmeester RN, BScN, CCHN(C), Cindy Baker-Barill RN BNSc, Megan Laan RN, BScN, MScN (c), and builds on a previous work by: Yvette Laforet Fliesser, RN, BScN, MScN, Ruth Schofield, RN, MSc(T), Carol Yandreski, RN, BScN, Liz McHugh, RN, BScN , Lorraine Athwal RN, MPH, CCHN(C) and Heather Lokko, RN, BScN, MPH, CCHN(C) on behalf of the Community Health Nurses’ Initiatives Group. (CHNIG)
A day in the life
Sonya is a public health nurse (PHN) who arrives at her office and sees the message light on her phone flashing. She checks her messages presuming the message might have been left by her client, Ms. Lee, who is suffering from post partum mood disorder (PPMD). PHNs often identify women who are at risk for, or experience, postpartum depression. The impact can be devastating for the family. Ms. Lee called to ask Sonya if there were any programs in the area for women with similar problems.
Over the past month Sonya has been collaborating with other PHN colleagues to submit a proposal to the Ministry of Health and Long-Term Care. The proposal is for the development of a Postpartum Depression Project which will help improve the health of women at risk for Post Partum Mood Disorder. Sonya plans to meet with her colleagues later in the day to draft a budget for the proposal.
Sonya speaks with her manager about whether the health unit’s current prenatal class curriculum could be modified to include information and skill building exercises for recognizing the signs and symptoms of PPMD. Her manager also reminds her that her report on this year’s flu campaign is due at the end of the week.
Sonya participated in the annual flu campaign as a nurse who provided immunizations with her health unit earlier this fall. As she puts the finishing touches on her report, Sonya feels proud of her contribution to keeping the people who live in her community healthy.
Afterwards, Sonya spends time working on a presentation to the PPMD Coalition. Sonya reflects on how much has been accomplished since the coalition of 20 community agencies formed a year ago. This group has held health fairs, professional education sessions, developed and distributed resources to professionals and to the public, as well as developed a website. The group also coordinated a campaign on television, radio & using posters to help the public understand PPMD.
Other PHN colleagues created and staffed a local central phone service for postpartum women and a drop-in service for postpartum women and their families was also established. Sonya returns Ms. Lee’s call and suggests that she participate in the program.
Sonya then checks her email and finds a few notes from her colleagues in neighbouring local health units. Together the group has identified a challenge of increasing community awareness of childhood inactivity and its impact on obesity and health. Sonya incorporates evidence into her daily practice. One of the recommendations from RNAO’s Primary Prevention of Childhood Obesity Best Practice Guideline is to collaborate with the school communities to promote regular physical activity among elementary school children. The PHNs plan to collaborate in the development of a campaign called “Turn off the Screens Week”, which is adapted from a similar campaign in another region. The campaign will be designed to encourage elementary school children and their families to be more physically active by being "screen-free" (television, computers and video games) for five consecutive days. To promote this campaign, PHNs will visit schools to involve students, their families, the community at large, and the media.
PHNs frequently partner with community groups or coalitions to better facilitate planning and share resources and expertise. It is generally a win-win situation for all involved. This “Turn off the Screens Week” campaign will be a great example of involving the community to promote family health.
To create a supportive environment for the children to be physically active, Sonya has been involved with the local municipal government and other public health staff to increase the infrastructure available for families to travel in active ways like walking and cycling. She has provided important information to the municipal government about the role that neighbourhood and street design can play in making it easier for community members to stay active. She also recognizes the dual role that her active transportation advocacy can play in improving health. In addition to increasing physical activity, active transportation can reduce greenhouse gas emissions and help to mitigate climate change.
The natural environment has recently been identified as an important social determinant of health and the nurses in her agency have been reviewing the Canadian Nurses Association report on nursing roles to address climate change.1 As a result, Sonya has also been involved with a local climate adaptation committee, working with community partners to identify vulnerabilities and assist the community to prepare for the impacts of climate change like extreme heat and loss of biodiversity.2
Public health nursing involves working with individuals, families, communities, and at a systems level. It is through this comprehensive and strengths-based approach that empowerment and enduring positive change can be realized.
Background
Public health nursing in Ontario is rooted in the traditions of Florence Nightingale, Jeanne Mance, and women in religious orders such as the Grey Nuns. Early North American PHNs understood the importance of social, economic, environmental, and political determinants of health, and believed that social activism and collaboration with community organizations and governments was a fundamental aspect of public health nursing practice.3
Although as of 2010, PHNs make up less than 2.87 per cent of all registered nurses in the province, they can be found across Ontario, protecting and promoting health.4 They do this by considering the many factors, including physiological, emotional, social, political, spiritual, historical, cultural and environmental, which can affect the health of communities and those who live within them.5 For PHNs, a “client” can be defined as an individual, family, group, community, population, system and/or society.6
Specialty Education
PHNs are registered nurses with a baccalaureate degree in nursing. Practising PHNs have the opportunity to take the CNA certification exam for community health nursing to acquire the designation CCHN(C).7 Public health nursing practice is guided by provincial regulatory standards, community health nursing standards of practice, core competencies for public health and public health nursing competencies.
The Canadian Community Health Nursing (CCHN) Standards of Practice form the basis of community health nursing practice. Public health nursing competencies are the integrated knowledge, skills, judgement and attributes required of a public health nurse to practice safely and ethically.8
Scope of Practice
The focus of public health intervention is to prevent rather than treat a disease through health promotion activities such as creating supportive environments, and advocacy for healthy public policy, strengthening community action, developing personal skills and reorienting health services towards a health-care system, which contributes to the pursuit of health.
PHNs require the ability to “synthesize… knowledge from public health science, primary health care (including the determinants of health), nursing science, and theory and knowledge of the social sciences to promote, protect, and preserve the health of populations”.9
In Ontario, PHNs work for official public health agencies in one or more core program areas, many of which are mandated by the Public Health Division of the Ministry of Health and Long-Term Care, and the Ministry of Children and Youth Services. These program areas include but are not limited to: chronic disease and injury prevention; family health; emergency preparedness, environmental health, school health, sexual health, immunization, and communicable disease control.
PHNs collaborate with other public health practitioners such as registered dietitians, dentists, physicians, health promoters, public health inspectors, epidemiologists and allied health professionals in the delivery of public health services. One important example of collaboration is seen in disease outbreaks such as SARS and pandemic planning for H1N1. PHNs are not only involved in communicable disease control work such as contact tracing, immunization and health education but they also address the social determinants of health such as poverty and homelessness, which contribute to poor health.
PHNs use a broad range of skills in daily practice, such as individual counselling, individual and group teaching/facilitation, advocacy, social marketing, community development and healthy public policy development. These make a difference to individuals, families, and groups, and can effect change at a community and systems level. This is done by considering the many factors that can affect the health of communities and those who live within them.10 Their roles include advocating for services, providing support, linking and referral to community resources, identifying emerging health issues and advocacy to assist individuals and families in finding safe housing, secure employment and other necessary supports.11
Practice Environment
PHNs have the unique distinction of practising in “a setting without walls”.12 They work in a wide range of settings to meet the needs of individuals, families, groups, communities, populations, and society. Examples include the client’s home, schools and post-secondary institutions, sexual health clinics, immunization clinics, municipal governments and settings where older persons reside.
Clinical Laddering
The Ontario government has taken a progressive step by mandating all 36 public health units in the province appoint a Chief Nursing Officer (CNO).
The leadership of nurses is essential in health promotion, disease prevention and during serious outbreaks such as a pandemic. The majority of health-care workers in public health units are nurses so it’s critical to have a Chief Nursing Officer at the highest level of decision-making.
This requirement strengthens the ability of nurses to respond during public health emergencies.
Liability Protection
Effective March 31, 2014, nurses are required to be protected from liability. RNAO members are automatically eligible for protection through Canadian Nurses’ Protective Society (CNPS) .
Current Status
PHNs can be found across Ontario, protecting and promoting health.14 With increasing fiscal challenges in Ontario health promotion, prevention, and protection are the key to a sustainable health-care system. A current focus on health human resources in public health has increased emphasis on increasing capacity of PHNs. Introduction of the PHN competencies and the 4th edition of Public Health ~ Community Health Nursing Practice in Canada have increased focus on the roles and activities of PHNs. New emerging professional development activities for PHNs will strengthen the PHN workforce in Ontario positioning PHNs with the knowledge skills and abilities to be leaders in health promotion in Ontario.
Links
Community Health Nurses of Canada (CHNC) http://www.chnc.ca/
RNAO - Community Health Nurses’ Initiatives Group (CHNIG) http://www.chnig.org
Canadian Nurses Association Community Health Certification (CCHN(C)) http://www.cna-aiic.ca/CNA/documents/pdf/publications/CERT_Comm_Health_2009_e.pdf
RNAO – Ontario Nurses for the Environment Interest Group (ONEIG) http://www.oneig.ca/
Canadian Nurses for Health and the Environment (CNHE) http://cnhe-iise.ca/
Alliance of Nurses for Healthy Environments (ANHE) http://envirn.org/
The Luminary Project – Nurses Lighting the Way to Environmental Health http://www.theluminaryproject.org/
References
1 Canadian Nurses Association. (2008). The role of nurses in addressing climate change. Ottawa, Ontario: Canadian Nurses Association. Retrieved from http://cna-aiic.ca/~/media/cna/page-content/pdf-en/ps105_nurses_env_health_e.pdf
2 Seguin, J. (2008). Human health in a changing climate : A Canadian assessment of vulnerabilities and adaptive capacity. Ottawa: Health Canada. Retrieved from https://library.sso.queensu.ca/vwebv/holdingsInfo?bibId=2990489
3 Falk Rafael, A., Fox, J., Mildon, B. & O’Donnell R. (1999). Position Statement on Public Health Nursing. Community Health Nurses Initiatives Group: RNAO: Toronto. Retrieved November 15, 2010 from : http://www.chnig.org/documents/Publications/04.doc
4 College of Nurses of Ontario (2010). All Nurse types Employed in Nursing in Ontario by Employment position. Data Query Tool. Retrieved November 15, 2010 from: http://www.cno.org/en/what-is-cno/nursing-demographics/data-query-tool/ *
5 Community Health Nurses Association of Canada. (April 2008) Canadian Community Health Nursing Standards of Practice. Ottawa
6 College of Nurses of Ontario (2002). Practice Standard: Professional Standards, Revised 2002. CNO: Toronto. p. Retrieved November 15, 2010 from: http://www.cno.org/Global/docs/prac/41006_ProfStds.pdf
7 Canadian Nurses Association (2010), Community Health Nursing Certification. CNA: Ottawa. Retrieved November 15, 2010 from:http://nurseone.ca/en/certification/what-is-certification/competencies-per-specialty-area/community-health-nursing
8 Community Health Nurses Association of Canada. (May,2009). Public Health Nursing Discipline Specific Competencies. Ottawa.
9 Ibid 4; p.3
10 Ibid 4; p.3
11 Ibid 1
12 Ibid 1
13 Canadian Nurses’ Protective Society. (2006). CNPS Services. Retrieved November 15, 2010 from: http://www.cnps.ca/cnps_services/index_e.html
14 Ibid 3
* Parts of this material are based on data and information provided by the College of Nurses of Ontario; however, the analyses, conclusions, opinions and statements expressed herein are those of the author, and are not necessarily those of the College.