Public Works

Even though it happened almost 30 years ago, Azella Collins, MSN, RN, can still remember one of the first patients she encountered when she was a young community health nurse working for a visiting nurses association. The man was living in a tiny apartment behind a printer’s shop in inner city Chicago. Although bedridden, he refused to go to a nursing home or live with relatives.

When Collins walked into the apartment, rats skittered in the corners as the elderly man struggled to sit up. The scene was so horrifying that she feared the rats would jump up on the bed at night and nibble his toes.

“I thought, ‘when I leave here, this man is leaving with me,’” she recalls.

Collins made arrangements with a nearby nursing home, whose director she knew, and persuaded the man that he needed to move to get the care he needed. By the end of the day he was out of the unsafe apartment and content in a clean bed in the nursing home.

Collins, who is second vice president of the National Black Nurses Association, has been a community and public health nurse for most of her career and is now an administrator for the Illinois Department of Public Health’s Illinois Perinatal HIV Elimination Program. Rather than working inside a hospital, Collins wanted to reach patients right where they lived, like the old man in the apartment, and to apply her skills and tenacity to help them get better.

Community and public health nurses work with individuals, families and groups, focusing on populations to improve the overall health of the public. They work for government agencies (such as county, state and city health departments and the U.S. Public Health Service), private nonprofit organizations, community-based clinics and in other settings. They teach people how to stay healthy and prevent disease and they collaborate with doctors, community leaders, teachers, social workers and other professionals and lay people.

The work they do runs the gamut, from vaccinating youngsters to teaching chronically ill patients about nutrition to advocating for the passage of legislation that will improve health care delivery. Public health nurses see the whole spectrum of life, from infants to geriatric patients, and they often work with the most underserved populations in the community.

“Community health nursing is so diverse. It requires everything you learn [as a nurse]. It uses all of you, and you never get bored,” says Aisha El-Amin, MSN, RN, who recently retired from a 40-year career in community health. Most recently she served as director of nursing for the Daughters of Charity Health Center at Carrollton in New Orleans, working with uninsured and underinsured patients.

She treasures memories of the proud mothers showing off their healthy school-age children, whom El-Amin had treated when they were infants, and the diabetes patients who successfully changed their lifestyles to lower their blood pressure and cholesterol. “They’d say, ‘Miss Aisha, look! Look at my weight!’ It was so rewarding when they would come back and tell their stories.”

Making a Bigger Impact

Nurses who have chosen careers in community and public health don’t just make a difference in individual patients’ lives. They impact entire communities, and this is what drives them forward to meet tough challenges.

“When I see families and communities empowering themselves to take care of their own health problems and advocating for themselves because we as nurses have helped them to do that, that is the most exciting thing,” says Kathleen Russell, DNS, RN.

Early in her career, as a young nurse in a public hospital in Indiana, Russell kept seeing the same patients with chronic health conditions, such as diabetes, being readmitted every three or four months because their conditions kept spinning out of control. As she learned about the challenges that minority and low-income urban neighborhoods faced to stay healthy, she yearned to the work in the community to make a difference through prevention.

After returning to school to get her master’s and then doctorate, Russell worked for county and state health departments. She also worked with the Indiana state health commissioner and the state legislature to develop county minority health coalitions to ensure that health care is provided in culturally and linguistically appropriate ways.

Now an associate professor at the Indiana University School of Nursing and president of the Black Nurses Association of Indianapolis, she continues to focus on improving the health of racial and ethnic minority populations, such as doing research on breast cancer screening among medically underserved African American women.

Edythe Harding, BSN, RN, also was drawn to public health nursing after she found that working in critical care in a hospital wasn’t quite the right fit. Even though she knew she was helping her patients in the hospital, she longed to do more for them. Two years ago, she took a job with the Mecklenburg County Health Department in Charlotte, N.C., and is now a clinical nurse supervisor working in family planning, women’s health and sexually transmitted disease prevention.

Harding, who is African American, likes the holistic approach of public health.

“We’re not just treating clients for the moment,” she says. “We’re getting to know them and what’s going on in their lives.”

In community and public health, nurses work autonomously and on interdisciplinary teams, often as leaders. They can also work in administrative roles, planning and managing efforts to serve populations.

Collins, for instance, works with agencies around the state to coordinate efforts to eliminate perinatal HIV transmission. She helps the organizations plan their programs, develop budgets and leverage other resources to sustain their work. Her role involves a creative mix of training, coaching and support, she says.

Strong Demand for Minority Nurses

Demand for community and public health nurses is high, and career opportunities in this specialty are expected to increase even more in the coming years. Experts believe more nursing services will shift from hospitals to community-based health centers, says Maxine Nunez, DPH, RN, a professor at the University of the Virgin Islands and secretary of the Association of Community Health Nursing Educators. Nunez, a native of the Virgin Islands, studied nursing in the United States and worked in community health on the mainland, then returned home to work and teach.

Because public health nursing often involves working to improve the health of medically underserved and economically disadvantaged minority communities that lack access to private health care services, nurses of color can make especially strong contributions in this field.

“In order for us to understand the issues of populations of color and provide culturally relevant care, we’ve got to have nurses from those communities working alongside other nurses and professionals to help educate them about the cultures,” Russell explains.

There is also a strong need for more bilingual nurses, adds Harding. For instance, almost 50% of the patients served by her county’s health department speak only Spanish, so the department prefers hiring nurses who speak both English and Spanish.

While salaries in public and community health are lower than those for some hospital nursing positions, nurses who love their jobs in public health say the satisfaction they get from their work makes up for that. But getting enough funding to hire the staff with the necessary experience and education to make a real difference in the field remains a challenge for leaders in public health, Russell believes.

In most cases, nurses must have a BSN degree to work in community and public health, although some health departments are hiring nurses with two-year degrees because of the nursing shortage. Community health educators, though, recommend at least a bachelor’s degree, and Russell advises graduate-level education for nurses who want to hold leadership positions. “To make system changes, it takes advanced education,” she says.

Treating Patients on Their Own Turf

Community health nursing isn’t for everybody. Nurses who want to see quick improvement in their patients may get frustrated with the specialty, which focuses on improving health over the long term.

“You have to understand this concept: Growth and improvement are slow. Change is very slow, almost invisible sometimes. You have to look deep to see it,” El-Amin says. “You have to meet people where they are, and that’s what community nursing is all about. You give more than you think you can give.”

Nurses must also be able to assess both individuals and groups, and they must be self-confident, creative and forward-looking, Nunez emphasizes.

“You have to figure out how you are going to address not only the public health problem that’s currently on the scene but also the next one arising,” she explains. “You have to be able to work not only in the here and now but begin to visualize what you will see in the future.”

Cultural sensitivity is critical, because community health nurses work with extremely diverse populations. For instance, Harding tells of a patient from an African nation whose husband did all the talking in the consultation about contraception. To treat the woman patient, she had to respect the culture and communicate through the husband.

Working in a community setting means nurses will not only encounter different cultures but also widely varying lifestyles within those cultures. “I stopped being judgmental toward patients a long time ago. Once I did, doors opened for me,” says Chris Ortiz, PhD, RN, PHN, who worked as a community health nurse for a public health department and for hospice and home health agencies. She is now an assistant professor at California State University, Fresno.

Nurses who are used to providing care in a hospital setting will find that the tables are turned when working with patients where they live, Ortiz continues. “In acute care, nurses have a captive audience. We label patients, dress them, tell them what to eat. But in the home, we’re the guests. We’re coming into their world. You have to listen—really listen—to the patient.”

As a home health and hospice nurse, Ortiz made home visits in tough neighborhoods, such as the Tenderloin district in San Francisco. She found that by showing respect to her patients, they responded with respect for her. Often patients would send someone into the street to meet her and escort her to their apartment.

But she also needed to maintain strong boundaries. She recalls once having to leave a home because the air inside was thick with marijuana smoke. Without condemning the people, she explained why she couldn’t stay, and the patient called later to apologize. “You have to be willing to walk into any situation and be able to size it up,” she notes.

Russell says community and public health nurses must have a sense of social justice and responsibility, and they can’t fall into blaming the victims. They must also be good problem solvers, have excellent negotiation skills and be able to work with other professionals and organizations as part of a team.

To be effective in community health, nurses must also guard against burnout. El-Amin says she had to learn that she couldn’t do everything. “All I could do was do my best in the time I had.”

Getting Involved

Russell advises nurses who are considering careers in public health to get involved in their communities by serving on the boards of neighborhood associations and community agencies. She also recommends that they participate in professional organizations to advocate for eliminating health disparities and for improving the quality of life for disadvantaged families and communities.

Ortiz suggests talking to nurses who work in public health, home health and hospice to get a feel for the specialty and whether it might be a good fit for you.

Many years have passed since Azella Collins helped the elderly man in the rat-infested apartment find a safer place to stay. Yet her passion for public health nursing is still as strong as ever. “I really do love this,” she says.