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What Is a Public Health Nurse?

Historical Visions of Public Health Nursing

Karen Buhler-Wilkerson, PhD, RN, FAAN

Lillian Wald, founder of the Henry Street Settlement (1893) in New

York city, invented the term public health nursing to put emphasis on the
community value of the nurse whose work was built upon an
understanding of all the problems that invariably accompanied the ills of
the poor. Walds practice among the sick poor quickly convinced her that
their diseases most often resulted from causes beyond an individuals
control and that treatments needed to be prescribed in an all-round way
with consideration for the social, economic, and medical aspects of each
case. By looking at nursing practice from the patients point of view,
encouraging personal and public responsibility, and providing a unifying
structure for the delivery of comprehensive, equally available health care,
Wald conceptualized a new paradigm for nursing practice.

Whether a patients problems were isolated and unusual or common

to many was, according to Wald, important to know because the process of
finding out the answer to this question often led logically to identification
of an appropriate remedy. Walds vision resulted in nursing practice that
went beyond simply caring for patients and their families during illness to
encompass an agenda of reform in health care, industry, education,
recreation, and housing.

What Wald called "our enterprise of public health nursing" was not
an isolated undertaking, nor was she a lone American heroine. Her
paradigm for nursing practice was based on knowledge gained during two
decades of experience in visiting nursing and owed much to Progressive
reform and the public health movement of the turn of the century.
Although Wald embodied the professionalization of visiting nursing, due
credit must also be accorded the thousands of nurses across the country
who legitimated the practice of nursing in the community.

To Teach Healthful Living and Disease Prevention

While Wald was developing her new agenda for the reform of
society and delivery of health care, the changing emphasis of the public
health campaign simultaneously created yet another aspect of the bond
between nursing and public health. As the focus of the public health
movement shifted from what eminent public health leader C-E.A. Winslow
described as environmental sanitation and bacteriology to the personal
conduct and health practices of the individual, it required a new worker, a
teacher of healthful living and disease prevention. By 1910, most of the
large visiting nurse associations and numerous boards of health and
education had initiated disease- prevention programs for school children,
infants, mothers, and patients with tuberculosis.

Health visiting offered nurses a new opportunity for professional

independence, status, and economic security. As one medical authority
suggested, they were the relay station to carry the power from the control
stations of science, the hospital, and the university to the individual homes
of the community. This was a time of unprecedented possibilities for
nursing. Not, surprisingly, the number of agencies seeking their services
had increased from only 58 in 1901 to nearly 2,000 by 1914. Nurses
entering this new field had also begun to specialize, limiting their work to
one age group or disease. Specialization, these nurses argued, allowed them
to become experts, to lead others, and to contribute to the much needed
literature in public health. They saw themselves as participating in the
growing specialization of the medical profession. Because it was difficult to
combine a focus on prevention with meeting the bodily needs of patients,
the roles associated with care of the sick and health teaching increasingly

Wald argued that the public health nurse was the link between
families social, economic, and health needs and the services they required
to become and stay healthy. She was therefore opposed to specialization
and to the distinctions between health teaching and direct patient care. If
the message of health was to be carried to troubled families, something also
needed to be done for these families. Thus, the increasingly isolated and
narrowly focused mission of health education challenged Walds vision of a
broadly focused agenda for nursing in the struggle for social betterment.
Specialization was antithetical to her concept of public health nurses
organic relationship to their neighborhoods.

Prevention vs. Cure?

By the late, 1920s, public health nurses had indeed demonstrated
their ability to advance the public health mission, but the field had reached
a turning point. Despite the intent of reformers for a conceptually coherent
and centrally structured set of public health services, there were
nevertheless 4,262 separate, small and independent local government and
voluntary agencies sponsoring public health nurses. This growth was
characterized by an idiosyncratic mix of initiatives providing an
unpredictable assortment of both preventive and curative nursing services.
Gaps and duplication of services were an inevitable outcome. Isolated and
uncoordinated, these agencies were increasingly vulnerable to shifts in
community support and perceptions of need. As the confusion grew, the
rationale for public health nursing became increasingly obscure to both its
practitioners and the public.

In response, many nursing leaders began to campaign for the

creation of comprehensive, coordinated community-based nursing services.
Leaders now considered separating the curative and preventive functions
of the public health nurse to be a mistake, and they argued for a combined
model that would unite both voluntary and publicly funded agencies.
Nurses within this more rational system would be general practitioners
who would care for all people in the neighborhood, in sickness and in
health, regardless of income or type of illness. Numerous studies and
demonstration projects from the 1920s through the 1940s confirmed that
such a system would eliminate duplication in administration,
transportation, and health services. Despite their ability to demonstrate that
this unification model met the needs of most of the patients it served,
however, organized nursing was never able to create the institutional
framework necessary to implement their vision.

The reality was that public health nursing was no longer able to
engage the support of the larger infrastructures of medical and wider social
institutions in their quest to create and finance comprehensive community-
based care. The social, medical, and demographic circumstances that had
created support for their work in the community were now much less
urgent. With fewer immigrants, declining death rates from often dramatic
and frightening infectious diseases, the growing dominance of chronic
illness, and the centrality of the hospital, the work of the public health
nurse seemed increasing inconsequential to the public.

Nurses as Guardians of the Publics Health

Over the years, public health nurses have assumed a variety of roles
and titles, but in the absence of an influential or cohesive constituency,
Walds vision of nurses as guardians of the publics health could only be
partially realized. Today, once again, frightening diseases, alienation among
the disenfranchised, a vexing economic climate, and unmet health needs of
populations at greatest risk constitute a crisis in caring. As we anticipate the
possibility of health care reform , one cannot help but wonder if public
health nursing might have the opportunity to be reinvigorated and returned
to the role Wald prescribed. As historian Susan Reverby suggested during a
previous campaign for health reform, such a paradigm shift could go a long
way toward making an inadequate medical care system into a health care
system that provides for all the public.


C.-E.A. Winslow. The Untilled Fields of Public Health. Science, 51 (9

January, 1920): 23-33.Karen Buhler-Wilkerson, Bringing Care to the
People: Lillian Walds Legacy to Public Health Nursing, American Journal of
Public Health, 83 (December 1993): 177886.

Karen Buhler-Wilkerson, Public Health Nursing: In Sickness or in

Health? American Journal of Public Health, 75 (October 1985): 115561.

Karen Buhler-Wilkerson. False Dawn: The Rise and Decline of Public Health
Nursing, 1900-1930. New York: Garland Publishing Co., 1990.

Susan Reverby, From Lillian Wald to Hillary Rodham Clinton: What Will
Happen to Public Health Nursing?"American Journal of Public Health, 83
(December 1993):166263.
Marla Salmon, Editorial: Public Health NursingThe Opportunity of a
Century, American Journal of Public Health, 83 (December 1993): 167475.