How Much Public Health is in Public Health Nursing?: How Much Public Health is in Public Health Nursing? Beth Mertz April 18th, 2006 Alaska PHN Conference


Presentation Overview : Presentation Overview Background to study Review California Study & Alaska preliminary results Managing Change in Public Health Nursing


Trends in Public Health Nursing: Trends in Public Health Nursing Public Health Nurses are the single largest component of the public health workforce Shift in focus of PH Leadership is calling for broader strategies Efforts are focusing on an improved articulation of the services associated with the three core public health functions -Smith, Kathleen and Noel Bazini-Barakat (2003) Public Health Nursing, v20, n1.


A Profile of Public Health Nurses In Five California Counties: A Profile of Public Health Nurses In Five California Counties Objective: explore practice and other transitions Methods: Mailed surveys The five participating counties were Alameda, Mendocino, San Bernardino, San Francisco, and Santa Clara. AK did this as an online survey statewide in early 2006.


Key Study Component: Key Study Component SYSTEM COMMUNITY INDIVIDUAL Importance of Activities Educational Preparedness Frequency of Activities


Demographics: Demographics The mean age of survey respondents was 49.4 years. Almost all PHNs are women (97%) and of white/Caucasian background (65%). The age and gender distribution in CA and AK are similar, however AK has fewer minority PHNs.


Client Demographics: Client Demographics The most frequent PHN client in CA is a Hispanic female under the age of 18 who is enrolled in Medi-Cal and is in good health. In AK, the age and gender results were similar, however most clients were either white or Native American, and on either Medicaid/Denali Kid Care or in a Native Health program


Education: Education Licensure as a PHN in California requires completion of an approved BSN program and documentation of public health coursework. Unlike the general RN workforce, most PHNs are educated at the baccalaureate level or above in nursing. The same generally holds true for AK, where 85% have a BSN & 14% have a MSN.


Job Market: Job Market The majority of PHNs have: been in the profession for more than 15 years have had only one employer during their careers, and express satisfaction with their jobs. In AK, the employment holds the same pattern, most PHNs have had one employer, and almost 90% note they are either somewhat or very satisfied with their job.


Job Market: Job Market Demand for PHNs outstrips supply and PHN managers uniformly report difficulties in recruiting for open positions. Nursing shortages may affect PHN more seriously in the future. A national report noted recruitment difficulties in all 6 states in the study (CA, GA, MT, NM, NY, TX). Source: HRSA (Public Health Workforce, January 2005)


Organization of Work: Organization of Work PHNs tend to work with a wide variety of other health service providers. Program focus areas are MCH/Adolescent (44%), and General (39%) Top worksites are, private home, public health department administrative office, county health clinic, community agency, school. AK top worksites are PHN Center & private homes


Generalist or Specialist Role : Generalist or Specialist Role =AK Staff Responses


Practice Roles: Practice Roles The most frequently performed and highly prioritized intervention is case management on the individual level. PHNs and their managers emphasize individual-family level interventions more than community or system level interventions. SYSTEM COMMUNITY INDIVIDUAL


Slide14: Summary Scores for Public Health Nursing Interventions


Importance and frequency of interventions: Importance and frequency of interventions


Slide16: Summary Score: Staff Educational Preparation for Interventions


Perception of “excellent” or “good” staff educational preparation: Perception of “excellent” or “good” staff educational preparation


Individual/family level interventions: Individual/family level interventions


Community level interventions: Community level interventions


System level intervention: System level intervention


Mean score 1-4 scale: Mean score 1-4 scale


Continuing Education: Continuing Education CA Staff identified their CE priorities as: Case management Epidemiology Physical assessment Foreign languages Health teaching Disease investigation AK Staff identified their CE priorities as: Health teaching Epidemiology Community Assessment Environmental Assessment Coalition Building Leadership Community Organization Multi-cultural Nursing Grantwriting


Continuing Education - CA: Continuing Education - CA Managers identified their top priorities for staff CE as: Health teaching Case management Community assessment Practitioner and agency collaboration Legal and health care finance Community organization Managers identified the following areas as top priority for their own CE: Legal and health care finance Research Health policy Community assessment Program planning and management Grant writing


Continuing Education - AK: Continuing Education - AK Managers identified their top priorities for staff CE as: Community Assessment Coalition Building Community organizing Leadership Managers identified the following areas as top priority for their own CE: Management Skills Leadership Community Assessment Health policy and policy development Research, statistics and evaluation methods


National Study of Local and State Health Departments: National Study of Local and State Health Departments For each profession (Public Health Nurses, Physicians and Dentists): What public health role does each profession play? What formal public health training do they have? What formal public health training do they need? Do health departments experience difficulty recruiting or retaining these professionals? Do recruitment and retention difficulties impact the services the agency is able to provide? Source: The Public Health Workforce, HRSA, January 2005


MPH and Collaboration with Public Health Training Programs: MPH and Collaboration with Public Health Training Programs Focused on those in leadership and management Experience difficulty recruiting or retaining MPHs Local and state health departments have mixed relationships with schools of public health or MPH programs This relationship may or may not help meet the need for new staff, upgrade existing staff or address continuing education needs of their workers Source: The Public Health Workforce, HRSA, January 2005


Continuing Education: Continuing Education Public Health Nurses have a twofold need for CE - As nurses, they need nursing CE to maintain licensure, but they also need public and community health skills to help advance the work of the organization and the profession A 2000 study* outlined the skills most needed and created a draft curriculum for providing this training. *Source: Gebbie, K (2000) Preparing Currently Employed Public Health Nurses for Changes in the Health System, AJPH, V90, N5, May.


Key Questions for PHN: Key Questions for PHN What is happening in the larger health care and government environments? How do these external influences impact the practice of public health nursing? How do current organizational structures support or inhibit activities in the environment, community, and within the profession? How can the PHN profession address these challenges in a strategic way? How can the PHN profession position its members best to deal with a continuous evolution of work?


Model for Change: Model for Change


The Health Care Environment: The Health Care Environment Changing Times


Environment: Environment External world key to success Connect the dots to see the opportunities Leadership task: interpret back and forth Change is the modern constant Who do we do this for?


External Drivers of Change: Increased competition Changing consumer demand Constrained resources Failed performance New social values Changing technologies New regulations External Drivers of Change


Generation Next : Generation Next Service orientated- but at the individual level Anti-institutional, highly individualistic Not hierarchical, participatory and democratic Flexible, change welcoming - Not in it for the long haul Value diversity Oriented to learning and new skill development Particularly focused on technology learning Find fulfillment through the community of work Gen NeXt Values:


PHN Environment: PHN Environment Only 3% of the $2 trillion going to health care goes to public health, but this is up from 2.5% in 1984* Revenue streams don’t always match core functions of public health Public health systems are redefining their role in the community, and hence redefining the roles of PHNs Nursing shortages impact resources and workforce availability *Source: Health Care Costs 101, CHCF


Vision: Vision Where are we going?


Vision: Vision What does a vision do? Paints a picture of the future Inspires, defines and aligns Informs workers, partners and customers


Vision: Vision From vision to systemic change Develop strategy based on vision Multi-level change process Context, Timeframe, Skills, Products Preferences – yours and theirs Learn from the process


Deliberate and Emergent Strategy: Deliberate and Emergent Strategy Deliberate Plans for the future Think, then act Strategies are formulated What do we intend? Can be realized or unrealized Smart = devising better strategies Emergent Patterns from the past, present and future Action, then reflection Strategies form What is on the ground? Can become deliberate Smart = noticing patterns and legitimating “Unexpected travel plans are dancing lessons from God.” – Kurt Vonnegut, Cats Cradle


Strategies: Context of Change: Strategies: Context of Change Focus the change efforts on the right problem


Example - workforce: Example - workforce What are the most pressing health professional workforce issues facing local and state health departments today? Are these problems driven by: inadequate financial resources? lack of qualified candidates? need for continuing professional education?


Model for Change: Model for Change


Teams: Teams How work gets done


LA County Public Health Nursing Model: LA County Public Health Nursing Model “Accountability for community health improvement outcomes increasingly demands a team approach and a common language” -Smith, Kathleen and Noel Bazini-Barakat (2003) Public Health Nursing, v20, n1.


Why Teams and Change?: Why Teams and Change? Need different perspectives to cope with complex and changing environment Need more diverse political coalitions for success Need different skills to meet dynamic environment Need to integrate various disciplines and areas Need creative responses to constraints


Teams: Teams Performance goals challenge Balance of task and relationship essential Rules and discipline work – see good meetings Clarity of goal essential –given or derived Performance curve – relationship then task Key Learnings


Organizational Structure & Job Satisfaction of PHNs: Organizational Structure & Job Satisfaction of PHNs Work environments in which supervisors and subordinates consult together concerning job tasks and decisions, and in which individuals are involved with peers in decision making and task definition, Are positively related to job satisfaction Source: Campbell, Fowles, & Weber, Public Health Nursing, Dec 2004


Culture: Culture


Institutional Culture in Health Care: Institutional Culture in Health Care Era of Professional Dominance – 1920-1964 1935 – Social Security Acts – Federal investment in public health systems and agencies Era of Federal Involvement, 1965-1982 Public health systems continue to evolve at multiple levels Era of Managerial Control and Market Mechanisms, 1983-present Based on the efficiency of outcomes Source: Scott, the old order changeth, 2001


Culture: Culture Culture comprises the norms and values that shape behavior in organizations Organizational culture is the backdrop for all change processes. It is so pervasive that it is by and large unnoticed, so it is rarely valued for its sheer raw power to advance or destroy a change.


Public Health Nursing Cultures: Public Health Nursing Cultures Government Public Health Nursing


Change and Culture: Change and Culture Needed reforms are often at odds with the culture Emergent needs: Work in teams Reform Change of focus Culture: Disciplines Stability Existing programs


Model for Change: Model for Change


Alignment: Alignment


Alignment: Alignment Policy and politics Its about them.. But not all of them – The Law of the Few Building capital Using power


Working toward Alignment: Working toward Alignment Understand the networks around your change issue Be clear about what you are proposing Know how each stakeholder values the change Develop good channels of communication Learn from them and adapt


Action: Action


Action: Action Pushing Vision Daily Decision making Problem solving Education – learning Coaching Budgeting Staffing


Action: Action Vision to Action Keep the vision clearly in mind Remember the anxiety of people in a changing system Address anxiety and uncertainty with clarity, resolve and commitment to work together to common ends Question to understand and empathize Develop skills and competencies: yours and theirs Identify clear system outcomes and tie rewards to these outcomes


Action: Action Balance Heart – Have the emotional issues been addressed? Head – Does everyone understand why it is important? Does everyone know what it looks like? Hands – Does everyone have the skills to stay relevant?


Action: Action Quick wins Low risk – high potential pay off Short term Confidence builder Skill builder Low hanging fruit


Model for Change: Model for Change


Recommendations: Recommendations Ensure that strategies to address the overall nursing shortage include a focus on increasing the supply of PHNs as well. Because regulations require that PHNs have baccalaureate nursing degrees, the training of PHNs is a key responsibility for these nursing programs.


Recommendations: Recommendations Reform PHN educational curricula to incorporate a greater focus on population health. Equipping PHNs with the skills needed for a public health model of practice may require consideration of educational reforms such as joint RN-MPH programs and more intensive continuing education.


Recommendations : Recommendations Critically appraise the organizational and financial constraints of local public health departments that result in prioritizing direct individual care rather than population health


Center for the Health ProfessionsUniversity of California, San Francisco: Center for the Health Professions University of California, San Francisco 3333 California Street, Suite 410 San Francisco, CA 94118 415-476-8181 http://futurehealth.ucsf.edu