Preparing Now for After COVID-19: The Need to Strengthen Public Health Nursing

By Monica J. Hughes, MSN, RN, NE-BC, CNE, and Lisa A. Campbell, DNP, RN, PHNA-BC

UNTIL THE NOVEL CORONAVIRUS disease 2019 (COVID-19), most Texans were not aware that public health nurses (PHNs) and other public health professionals were hard at work promoting and protecting the health of our communities.

The quiet work we engage in, largely unseen and taken for granted, means striving for equity in maternal health outcomes, educating youth on the risks of vaping, preventing childhood injury, tackling health disparities, and preparing for disasters. Society relies on public health’s presence and its success, without much thought on its structure, requirements, funding, or workforce.

That is, until a threat like COVID-19 emerges, and the emperor is revealed to be, at best, barely dressed. Every community, suburb, and big city across Texas now realizes the public health infrastructure is not adequate due to decades of chronic underfunding, job eliminations, and increased workload for health professionals. 1

FALLING BEHIND THE CURVE

In 2008, the Association of Public Health Nurses (formerly the Association for State and Territorial Directors of Nursing) made clear recommendations for a minimum ratio of one PHN to 5,000 residents, with even more nurses needed in vulnerable communities. 2

The national PHN workforce falls almost 31,000 nurses short of that standard, and Texas is behind as well. Although no accurate accounting of PHNs in Texas exists, a 2020 study indicates that as a result of inadequate PHN staffing, PHN workloads continue to increase and the ability for public health to expand services in Texas is curtailed. 3

The Texas Department of State Health Services has 154 local health entities spread across 11 regions and 254 Texas counties, providing essential public health services unrelated to an outbreak. When the need for an urgent public health response arises—in this case, due to the COVID-19 pandemic—budgetary shortfalls and understaffing mean essential programmatic work is set aside.

TAKING A BACKSEAT

When outbreaks take priority, we are left with tuberculosis treatment programs understaffed, chronic disease surveillance unattended-to, connection to services for social programs limited, and public health clinics shuttered. PHNs typically managing these services are pulled away to meet more pressing challenges, resulting in broadening inequities for the most vulnerable who rely on the regular operation of public health services to help meet their needs.

As a result of the current crisis, the federal government has set aside $1.5 billion to support public health departments as a part of the Coronavirus Aid, Relief, and Economic Security (CARES) Act. 4 This funding supports COVID-19-related activities, such as surveillance, disease testing and contact tracing, infection control, risk assessment and mitigation, and of course, increasing the availability of personal protective equipment.

PHNs are educated, prepared, and ideally suited to assist, but reductions, combined with inconsistent recruitment, entry-level preparation, and inadequate training, have created a shortage in the state’s PHN workforce. The CARES Act funds, filtering down from the federal level to the state and then the local health entities, can and should be used to strengthen Texas’s PHN workforce.

BUILDING A STRONGER WORKFORCE Public health nurses are all too familiar with the cycle that follows an outbreak of this kind: limited funding comes in, earmarked for a purpose related to the threat; in time, a renewed period of neglect settles in as interest in public health wanes again; a new disease (or disaster) emerges, and the cycle starts again. This virus has already revealed glaring inequities that affect health: food and housing insecurity, unemployment, and racially disparate outcomes. It doesn’t have to be this way. On the other side of this crisis, PHNs will go back to the quiet and unseen work they do, trying to put these things right. We invite you to join your voices with ours in advocacy, calling for a commitment to dedicate CARES Act funds to bolster the PHN workforce. It is imperative that the growth and stabilization of the PHN workforce be addressed today for the benefit of the public’s health in the days to come. Together, we must take a stand and call on our governmental entities to invest in a stronger foundation for our PHN future.

REFERENCES 1. Association of State and Territorial Directors of Nursing. (2008). Report on a Public Health Nurse to Population Ratio. Quad Council Coalition. 2. Association of State and Territorial Health Departments. (2014). Budget cuts continue to affect the health of Americans. 3. The Texas Center for Nursing Workforce Studies. (2020). Texas governmental public health nurse staffing study. Texas Department of State Health Services. 4. Coronavirus Aid, Relief, and Economic Security Act or the [CARES Act], H.R.748, 116th U.S. Cong., 2nd Sess. (2020).