Rebuilding Community-Based and Public Health Nursing in the Wake of COVID-19

Patricia Pittman, PhD, FAAN; Jeongyoung Park, PhD


Online J Issues Nurs. 2021;26(2) 

In This Article


Public health and community health nurses are not new to this country. Indeed, they were a central force in healthcare from 1910 to 1940, losing prominence only as the medical model of care and the rise of hospitals gained traction through the mid-20th century (Pittman, 2019b). Efforts to revitalize public health nursing have continued over time, especially by organizations such as the Association for State and Territorial Directors of Nursing (ASTDN) (now the Association of Public Health Nurses).

Figure 1 shows the range of activities public health nurses are engaged in, all of which are essential contributions to address health equity. Since the early 1940s, there has been a general convention that at least one public health nurse is needed per 5,000 population. In 2008, the ASTDN called for the formalization of this goal, and specifically for additional nurse supervisors, and a higher density of public health nurses in high poverty communities (Keller & Litt, 2008).

Figure 1.

Contributions of Community/Public Health Nurses
(Keller & Litt, 2008)

Following the 2010 Affordable Care Act (Patient Protection and Affordable Care Act, 2010), experts hoped that progress was being made toward addressing healthcare inequities with this change to the healthcare infrastructure. Many predicted that value-based payment would provide an incentive for healthcare organizations to hire more nurses outside of hospitals, in areas such as public health and community-based settings (Larson, 2017; Pittman & Forrest, 2015; Salmond & Echevarria, 2017). The rationale was that as hospitals assumed more risk under Accountable Care Organizations and other value-based payment programs, care would shift outside of the hospital to ambulatory settings and homes. We would invest in public health and upstream initiatives, such as coordination with social services, housing, and food security. (Larson, 2017). Some chief nursing officers in hospitals were even calling for large health systems to create a chief nursing officer position for community-based nursing (Pittman & Forrest, 2015).

At the same time, many argued that nurse leaders should emphasize the importance of recommitting to the foundational practice of public health nursing, as exemplified by Lillian Wald in the period of 1910 to the late 1930s (Hassmiller, 2013; Pittman, 2019a; Sullivan-Marx, 2020). This call became more compelling as researchers identified a surge in so-called diseases of despair (i.e., primarily behavioral health-related challenges) and noted that the centralized medical model based in hospitals was failing. The increased interest in SDOH, driven in part by the Robert Wood Johnson Foundation Culture of Health goal (n.d.), and the continued emphasis on deepening outcome-based payment in health reform, also highlighted the promise of models that function at the intersection of nursing and social work.

When the COVID-19 pandemic appeared in early 2020, nurses in critical care settings occupied the headlines. The reported shortage of critical care nurses renewed appreciation for the essential role hospitals play during a public health emergency. Nurses who were working in intensive care units under dangerous physical and emotional conditions were hailed as heroes and seen as the symbol of the entire profession. Nothing about this shift in the conversation was unfair or regrettable. However, as has happened numerous times in the last half-century, the fear of a nursing shortage in hospitals, for a time, pushed the issue of community and public health nursing aside, once again (Pittman, 2019a).

When the Biden Administration took office in 2021, priorities shifted and the implications of the COVID-19 pandemic for public health and health equity became center stage. On January 21st, one day after assuming office, President Biden issued an Executive Order that established a Public Health Workforce Program. This order would determine how to deploy personnel in future public health threats; establish a five-year budget requirement for a sustainable public health workforce, including Public Health Service Commissioned Corps; and establish a U.S. Public Health Job Corp that would conduct contact tracing, assist in vaccination outreach and administration, and assist with training to provide testing (Biden, 2021).

Implicit in this measure was an acknowledgment that the prevention of community spread of COVID-19 could be improved. Beyond the perceived mismanagement and politicization of the pandemic by the former administration by many, the new policies reflected the notion that more could have been done to prevent the spread with a robust public health workforce in the community. Public health infrastructure had not been a priority for many years (Taylor, 2018). Areas of weakness noted in the current pandemic included coordination between local, state, and federal roles; community education on the importance of public health prevention measures, surveillance through contact training, COVID-19 testing, and planning for the vaccine rollout (Sullivan-Marx, 2020).

An example that demonstrates the importance of a robust infrastructure concerns the vaccine rollout. West Virginia and New Mexico were far more successful in quickly vaccinating their residents than others. These two rural states had maintained a stronger public health infrastructure than other states. They turned to their public health workforce, rather than the fragmented private sector pharmacy and healthcare delivery system, during the vaccine roll-out, taking vaccines to hard-to-reach populations (Cunningham, 2021).

In March, Congress passed the American Rescue Plan Act (ARP) of 2021. The ARP provides a significant funds for the public health workforce through multiple mechanisms, including funding for local health departments. In keeping with the goals announced in the earlier Executive Order (Biden, 2021), $7.66 billion in the new law is targeted to establish, expand, and sustain a public health workforce, including awards to state, local, and territorial public health departments (ARP, 2021).

As we contemplate the implications of this new opportunity for nurses and the profession of nursing, it is important to understand whether payment reforms and the calls for nurses to address SDOH were indeed having an effect before the pandemic. In order words, where does the nursing workforce stand today, and is it positioned to expand its role in community health and public health?

In this analysis, we question the progress made prior to the 2020 pandemic in terms of strengthening community-based and public health nursing and discuss the implication of the recent legislation (ARP, 2021) for the future of community and public health nursing.