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

Patricia Pittman, PhD, FAAN; Jeongyoung Park, PhD

Disclosures

Online J Issues Nurs. 2021;26(2) 

In This Article

Analysis of Workforce Data

We analyzed the last four iterations (2000, 2004, 2008, and 2018) of the National Sample Survey of Registered Nurses (NSSRN), performed by the National Center for Health Workforce Analysis ([NCHWA], 2018), and data from the National Association of County and City Health Officials ([NACCHO], 2019) from 2008 to 2019. Our analysis included evaluation of the data in these documents over time and consideration of other trends. Using the NSSRN over time, we first conducted descriptive analysis on changes in nurse employment in community and public health settings, as well as in other primary care settings. We also examined county and city employment data over time to trace back a sub-set of community/public health nurses, i.e., nurses in local health departments, and compared with trends of other occupations employed in local health departments. These findings revealed that not only did the expected expansion of nursing in to community and public health settings not occur, but the trends were headed in the wrong direction.

As shown in Figure 2, data from the most recent NSSRN (2018) revealed that the current distribution of nurses is still weighted heavily toward hospital employment (62.6%). Just 1.4 % of registered nurses (RNs) are employed in community/public health non-clinic settings (e.g., state health or mental health agency; city or county health department), and 1.6% are employed in public health/community clinic-based settings (e.g., rural health center, Federally Qualified Health Center [FQHC], Indian Health Service, TRIBAL Clinic), for a combined 3% of the nurse workforce.

Figure 2.

Distribution of RNs by Employment Setting 2018 (n= 3,272,871)
*PH/CH not clinic-based includes State Health or Mental Health Agency, City or County Health Department. PH/CH clinic-based includes Rural Health Center, FQHC, Indian Health Service, TRIBAL Clinic, etc.
Source: Authors' Analysis Based on the National Sample Survey of Registered Nurses, 2018 (NCHWA, 2018)

Analysis of NSSRN Over Time

When we examined the NSSRN (2000; 2004; 2008; 2018) over time, we saw a clear and discouraging trend. As shown in Figure 3, RNs in both clinic and non-clinic-based community/public health jobs dropped dramatically. RNs in non-clinic-based community/public health jobs fell as a percent of the total RN workforce from 3.2% (69,837) in 2000 to just 1.4 % (47,226) in 2018. There was a similar drop in clinic-based jobs, from 3.5% (76,127) to 1.6% (53,084). The Table provides the descriptive data used to compile Figure 3.

Figure 3.

RNs in Community/Public Health*, 2000–2018
*PH/CH not clinic-based includes State Health or Mental Health Agency, City or County Health Department. PH/CH clinic-based includes Rural Health Center, FQHC, Indian Health Service, TRIBAL Clinic, etc.
Source: Authors' Analysis Based on the National Sample Survey of Registered Nurses, 2000, 2004, 2008 and 2018 (NCHWA, 2018)

Primary care settings (beyond the publicly-funded community clinics described above) cannot be traced back to the early NSSRN surveys (2000; 2004; 2008), so we examined two other categories: private medical practice and nurse-owned practices. The decline was less dramatic than in community health/public health, but we found a drop in nurses employed in private medical practice from 9.2% in 2000 to 6.9% in 2018, again with a slight increase in the absolute numbers (203,346 to 226,524). Nurse-owned practices remained flat at just .3% over time, even with the absolute numbers almost doubling from 5,978 to 10,655 (NCHWA, 2018).

Other Trends

Trends in additional non-hospital categories also challenged the predictions. For example, school -based nurses declined as a percentage of the total nurse workforce, from 3.8% to 2.9%, although their actual numbers increased by a little over 10,000 (83,269 to 93,344) (NCHWA, 2018).

To understand why there are not more public health nurses, it is also worth looking at data on a sub-set of public health nurses: those working in local health departments. These nurses are a critical part of the governmental response to any public health crisis, including COVID-19. We analyzed county and city health employment data (NACCHO, 2019) from the years 2008–2019. As shown in Figure 4, the number of nurses declined from just over 33,000 to just over 21,000. This decline mirrors the NSSRN data presented in Figure 3, but it also reveals another puzzling data point: the decrease of nurses was faster than any other occupation within public health. Behavioral health staff were falling but have had a significant uptick since 2016. Other staff, such as epidemiologists and preparedness staff, have increased slightly over time (NACCHO, 2019).

Figure 4.

RNs and other Occupations in Local Health Departments, 2008–2019
Source: Authors' Analysis of 2019 National Profile of Local Health Departments, National Association of County and City Health Officials (2019)

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