Restore Community Nursing

(Illustration by David Plunkert) 

My mother was a registered nurse. From an early age, I remember neighbors knocking on the door of our suburban home in Cherry Hill, New Jersey, to ask her questions about a rash on their newborn, to have their blood pressure checked, or to discuss lab work results they had just received.

I followed my mother into nursing. My first job out of nursing school was at East Camden Middle School in Camden, New Jersey, one of the poorest cities in the United States. Tasked with the care of more than 600 students in grades five through eight, alongside numerous teachers and staff, I spent my days offering first aid, treating shortness of breath from asthma, and screening for hearing and vision problems. My scope also included collaborating with school and community partners to identify and assist students and families with food insecurity, housing instability, behavioral issues, and other socioeconomic challenges.

How my mother served our neighborhood and how I served a middle school is a model for smaller-scale, community nursing that should be replicated across the 84,000 census tracts that define the American landscape. Each tract, averaging 4,000 inhabitants, would be much healthier if it had a dedicated nurse sharing health information and collaborating with community partners to combat social isolation, housing instability, and food insecurity, and address other social determinants of health.

The evidence is clear on two points. First, such social factors have a greater influence on health outcomes than clinical care. Despite spending more per capita on health care than any other nation, the United States has dramatically worse health outcomes when compared with other affluent nations, in part because the social circumstances many Americans face leave them vulnerable. No health system can rely on hospitals alone to address basic social determinants of health. Second, the health of populations improves when nurses, the largest segment of our nation’s health-care workforce, work within communities to increase high school graduation and employment rates, access to parks and playgrounds, and other community health factors.

Nurse-Education Reform

The nursing profession has a rich history deeply rooted in community care. However, more than half of nurses today work in hospitals. How did nurses go from providing direct care in communities to becoming hospital employees? Beginning in the 1930s and increasing after World War II, local, state, and federal governments promoted the construction of hospitals and the professionalization of medical care. Communities built more hospitals, and the beds of those hospitals were filled with people with diseases and illnesses who needed nursing care.

Hospitals had a growing need for workers trained to provide skilled care to patients with conditions that required technically complex treatment. Hospitals hired more nurses and became sites for hospital-based nurse-training programs. While community colleges and universities eventually stepped in to provide nursing education—these institutions educate most nurses nowadays—they retained the model of nursing education that hospitals developed.

This history partially explains a twofold problem that US health care faces today. First, the United States is experiencing a shortage of nurses, especially nurses prepared to address the challenges faced by rural communities remote from hospitals. Equally troubling, nursing schools are turning away qualified applicants because they do not have enough seats. The nation needs more nurses than just those who wind up staffing hospitals.

There are more than five million registered nurses (RNs) in the United States, and the profession consistently ranks highest among the nation’s most trusted professionals. Yet we don’t have enough, as the COVID-19 pandemic underscored. Its disproportionate impact on the most vulnerable highlights the urgent need for census tract nurses, who can help construct care networks and provide a safety net for the most susceptible members of our society.

The challenge is to redesign nursing education to prepare for a future health system that nutures communities and fosters a healthier, more resilient nation.

Nurses have an impressive history of actively engaging with communities to establish care networks to improve health. Lillian Wald (1867-1940), a trailblazing figure in public-health nursing and a visionary leader in the nursing profession, laid the foundation for such community-oriented care. In 1895, she established the Henry Street Settlement, a comprehensive care network designed to enhance the well-being of immigrants residing on the Lower East Side of New York. She coined the term public-health nurse and advocated for nurses to establish an “organic relationship with the neighborhood,” serving as the cornerstone for a universal service to the community. Her legacy continues today in such programs as the Nurse-Family Partnership, which delivers prenatal and early childhood care to low-income, first-time mothers through the expertise of registered nurses. Extensive research has demonstrated the positive impact of this program on the health outcomes of both mothers and their children.

It is now imperative to transform nursing education, equipping students with the necessary tools to construct and fortify care networks reminiscent of historic successes like the Henry Street Settlement and modern programs such as the Nurse-Family Partnership.

The way nursing is taught today is unduly shaped by hospitals. Consider, for example, the extensive clinical rotations required of entry-level nursing students. Originating from the 1930s need for hospital staffing, these rotations are resource-intensive. Two of the primary reasons why nursing schools deny admission to thousands of qualified applicants every year are a shortage of faculty and a shortage of clinical placements. Yet we have no evidence that all the resources devoted to clinical rotations contribute to the clinical competency of nursing students. In addition to getting back to our community roots (e.g., community health, public health), our goal as a nation should be to adopt innovations that enable us to educate more entry-level nurses more efficiently (e.g., less time, fewer faculty) and equip them to serve communities away from a hospital setting.

We can reach this goal by dramatically increasing the use of simulation. A growing number of nursing schools are already replacing clinical rotation hours with simulation (e.g., high- and low-fidelity mannequins, standardized patients, virtual reality, and clinical vignettes) to replicate real clinical scenarios. Through simulation, students develop critical thinking skills, apply what they are learning, and problem-solve without endangering patients or tying up valuable clinicians’ time.

Simulation not only trims resource requirements but also offers a standardized, tailored learning environment. Making this shift enables educators to create precise clinical scenarios for students, preparing them for a diverse array of real-world situations that they may not get in clinical rotations. Using standardized patients, students can be prepared to respond appropriately to patients with injuries from intimate partner violence. With high-fidelity mannequins, students can practice pelvic exams or help in labor and delivery.

To be sure, students gain some important experiences by participating in clinical rotations (e.g., time management, teamwork); however, we must scrutinize whether the resource-intensive model aligns with the actual clinical competency enhancement. A goal ought to be equipping the next generation of the nursing workforce for a future beyond the confines of acute care.

The Costa Rica Model

We are not going to solve the nursing workforce challenges of tomorrow by directing the lion’s share of resources to addressing shortages of faculty and clinical training sites. Instead, we need a new paradigm in nursing education that seeks to eliminate the nursing shortage.

Fortunately, organizations such as the American Association of Colleges of Nursing are making important investments to develop a new foundation for nursing education. Funding proposals, including the Future Advancement of Academic Nursing (FAAN) Act, should focus on developing best practices, such as simulation and competency-based education, for all nursing schools to implement.

As schools of nursing progress in developing, implementing, and disseminating this innovative approach to nursing education, our nation will see a rise in the number of nurses prepared to reconnect with the profession’s community-centered origins and collaborate within multidisciplinary teams to enhance population health. A prime illustration of the successful adoption of this approach is seen in Costa Rica, where advancements in health outcomes, accessibility, and quality have been achieved through the implementation of a multidisciplinary primary care model. In Costa Rica, each citizen is assigned to a team responsible for delivering care within a specific geographic region encompassing approximately 4,000 individuals. This team-based approach has operated for about 25 years, initially concentrating on medically underserved rural regions before expanding to urban areas, including the capital, San José.

Costa Rica’s multidisciplinary model of community health-care delivery offers valuable insights for the United States. The 84,000 census tracts that define the US landscape average about 4,000 inhabitants and are similar in size to the geographic regions in Costa Rica. The community care that nurses deliver in this model is similar to what I provided as a school nurse in Camden. But a US model that followed this example would extend such care across all ages in an entire census tract. With a dedicated nurse sharing health information and collaborating with community health workers and other partners to address social isolation, housing stability, food security, and other social determinants of health, census tracts and, by extension, the whole country would be much healthier.

We can revolutionize nursing education and care by simply embracing its historical community-focused roots. The challenge now is to redesign nursing education to prepare for a future health system that nurtures communities; fosters a healthier, more resilient nation; and inspires and trains a larger and more effective generation of nurses.

Read more stories by Robert Atkins.