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Chapter 1 Responses to Critical Thinking Activities
1. Experience with epidemics, developments in science, and changes in health priorities
helped to establish the field of public health. Discuss the key time periods that shaped
the development of public health systems and influenced public health nursing.
The nineteenth century brought significant changes that shaped modern public health efforts
in the United States. During this period of the sanitary era, social Darwinism was used to
explain the association of disease with “filth” and poor hygiene. At the same time, the Industrial
Revolution in Europe and the United States drew poor, rural populations to urban centers for jobs
in crowded cities. Factory workers living in cramped, unsanitary conditions suffered from high
rates of infant mortality, alcoholism, and disease. By the mid 1800s, however, the beliefs of the
sanitary era were being challenged by the newly emerging, morally neutral germ theory.
Also, in the 1800s, William Rathbone experimented with early district nursing and, through
consultation with Florence Nightingale, initiated this ultimate precursor to public health nursing.
Meanwhile, wealthy philanthropic “ladies” in the United States provided private support to a
variety of different services that brought sick care, supplies, and visiting nurse services into the
homes of the poor and suffering. Lillian Wald and Mary Brewster had wanted to be visiting
nurses and so moved to Manhattan’s Lower East Side in 1993 to provide home care to those
living in poverty.
As the Henry Street Settlement House was established by Wald and her colleagues, their
work took on social reforms in order to have a broader impact on improving the health of their
populations. Their efforts in community and in policy change were shaped and supported by
philanthropists and, ultimately, by the development of agreements with the American Red Cross
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and the Metropolitan Life Insurance Company. They advocated healthy policies reflective of the
period, including women’s suffrage and antiwar strategies, which put them increasingly at risk
with conservative political forces. Wald struggled with maintaining funding as a result of some
of the decisions she and other reformers chose to support. These risks worsened for subsequent
nursing reformers who suffered under the weight of McCarthyism, as population-level social and
health reforms were viewed as expressions of communism. By this time, the growth and
prominence of hospitals as the point of care also threatened the prominence of public health
nursing.
2. Compare the role of historical social reformers in the development of home nursing and
public health nursing. Analyze the influence of these historical social reformers on
current expectations and roles of public health nurses.
Lillian Wald began as a “visiting nurse” in the home, but she quickly perceived the broader
environmental influences that were shaping the health of those in her community. The
experiences that she and her colleagues had in the homes of the poor informed their
understanding of negative ecological forces. The role of the public health nurse was thus
established to address factors that impacted health at the population level. In addressing these
factors, they sought changes to national policy, helped to establish supportive structures in their
community, supported the right for women to vote, and advocated for comprehensive services to
women and children.
Public health nurses today are very proud of this early legacy of reform and advocacy.
Lillian Wald continues to be held up as a significant role model within the profession. Today
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public health nurses are expected to focus their attentions on health improvement at the
population level and to advocate for policy reforms and structures that will drive improved
health. At the same time, public health nurses often serve families in their homes and carry with
them the experiences of participating with struggling families burdened by poverty. As many
public health nurses today work in governmental settings, they often feel restricted from full
participation in the broader advocacy that shaped Wald’s activities. Nursing collectives, trade
associations, and other avenues exist (within and outside of their work settings), however, for
public health nurses to exercise their role in policy change and advocacy.
3. Numerous social factors influenced the development and formalization of public health
nursing into a broadly reform-minded, social justice–oriented form of nursing. Debate
the social and philosophical influences that shaped public health nursing practice in the
twentieth century and how and why public health nursing changed over time.
Public health nurses responded to the poverty and neglect of whole communities suffering
under the impact of the Industrial Revolution. As these public health nurses engaged with other
reformers of the time, they found new opportunities for themselves (as they were frequently from
the middle- and upper-class and had been previously constrained by the expectations of the
Victorian era). The chance to engage in reform-minded debate created an opportunity to form
new opinions regarding how to address health in social context.
Over time, public health nursing has been shaped by feminism, first by the role of nurses in
pushing for suffrage and later by the nursing profession’s apparent disengagement from the
feminist movement of the middle and latter part of the twentieth century. Perhaps due to the cost
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of the risks that public health nurses had taken during the McCarthy era and other repressive
periods, nurses perceived feminism as being too contentious and held back from this and other
controversial social reforms.
Public health nursing was also influenced over time by the transition of their services from a
privately sponsored, independent practice to that of a largely government-supported endeavor in
which they had much less control over their activities. They also became progressively
dependent upon and involved with an increasingly influential biomedically focused and hospitalbased system of health care delivery. This focus on hospital care and medical technology as well
as a corresponding decline in acute infectious disease lessened the visible impact and prestige of
public health nursing both to the public as well as in the broader nursing profession.
4. Analyze the influence of political barriers to advocacy and public health improvement
that public health nurses encountered in their efforts to improve social conditions that
impacted health in their communities.
Wald and her colleagues viewed health broadly and perceived policies and social norms that
negatively impacted the health of their populations as within their purview for change. This took
them into advocacy work in support of the rights of women and minorities and against war and
oppression. While they engaged prominent, wealthy supporters as well as broad communitylevel support in their efforts, their actions brought them into conflict with powerful forces
determined to maintain the status quo.
Political barriers existed for early public health nurses in terms of initially not even being
allowed their right to vote. As this battle was one, they encouraged new voters from within their
communities to support health policies. New political barriers were then raised when, for
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example, they passed the Sheppard-Towner Act in favor of funds for maternal and infant health
care, only to have the act not renewed when it was seen as being associated with communism.
Ultimately, political conservatism and then the McCarthy era put great pressure on public health
nurse reformers to limit their activities as they risked the loss of financial and public support in
their efforts toward health reform.
5. Efforts in nursing professionalization played a significant role in the relationship between
public health nurses and the broader nursing profession. What impact did this have on
the development of public health nursing?
The progression of nursing from an informal provision of “nursing” care by female family
members and religious orders, to nurses trained in women’s schools, and then hospitals and
universities, created a variety of avenues in which people entered nursing and, to this day,
influences nursing education. In the early twentieth century, public health nurses were among
the elite of the nursing profession, in part because they were among the best trained and had
more often attended “prestigious” schools of nursing. As nursing schools proliferated and
hospital settings became more popular for nurses and the public, debates over training
requirements also flourished.
Discussions within the nursing profession about training and practice were integral to debates
over and differences related to race and class. The debates carried on in organizations such as
the American Nurses Association, the National Association of Colored Graduate Nurses, and the
National Organization of Public Health Nurses where the notion of professionalization was
diversely perceived as exclusionary, elitist, legitimizing, critical to maintaining a visible role in
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reform, and a mechanism for formalizing nursing independence. These discussions still, at
times, divide the nursing profession today and partly explain issues such as the array of levels of
nursing education and disagreements over unionization among nurses. As modern discussions
and historical analyses lead nurses to a resolution over some of these issues, however, more
attention can be and is paid to providing a collective and respected nursing voice to the
promotion of healthy public policies and reforms.
6. Public health nurses today assume the legacy of early public health nursing reformers,
still encountering some of the same system barriers, but still defining the public health
nursing role in terms of improving the health of whole populations. Debate the
similarities between public health nurses of today and those in history.
Early public health nurses faced serious functional constraints in terms of their early lack of
access to voting, fewer opportunities for advanced education, Victorian era beliefs about a
woman’s role, little to no technological capacity for widespread communication, and even deeper
divisions between racial and ethnic groups than we have today. Today’s public health nurse has
constraints such as strong ties with government that can limit some forms of advocacy, a system
for improving health that is predominately focused on hospital-based sick care, funding streams
that are more likely to support activities focused on the individual, and a weak voice within the
nursing profession.
Public health nurses of today, however, have a variety of resources at their disposal for
carrying on the legacy of social reform that was laid down by their foremothers. They have,
among other things, the opportunity for full participation in the American political system, they
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have wide educational opportunities that are ostensibly open to all racial and ethnic minorities
and to women, and they have the ability to mobilize nurses and other partners around the world
through major advancements in communication and travel. In addition to these resources, the
strong ties that public health nurses have with government today also provides an avenue for
advancing and informing policy from within governmental systems in which they have a more
powerful potential for influence.