Contributor – Ashley Booth

The nursing field has a deep history in the community. Called healers or caregivers, for centuries nurses were the holistic practitioners that we know from oral tradition and experience would cure, treat, and care for people (Ehrenreich, Egenes). But as institutions such as alms houses and hospitals became more popular, nursing practice became more centralized to these buildings to better isolate diseases from the general public and to provide focused care (Glasper, Upenn, Edgecombe).

Along the way, nursing pioneers such as Florence Nightingale began to standardize nursing education. She championed sanitation and infection control initially in the hospital setting, but recognized the importance of improvements in every setting of care delivery — in medical wards and infirmaries in places such as workhouses (Turkowski, Monteiro). She even helped design coursework to train nursing students on sanitation, health education and water quality (Edgecombe, Monteiro), and these community-focused nurses eventually became known as district nurses in the UK. For centuries, we have known that acute care and community health are important, dual pathways in nursing. Yet the pipeline into a community nursing career is unclear.

Early on in nursing school I found myself drawn to community-based care and actively sought it out. I worked as a community outreach program intern hosting a community senior health fair. I trained to be a lung ambassador to educate kids in the community about respiratory health. During my public health clinical rotation, I performed home visits and healthy eating demonstrations through one of the local catholic charity organizations. This felt like nursing because it matched what I was coming to understand as essential to nursing practice: seeing the whole person and recognizing the biopsychosocial factors that influence their health.

To me, community and public health nursing are fundamental to caring for any individual. This branch of nursing readily integrates modern ideas such as the social determinants of health and upstream models of care, like the Butterfield Upstream Model for Population Health (BUMP Health), and Critical Caring (Falk Rafael). While concepts such as health promotion, prevention, and the interplay of politics and social justice are often introduced in the classroom, they become far more tangible in real-world community settings. Unfortunately, there are limited opportunities for hands-on clinical experiences that bridge these concepts with actual practice. Nursing models like BUMP Health that help explain the importance of these experiences in addressing health inequity and how public health nurses can affect health outcomes early on a systems level in the community (Butterfield). In contrast, my acute care clinical experiences often brought me face-to-face with the consequences of health inequities at their most severe. As a nursing student, I found it challenging to balance the demands of clinical tasks with the need to understand the broader environmental factors affecting my patients’ health.

This felt like nursing because it aligned with what I was coming to understand as essential to nursing practice: seeing the whole person and recognizing the biopsychosocial factors that influence their health.

As much as I saw this as a path forward for my nursing career was in the community, the way to start became less clear. I noticed there were minimal new graduate opportunities to work in the community. Most entry-level community nursing positions required hospital experience, and the few new graduate residencies in the community space were very competitive.

I was determined however and started my first clinical role as a primary care nurse at a community health center. I was not using the tactile inpatient nursing skills I learned in school—I was connecting patients and families to community resources while navigating the relationships between the individual, their culture, health literacy, family, socioeconomic restraints, and policy. My community health nursing practice reflected Szanton and Gill’s nursing theory, Facilitating Resilience using a Society to Cells framework, which illustrates how to approach resilience in and resistance to health challenges by taking a holistic view of six different domains or “factors”: cellular, physiological, individual, family, community and society (Szanton). Many of the barriers to care for my patients included transportation, cost, and family obligations; they were difficult and necessary to address while also providing health education, prevention care and screenings.

These encounters were often very personal and required skills in relationship building and reflexivity in clinical decision making. Not every person is ready to discuss all aspects of their health at one time. Often their understanding of medications and disease progression took time. It was in this setting, in the community, that I saw how much partnership and flexibility is needed to care for someone and how important it was to establishing rapport by help in other aspects of the community – a principle emphasized in Critical Caring theory for public health nursing (Falk-Rafael, Adeline R., & Betker). I was involved in neighborhood events, health fairs, vaccination clinics and advocating for policy at the local level to improve equity and access. This was necessary to understanding how to approach, find resources, and provide care for the local community.

We must build up the pipeline into community nursing

As health inequities persist and the burden of chronic disease increases, there is an urgent need to expand community nursing education and strengthen the workforce in care coordination and case management (Flaubert, Zeydani, Kulbok, Butterfield). Addressing today’s complex health challenges requires nurses who are trained in in social determinants of health, population health and competency-based practice—skills that match the AACN domains for nursing and concepts for nursing practice (Flaubert, Lewis).

Florence Nightingale encouraged nurses to translate their acute care skills to the community (Monteiro), and pioneers like Lillian Wald and Mary Brewster demonstrated how nurses could lead community-based care through initiatives like the Henry Street Visiting Nurse Service, working with community activists to deliver care from clinics to homes (Fee, Buhler-Wilkerson). Theoretical frameworks like Society to Cells and The Critical Caring theory offer a valuable structure for teaching and clinical rotations to navigate the complex realities of community health nursing and prepare for practice that understands the importance of the nurse-client relationship and that truly meets patients where they are.
Although public health nursing formally emerged in the late 19th century, today’s entry-level nursing opportunities and career plan are few or minimal exemplars.

At my first nursing job fair, nearly all the positions were hospital placements. But when reflecting on nursing history, it’s clear that the nursing profession started in the community. Even in its more modern-day renaissance with Florence Nightingale, nurse training and education took place concurrently in the hospital and the community, and included new nurses alongside nursing students. Expanding community-based pathways would not only strengthen the nursing workforce but also support long-term career growth and improve nursing retention (Nashwan). While I fully recognize the essential role of hospital-based nursing, I encourage institutions to offer more community-focused training and career opportunities—especially as our population ages and demand for care outside the hospital grows.

Works Cited/References

1. Buhler-Wilkerson, K. (1993). Bringing care to the people: Lillian Wald’s legacy to public health nursing. American Journal of Public Health, 83(12), 1778-1786.

2. Butterfield P. G. (2017). Thinking Upstream: A 25-Year Retrospective and Conceptual Model Aimed at Reducing Health Inequities. ANS. Advances in nursing science, 40(1), 2–11. https://doi.org/10.1097/ANS.0000000000000161

3. Edgecombe, Gay. “Public Health Nursing: Past and Future, A Review of Literature.” World Health Organization, WHO Regional Office for Europe, 2001, iris.who.int/bitstream/handle/10665/108460/E74237.pdf;jsessionid=11CC1636C6C0677BD158B5FBF086C950?sequence=1

4. Egenes, K. J. (2017). History of nursing. Issues and trends in nursing. 2nd ed. Burlington, MA (USA): Jones & Bartlett Learning, 3-28.

5. Ehrenreich, B., & English, D. (2010). Witches, midwives, & nurses: A history of women healers. The Feminist Press at CUNY.

6. Falk Rafael, Adeline R. RN, PhD. The Politics of Health Promotion: Influences on Public Health Promoting Nursing Practice in Ontario, Canada from Nightingale to the Nineties. Advances in Nursing Science 22(1):p 23-39, September 1999.

7. Falk-Rafael, Adeline R., & Betker, Claire. (2012). The primacy of relationships: a study of public health nursing practice from a critical caring perspective. ANS. Advances in Nursing Science, 35(4), 315–332. https://doi.org/10.1097/ANS.0b013e318271d127

8. Fee, E., & Bu, L. (2010). The origins of public health nursing: the Henry Street Visiting Nurse Service. American journal of public health, 100(7), 1206–1207. https://doi.org/10.2105/AJPH.2009.186049

9. Flaubert, J. L., Le Menestrel, S., Williams, D. R., Wakefield, M. K., & National Academies of Sciences, Engineering, and Medicine. (2021). The Role of Nurses in Improving Health Care Access and Quality. In The Future of Nursing 2020-2030: Charting a Path to Achieve Health Equity. National Academies Press (US).

10. Glasper, A. (2020). How Nightingale’s concept for a school of nursing changed global nurse education. British Journal of Nursing, 29(15), 904-905.

11. Kulbok, P. A., Thatcher, E., Park, E., & Meszaros, P. (2012). Evolving public health nursing roles: focus on community participatory health promotion and prevention. Online journal of issues in nursing, 17(2), 1.

12. Lewis, L. S., Rebeschi, L. M., & Hunt, E. (2022). Nursing education practice update 2022: competency-based education in nursing. SAGE Open Nursing, 8, 23779608221140774.

13. Monteiro L. A. (1985). Florence Nightingale on public health nursing. American journal of public health, 75(2), 181–186. https://doi.org/10.2105/ajph.75.2.181

14. Nashwan A. J. (2023). The Vital Role of Career Pathways in Nursing: A Key to Growth and Retention. Cureus, 15(5), e38834. https://doi.org/10.7759/cureus.38834

15. Szanton, S. L., & Gill, J. M. (2010). Facilitating resilience using a society-to-cells framework: a theory of nursing essentials applied to research and practice. Advances in Nursing Science, 33(4), 329-343.

16. Turkowski, Y., & Turkowski, V. (2024). Florence Nightingale (1820-1910): The Founder of Modern Nursing. Cureus, 16(8), e66192. https://doi.org/10.7759/cureus.66192

17. University of Pennsylvania: School of Nursing (n.d.). What is a Public Health Nurse?. https://www.nursing.upenn.edu/nhhc/home-care/what-is-a-public-health-nurse/

18. Zeydani, A., Atashzadeh-Shoorideh, F., Hosseini, M., & Zohari-Anboohi, S. (2023). Community-based nursing: a concept analysis with Walker and Avant’s approach. BMC Medical Education, 23(1), 762.

About Ashley Booth

Ashley Booth is an alumnus of Johns Hopkins School of Nursing. After graduating, she began her clinical career as a community health nurse. More recently, her work has involved supporting action and ethnographic research using human-centered design and co-design with communities in the Baltimore area. These experiences have deepened her commitment to community and public health nursing, which she looks forward to exploring further as she begins her PhD studies this Fall.