Florence Nightingale Was an Epidemiologist Too

Whether you’re getting an annual checkup or being treated for an urgent condition, your first stop is almost always with a nurse. Nurses have long been the front lines of patient care. Increasingly, they are also taking on the mantle of prevention and public health.

“Nurses are at the epicenter of acute care and population health,” says Bobbie Berkowitz, Dean of Columbia University School of Nursing and professor of Health Policy and Management. For them, patient care today is seen in the larger context in which the physical and social environment determines health on a community level.

This alignment between public health and nursing is nothing new. Florence Nightingale was a member of the American Statistical Association and frequently used health data to understand how physical and social factors influence an individual’s health. Loretta Ford, founder of the first nurse practitioner program, worked to address healthcare access in underserved communities. And Lillian Wald, a 19th century nursing education pioneer, examined TB patients by asking about sanitation, nutrition, and housing conditions.

These days, Columbia’s School of Nursing, like many other nursing programs across the country, educates its students, not just in clinical skills, but also in disease prevention and health management. In particular, nurse practitioner programs are increasingly popular: since 2010, there has been a 92 percent uptick in the number of nationwide nurse practitioners, reaching a total of over 200,000 in the U.S. today.

Elaine Larson, Anna C. Maxell Associate Dean for Research at the School of Nursing and professor of Epidemiology, said her decision to pursue a public health PhD was a “no brainer.” Nursing’s emphasis on prevention has helped make healthcare more equitable, she says, particularly in rural areas and communities with underserved populations. “We have a moral obligation to solve problems as systematically as possible so that patient visits don’t have to recur over and over again.”

The context is a 2010 report by the National Academy of Sciences, Engineering, and Medicine: Health and Medicine Division called “The Future of Nursing” which urged greater responsibility in the face of escalated costs and a shortage of primary care physicians. Today, the Affordable Care Act authorizes up to $50 million for nurse practitioner-managed clinics. And 21 states and the District of Columbia allow full practice authority for nurses, freeing them to care for patients without physician oversight. But contrary to common misperceptions, nurses have no interest in replacing doctors.

“It’s about a continuum of care,” says Susan Michaels-Strasser, senior implementation director of ICAP and associate director of ICAP’s nursing programs. “Nurses, doctors, and public health professionals all need each other.”

That’s true outside of the U.S. too—especially in low-income countries where there are few physicians. According to the WHO, nurses and midwives provide 80 percent of healthcare services in almost all countries.

Michaels-Strasser, also an assistant professor of Epidemiology, has lived and worked in Africa for over 14 years and says that nurses there see many more patients than doctors, and often take a leadership role in the care of patients and communities with infectious diseases like HIV/AIDS and Ebola. Recalling her time as a young nurse at a rural mission hospital, Michaels-Strasser remembers the depth of services: a large community outreach program for vaccination and maternal health, an outpatient department, four in-patient wards, a maternity unit, and even a small surgical space.

“We had a lot of patients and about 20 nurses and aides," Michaels-Strasser said, “but for over a year, not one doctor.”

Those nurses need stronger policy and health system support too, like better backup systems so that nurses are not alone in the field, and legislation that enables nurses to legally prescribe essential medicines. The outcomes of those conversations could have a lasting impact. 

Such was the appeal for Kaitlin Erickson, a graduating MPH candidate in Population and Family Health, who is set to begin a three-year nurse practitioner program at Yale School of Nursing in the fall.

“My public health background, especially in terms of social justice, really allows me to consider more than just bedside manner,” says Erickson. “I’m excited to take the knowledge I learned here and apply it into a holistic model of patient care.”