Public Health

Public Health Nurse Training

District nursing or visiting nursing existed in many cities and towns throughout the United States around 1900. Most early visiting nurse services received funding from either private donations or a mixture of private donations and public funds. As the popularity of this nursing role grew, the responsibilities placed on the trained nurse increased to include maternal child health, communicable diseases (especially tuberculosis), school health, chronic disease care and care of the elderly. Nurses cared for families in their homes which included preventive and sick care covering a wide variety of conditions. Therefore, their knowledge had to be broad based in order to meet the challenges they faced.1

As early as 1881, Florence Nightingale described the higher level of training expected in the district nurse,

... a district nurse must nurse. She must be of a yet higher class, and of a yet fuller training than a hospital nurse, because she has not the doctor always at hand, because she has no hospital appliances at hand, and because she has to take notes of the case for the doctor, who has no one but her to report to him.2

Nightingale astutely emphasized the autonomous nature of the public health nurse’s scope of practice. The increased autonomy of public health nursing practiced required a corresponding increase in the level of theoretical training and fieldwork required for competency in public health work.

In the early part of the twentieth century American nurses had three options for specialized training in public health nursing: elective coursework and fieldwork in the third year of a hospital training program, a post-graduate apprenticeship with a visiting nursing association, or post-graduate training in a university program. Each type of training program for public health nursing agreed that a balance of theoretical training and fieldwork were essential for the proper training of a public health nurse. In 1906, the Boston Instructive District Nursing Association offered a four month intensive course of public health work with district nurses under close supervision and daily debriefing with the superintendent of nursing supplemented by lectures. The post-graduate student received no salary only room, board, and car fare. In 1910, Teachers College at Columbia University established the first college public health nursing course supplemented by two months of practical work at the Henry Street Settlement. Settlement houses such as New York’s Henry Street and Chicago’s Hull House District accepted a select group of students for fieldwork prior to or after didactic training. University programs lasted eight months to one year and included courses in biology, applied bacteriology, social work, preventive medicine, sanitation, household economics, modern social problems, and public health legislation combined with two to three months of fieldwork.3

In 1912, a founding mission of the National Organization of Public Health Nursing (NOPHN) was the standardization of the training and practice for the public health nurse. The NOPHN described the requirements for preparation as a public health nurse: age twenty-five years, graduate registered nurse of a hospital training school of no less than 50 beds and two years of training including obstetrics, and training in visiting nurse work. The NOPHN endorsed schools of nursing that embodied the scope and standards established by the organization. By 1921 twenty-four universities, including Columbia, Ohio State, Johns Hopkins, Western Reserve University, and Simmons College, offered courses in public health nursing twenty of which were endorsed by the NOPHN.

Early visiting nursing associations (VNAs) accepted all three of the early forms of training available to public health nurses including post-graduate work, apprenticeship, and public health electives during registered nurse training programs. As state health departments began to hire more nurses the qualifications and standards of care increased. Many health departments found it difficult to find nurses with the requisite public health training.4

The state of Mississippi received funding for more public health nurses from the National Tuberculosis society and the American Red Cross. In 1920, the American Red Cross funded a position for a public health nurse to join the Mississippi Board of Health and oversee all public health nursing activities. In 1924, Mississippi absorbed full responsibility for funding public health nursing programs. Mary D. Osborne became Director of Public Health nursing for the Mississippi State Board of Health in 1921. Osborne planned to recruit and train Mississippi women as public health nurses and midwives. Osborne used grant money from the Sheppard-Towner Act to train nurse in maternal and child health, and communicable diseases. Osborne established a three month orientation for nurses new to public health.5

Despite these funds, public health nursing practice faced many barriers in the South. There were few training schools for public health nursing in the Southern states in the 1920s and 1930s. Interested nurses with means enrolled in public health post-graduate public health training programs in the North. However, many nurses could not afford northern post-graduate training programs, so many southern nurses in the 1930s trained by apprenticeship and on the job to become public health nurses. In order to overcome barriers to hiring qualified public health nurses, apprenticeship programs became necessary in the South. Some visiting nursing associations provided room and board to novice nurses during public health training. Nurses who did receive scholarships to train in public health attended Vanderbilt University, Teachers College, or Western Reserve.6

There were even fewer opportunities for Black nurses in the South to obtain public health training. In 1929, the Rosenwald Fund and the Rockefeller Foundation provided funds to establish jobs and training opportunities for Black public health nurses. Public health nurses, in turn, provided training programs for Black granny (lay) midwives in Mississippi. After completed public health training Mississippi midwives were issued a license to practice midwifery.7 Thus, some limited opportunities existed for Black women to advance their standard of practice through education, both professional nurses and local lay midwives.

In the 1930s, despite public health training opportunities, Mississippi continued to have difficulty staffing all counties with qualified public health nurses. Caroline Benoist, who trained at Johns Hopkins and apprenticed at the Chicago Lying in Hospital, became a valued asset in training other public health nurses within Mississippi Public Health departments.8

Sarah Craig, MSN, RN
University of Virginia Center for Nursing Historical Inquiry

• 1. Karen Buhler-Wilkerson. No Place Like Home: A History of Nursing and Home Care in the United States. (Baltimore, MD: John Hopkins University Press, 2001.)
• 2. Florence Nightingale. On Trained Nurses for the Sick Poor. (London, England: Spottiswoode & Co., 1881.) [Quote reprinted in Annie M. Brainard. The Evolution of Public Health Nursing. (New York, NY: Garland Pub, 1922, p. 127.)]
• 3. Annie M. Brainard. The Evolution of Public Health Nursing. (New York, NY: Garland Pub, 1922.).
• 4. Ibid.
• 5. Ibid.
• 6. Ibid.
• 7. Mississippi State Department of Health. Public Health Nursing 1920-1949. Available at: http://msdh.ms.gov/msdhsite/_static/4,10786,204,564.html
• 8. Caroline Benoist Papers. Center for Nursing Historical Inquiry. University of Virginia School of Nursing.