Submitted by Cody J Sliger, MSN, APRN, FNP-C
Texas Tech University DNP Student
As a Family Nurse Practitioner (FNP) in a Federally Qualified Health Center (FQHC), I frequently encounter complex medical needs and complex psychosocial needs. I utilize primary care, advanced practice nursing competencies that I have already learned to take care of my patients. Yet as I gain experience in my practice, I reflect and think to myself, “what about the changing environment of healthcare? What about the changing environment of the legislature?” In turn, this question has led me to the emerging role of the Doctor of Nursing Practice (DNP) in Population Health.
During my MSN program, I remember briefly learning about population health and public health. I began to think about life outside of the hospital, which led me to discover more about public health. When I think of public health, I think about the local health departments, birth control pamphlets, and reportable diseases, not an emerging aspect of my future practice as a DNP-prepared FNP. So how can the DNP in acute and primary care contribute to emerging public health practices in an FQHC setting?
Health disparities are still being observed despite ongoing federal, state, and local government efforts. In 2017, the CDC published an article that discussed three versions of public health, beginning in the 19th century. Public Health 1.0 began as an observed period of growth of epidemiologic sciences and was considered an essential federal service. Public Health 2.0 started in the middle of the 20th century to expand across the USA, emphasizing specific targets but was still limited to government agencies and related organizations. Finally, public Health 3.0 is currently evolving, and it stems from communities working to improve and treat social determinants of health. To do so, the authors recommend working directly with community stakeholders to implement public health policies “upstream.”
Working in an FQHC, I have never considered my involvement in these upstream health initiatives to improve the population's health. Zaccagnini and Pechaceck (2021) assert that an FNP in an FQHC can use developing and emerging skills to be “better equipped to articulate strategic population health positions effectively with non-nursing professionals.” In other words, utilizing population health metrics and practice insights, I can work with other stakeholders such as FQHC stakeholders, administrators, and support staff to promote and engage in interventions to improve the community's health. This is especially important when those patients have more than one medical condition. I take care of patients with multiple chronic conditions (MCCs) while utilizing quality evidence-based practice to provide the highest quality care cost-effective to a group of patients that would otherwise potentially be marginalized or considered a lower priority (Kuebler, 2017).
Interprofessional collaboration is a first step toward upstream intervention, but it is not sufficient on its own; community partnerships and advocacy are crucial for the translation of evidence into practice and improved outcomes. Rosin et al. (2017) describe how DNP students have helped refugees in the United States with evidence-based practice and transcultural nursing theory to better understand their patients' perspectives by utilizing interpreters and “the 4 C's” of assessment (what do you call the problem, what causes the problem, how are you coping, and what are your concerns?). Gaining insights into individual social needs is crucial, but a comprehensive, participatory community assessment is the foundation of upstream intervention.
So when discussing DNP and public health, another question that I asked as I investigated public health was, “do I work in public health?” While public health itself is not a physical practice location, family practice isn't exactly the first location that comes to mind. According to the American Public Health Association Public Health Nursing Section (2013), “Primary care and public health share a focus on prevention, population health, transitional care, and care coordination across settings to promote health through collaboration.” Viewing my practice through this lens has helped me realize that the DNP-trained FNP is poised to serve to improve the public's health and position to provide care for the individual, the family of the individual, and the community. Note from CPHNO: These reflections convey the important role that advanced practice nurses play in promoting public health and advancing health equity. Exactly one year ago, CPHNO member organizations published an open letter to the authors of the Future of Nursing: Campaign for Action’s Building Coalitions to Promote Health Equity toolkit, reinforcing the value of the public health nursing lens centering on social justice.