Nurses needed: Public health nursing in Maine

Edith Soule/Maine Public Health Nurse

Taken from Maine Nursing: Interviews and History on Caring and Competence 

Maine’s first public health nurse (PHN) was Edith Soule. She is second from the right in the picture above. In 1920, Edith was named director of the newly created Division of Public Health Nursing and Child Hygiene. Two years later she asked Governor Percival Baxter for funding to hire more nurses who could travel throughout the state. In 1923, a second nurse was hired.

The primary role of the public health nurses was to improve the health of pregnant women and their babies and reduce the infant mortality rate. Over the years, the program grew and the number of nurses fluctuated, reaching as many as 100. In September 2017, there were only 10. Today, it’s estimated that there are about 16 public health nurses in Maine. Estimated, because no one I asked knew for sure.

Successes and challenges

In 1996, Dr. Anne Dora Mills arrived in Maine State Government to become director of the Maine Center for Disease Control and Prevention (Maine CDC), then known as the Maine Bureau of Health. At that time, she said there were 88 public health nurses serving across the state, a decline from a few months earlier when positions were cut because of a recession. “They were still a strong force who were focused on their original mission of addressing infant and maternal mortality and health issues,” she said, “but had also expanded to address many infectious diseases on the frontlines.”

These are some examples of the accomplishments of Maine’s Public Health Nursing Program:

  • They were our army for addressing any kind of outbreak. We would send them to an outbreak location and they would investigate the source (with direction from us in Augusta) and provide guidance.
  • They were instrumental in addressing a long tuberculosis outbreak in southern Maine.
  • They would conduct vaccine clinics, either in an outbreak or other situations when needed.
  • During the ice storm of 1998, they went door to door in the heaviest hit areas to make sure people were operating generators properly and were okay.
  • After 9/11, they were more fully trained in public health emergency preparedness, and were indeed on the frontlines of anthrax threats, vaccinating people against smallpox, etc.
  • They were some of the first responders to the arsenic poisoning in New Sweden in 2003.
  • During an outbreak of the H1Ni strain of influenza in 2009, public health nurses organized and participated in 238 immunization clinics around the state.

Keeping nurses in the program was a constant challenge. When a federal maternal child health block grant was cut (which happened repeatedly), PHN positions also went. When the state budget needed to cut a general fund position — to save money and/or use the position line for something else — PHNs were often the target.

“Their work was successful,” said Dr. Mills. “Infant and maternal mortality were low and we were not felt to be at risk for terrorism or a pandemic. So, I would be told, ‘We just need one or two of your PHN positions’. The problem is that it happened repeatedly, especially when we hit very hard state budget times, such as the 2008 recession. When I left in 2011, I believe there were only about 60 of them.”

The Public Health Program’s 2010 annual report, which marked its 90th anniversary, included robust productivity statistics for fiscal year 2010:

  • Saw 4,133 unduplicated clients
  • Provided a total of 21,581 hours of service
    • 10,382 hours for individuals
    • 4,503 hours for population-based services
    • 6,696 hours for non-visit case management

The annual report also pointed out that Maine’s Public Health Nursing Program had been granted full accreditation by meeting national standards of excellence as put forth by the Community Health Accreditation Program (CHAP), a nationally recognized accrediting body. “We were one of, if not the only one in the nation,” said the program’s former Director Jan Morrissette.

The following year, 2011, Governor Paul LePage took office. It soon became clear to Jan, who had headed the Maine Public Nursing Program for six years, that there would be little to no support for the program under the new administration. She decided to move on. Her position was filled, but other open positions were not.

Sarah DeCato worked under Jan during her four years as a public health nurse in Maine’s program. “What I love about public health nursing, in particular, is that it really focuses on health promotion and prevention.”

Sarah’s main focus was maternal and child health. She made multiple and repeated visits to expectant and new mothers throughout her assigned region. The service was open to any new mother in Maine, but most of her clients were in high-risk situations. “It could be a teen mom, somebody who had an opioid addiction. somebody with diabetes or hypertension who needed continued monitoring between doctor’s visits.”

Lindsay Luetje with her preemie twins

Lindsay Luetje was one new mother who did not fit that profile but still benefited greatly from Sarah’s visits after giving birth to premature twins five years ago. During their 18-day stay in neonatal intensive care, someone recommended that she sign up for visits from one of the state’s public health nurses. She didn’t think it would be necessary but changed her mind once they got home. Caring for the babies and not getting enough sleep was often overwhelming for Lindsay and her husband and the pediatrician also wanted them to have weekly checkups in the beginning. That’s when Sarah stepped in.

“Sarah was like this angel,” said Lindsay. “She was so kind and so resourceful. She was checking on them but she was checking on me as well and helping me with different strategies that are necessary to help a new mom, as well as the babies. She asked, how’s breastfeeding? Are you taking care of yourself? How’s sleep? Your stress levels?”

Checking on the well-being of the entire family, not just the patient, is one of the hallmarks of public health nursing and what distinguishes it from home health nurses. “When public health nurses go into the home, they are not only assessing the child’s and the mother’s well-being, they are assessing the well-being of everyone in the home,” explained Rebecca Boulos, Executive Director of Maine’s Public Health Association. “They are assessing if the heat is turned on or if there is food or if the home is safe. One of the most important things about public health nurses is that they’re trained to look at that entire environment, not just a checklist of indicators for a child’s well-being. If those needs aren’t being met, they would know what kind of resources are available in the community. It’s not just a one and done. They visit for many weeks. It’s a continuing relationship.”

Reaction to diminishing support

Sarah left Maine’s Public Health Program in 2014. She had two small children and her work — all the traveling she did to help Maine families — presented some challenges for her own. In late 2015, in a different job, she reached out to the Public Health Nursing Program to discuss collaborating on a project.

“Little did I know how much was changing within that system at that time and the minimal support that was in place for them,” she said. “I started to hear that things were happening at the state level in regards to dismantling the [public health nurse] workforce and making it a really difficult place to work. Positions weren’t being filled, nurses were being told they weren’t being productive, and work environments were becoming very micromanaged.”

“I think there’s a lot of micro-managing going on by people who don’t understand what public health nursing is at all,” echoed Jan. “It’s not a supportive environment and that’s an understatement.”

In the fall of 2016, recently elected State Senator Brownie Carson read a series of articles in the Bangor Daily News about what was happening with the public health program. “I learned about the intentional dismantling of Maine’s public health nursing program and it didn’t make sense to me,” he said. “The more I learned, the more I thought this was a serious mistake, not just because of the essential value of public health nurses, but because it was an inexpensive way to keep newborns or nearly newborn kids from having to go back to the hospital and  from having much more invasive care that separates them from their moms and can be very expensive. The more I looked at this the more I realized we needed to reverse this situation.”

As soon as he got to Augusta and was sworn in, he began working on LD 1108, an Act to Restore Public Health Nursing Services. “The goal,” said Senator Carson, “was to restore the nursing service from the low twenties back to the 59 that had been in the service when Jan Morrissette directed the program.”

At a public hearing before the Legislature’s Health and Human Services Committee in April 2017, 59 people testified. Fifty-eight spoke in favor of the bill.

Excerpts from some of the testimony:

The refusal of the DHHS/ CDC to fill the available PHN positions to properly implement services for our families affected by the opiate crisis and to, totally, silently withdraw services for other populations is beyond unfortunate. It is unethical and dangerous. Susan D. Mackey Andrews, member of the Maine Children’s Growth Council

Infant mortality rates are up … a lot. Drug affected births are up … a lot. Treatment-resistant tuberculosis is becoming more of a problem that could explode on us at any moment. The H1 N1 virus is a recent reminder that a major public health outbreak can always be right around the corner. The fact is we don’t know what we don’t know. We don t know what the next outbreak or public crisis is. The key to getting through it is to be prepared and presently, we are not prepared. Senator Roger Katz

The citizens of Maine expect their Public Health Department to identify contagious diseases and they expect to be protected. To provide this protection, Public Health Nurses are the vital link in protecting all of us when outbreaks occur and outbreaks will occur. Dr. Stephen Sears, former state epidemiologist.

If I had everything going for me and I needed this valuable help, can you IMAGINE what kind of impact Sarah’s (and her colleagues) work has on a family in much different circumstances? Lindsay Luetje.

One person spoke against the bill — Dr. Christopher Pezzullo, State Health Officer.

Due to concerns this bill would be costly and harm existing collaborative efforts, the Department of Health and Human Services is in opposition to this bill.

I reached out to Dr. Pezzullo for further explanation, but have not yet received a response.

A new law to restore public health nursing in Maine

Senator Carson’s bill passed by a wide margin in the Senate and a more modest one in the House. The Governor vetoed it on August 1st, as expected. “Late on August 2nd,” said Senator Carson, “just about 24-hours after the Governor vetoed it, the override vote was held in the House and I didn’t know what was going to happen. There were some very passionate floor speeches and we won that override 101 to 34. It’s a number I’ll remember forever.”

The new law mandated the Maine Department of Health and Human Services (DHHS) to fill not the 59 positions that were in the original bill, but 48 positions that were already funded and budgeted for the current fiscal budget. The deadline for filling the positions was March 1, 2018.

In February, DHHS Commissioner Ricker Hamilton indicated that nine positions had been filled. He also noted in a mandated report to legislators that Maine is experiencing a nursing crisis and that DHHS had partnered with the University of Maine System and the Maine Nursing Action Coalition to try and address the situation. He said that despite the crisis, his department continued to make progress in complying with the new law.

I reached out several times to DHHS asking for an interview with Ricker Hamilton. DHHS spokeswoman Emily Spencer responded earlier this week, asking for my questions. I have not yet received any answers.

In the meantime, it doesn’t appear that any job openings for public health nurses are even being listed on the DHHS website anymore. “There’s not only nothing listed for job openings,” said Senator Carson, “there’s nothing there, period, for public health nursing. There’s a phone number. If I were running DHHS or the CDC I would be busting my chops because of the value of public health nursing and it is very, very clear that they have not.”

What worries Rebecca Boulos most is the possible consequences of not rebuilding Maine’s public health program. “The clearest example of the downside of not having a strong public health infrastructure has thankfully, not happened yet,” she said, “which is a significant infectious disease outbreak. If that were to happen, the lack of a public health nursing system would be very, very apparent.”

“The people of Maine deserve better,” said Jan Morrissette. “I’m sad. I’m mournful. I’m very disappointed in this administration that they would do this. We have talented, dedicated nursing staff who want to be out there providing services and there’s obstruction to them being able to do that.”

If I get responses from Dr. Pezzullo and/or Ricker Hamilton or any other additional information, I will update this blog post.

Upcoming segments of Nurses Needed

The next segment of Nurses Needed runs Friday, May 11. In honor of nurses week, we’re going to show our nurses a little love. If you have a story you’d like to share about a Maine nurse, send it to me.

Monday, May 14, we’ll wrap things up with a look back at the history of nursing in Maine.

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Diane Atwood

About Diane Atwood

For more than 20 years, Diane was the health reporter on WCSH 6. Before that, a radiation therapist at Maine Medical Center and after, Manager of Marketing/PR at Mercy Hospital. She now hosts and produces the Catching Health podcast and writes the award-winning blog Catching Health with Diane Atwood.