1950-1959: The Growth and Transition of Public Health Nursing
The 1950's began with great prosperity and many social and economic changes nationally and within the state. Mississippi was experiencing population migration both out of state, which had begun during the war years, and of migration of farm populations to towns and cities within the state. The mechanical cotton picker had arrived as well as a whole array of sophisticated machinery. Small farms disappeared; even larger farm operations expanded. A well educated farm manager, a few skilled machine operators, and an airplane pilot could produce better and more cotton than 140 field hands, according to McLemore's History of Mississippi. A great industrial expansion spurred by the agricultural revolution in the 50's provided jobs and opportunities throughout the state.
Federal funding had been made available through the Hospital and Reconstruction Act in 1946, also known as the Hill-Burton Act, for construction of health care facilities. The Mississippi Board of Health accessed these funds to build county health departments and branch clinics. Newly constructed facilities would improve both the access and the quality of care being rendered by public health nurses throughout the state. Still, a few counties had no organized county health departments.
While more active professional nurses and more students in schools existed by the early 1950's than any previous time, the increase in numbers and caliber of nurses had not kept pace with the need for service. A 1952 report on the status of nursing in Mississippi compared one active registered nurse per 634 persons in the nation to one active registered nurse per 1,629 persons in the state, a nurse- to-population ratio of less than one-half the national average. The national ratio was not considered ideal according to the report and confirmed the serious situation in the state for nursing personnel. The inadequate number of schools and the lack of a baccalaureate school of nursing within the state were factors that needed attention.
Each decade seemed to bring ever more and new challenges to public health nursing. Louise Holmes, having assumed the role as Director of Public Health Nursing, was faced with recruitment and placement of qualified nurses throughout the state. Holmes reported on the critical nature of the early 1950's in a 1955 position paper, "Review of Changes, Problems, and Needs of Public Health Nursing." Though few more total nursing positions existed, the turnover of nursing personnel along with the increased demand for nursing services was a major problem for delivery of care and services, she reported. The war emergency nurse classification was discontinued. Some nurses returned from military duty, and a few returning servicemen brought back wives who were nurses, several who were eager to do public health nursing. Orientation centers had been discontinued by this time as nurses could no longer leave their homes and families for extended periods. The orientation process was restructured. The orientation manual was revised with the Field Advisory Nurses and the senior staff nurses assuming the responsibility of orienting new nurses.
Education for public health nurses continued to be a priority as well to ensure competency of all public health nurses. Early on, Holmes was able to send eleven nurses for a short course in the care of the premature infant and two nurses for courses in supervision of public health nursing. Seven carefully selected nurses received scholarship assistance to attend Peabody College and Vanderbilt University for public health nursing study. Nine nurses took the National League for Nursing Achievement test which qualified them to meet Merit System Classification of Public Health Nurse I. Other nurses attended conferences on venereal disease nursing, obstetrical nursing, child health nursing, group leadership, and mental health.
In 1950, the Crippled Children's Service began to broaden its scope of services to include heart disease. This included a whole range of cardiac treatment from the correction of congenital heart defects to long term prophylactic treatment of rheumatic heart disease. Public health nurses responded to these services as many children were in need of this specialized service. At times, these children needed immediate referral to a hospital in Memphis, Jackson, or Mobile. More often mobile screening and follow-up clinics, established in the late 1940's and held quarterly in strategic locations of the state, were the referral source for the nurse. In preparation for the heart consultation, the public health nurse did preliminary testing which included a chest x-ray, blood work, and a cardiogram.
The regional clinics continued through the 1970's, being discontinued in the early 1980's when a reconstructing of Title V of the Social Security Act (PL-77-35) grants expanded and improved access to care for infants and children.
Disaster did strike Mississippi again in the early 1950's. The most virulent and widespread polio epidemic hit the state between 1951-1952 with about 1,450 cases diagnosed in the two-year period. Pregnant women were more vulnerable and the bulbar type more prevalent than ever.
One pregnant public health nurse was stricken. After delivering a healthy full-term baby, she fortunately recovered and she later successfully returned to public health nursing though residual disabilities were evident. These devastating outbreaks of crippling disease intensified the follow-up and rehabilitation services provided by local public health nurses and by the quarterly mobile Regional Crippled Children's Clinics that had previously been established. These were great days for the families, patients, and public health nurses who received guidance and support from specialized nurses, physical therapists, brace technicians, and physicians who manned these clinics. Women's clubs usually assisted with registration and snacks for children. Public health nurses never missed a chance to promote good nutrition and to involve civic and community organizations.
Due to the severity of the polio epidemic in Sunflower County as reported by the Biennial Report of the State Board of Health, 1951-1953, the Centers for Disease Control arranged for six nurses to receive epidemiology training.
By 1955, the injectable Salk polio vaccine became available, and mass immunization efforts began to reduce this dreaded disease. Disposable syringes and needles were not yet available; so needles and syringes had to be sterilized for reuse. Nurses carried the large Brown Bag and its paraphernalia to each immunization site, providing her means to complete her mission. Gratefully, another predicted epidemic did not occur. Salk vaccine and Herculean efforts to reach every child paid off!
Tuberculosis remained a major health threat during this period. By the early 1950's, streptomycin, para-aminosalicylic acid, and isoniazid provided effective treatment. Active tuberculosis cases, often sent away from home to the Sanatorium, could now be treated at home under the care of public health nurses. Mobile x-ray units had been activated in the late 1940's to improve diagnostic services and access to care. Public health nurses were vital to the tuberculosis control efforts in their communities by determining contacts to cases of tuberculosis and coordinating diagnostic tests for contacts and cases. Due to limited medical coverage, treatment plans were established for the public health nurse and patient through medical case conferences. Public health nurses sought community resources such as Sunday School classes, the Tuberculosis Association, and civic organizations to provide financial assistance to patients in need of medications and other medical care. Often times, with no other resources available, public health nurses used personal funds to assist in accessing needed care for tuberculosis patients. Vital statistics reported that tuberculosis was no longer one of the top ten leading causes of death in Mississippi in 1957. The mission to improve morbidity and mortality was being met.
The infant mortality rate declined from 54.5 in 1940 to 36.4 in 1950. Significant contributions in lowering the mortality rates included the increased availability of local hospitals resulting in more physician-attended deliveries and the Emergency Maternity and Infant Care Program initiated in the early 40's. While great strides had been made in lowering maternal and infant mortality, public health recognized the need to continue intensified efforts to provide prenatal care and to supervise the midwives. Statistics identified greater declines in mortality for white births than black births.
In 1955, some 1,614 midwives continued to practice, attending thirty percent of the births in the state. Improved access to medical care, transportation, education, and standards of living supported the discontinued need for midwife services. The Midwife Program had always been one of supervision rather than promotion. Public health nurses continued to hold monthly educational meetings with the midwives, who frequently assisted the public health nurses in clinic activities, home visits, and in the provision of care to mothers and babies. In addition, public health nurses participated in the annual county midwife meeting, a grand event and celebration where the annual permits to practice were issued.
The major syphilis case-finding project initiated through public health nursing services in the late 1940's identified congenital syphilis as a major contributor to the high incidence of infant morbidity and mortality. In 1950, the Children's Bureau and the U.S.P.H.S. in conjunction with the Mississippi Board of Health conducted a one-year congenital syphilis research study in Washington and Sunflower counties, chosen because of the high syphilis case rates in the locations.
This study proved that if a mother received adequate treatment during pregnancy, even as late as the third trimester, the outcome was a healthy baby. The Mississippi Board of Health and its public health nursing staff attracted national attention for this study. The U.S.P.H.S. utilized Mississippi as a nine-week field training program to educate nurses in the field of epidemiology and venereal disease treatment and control during this research period.
Not until 1954 could Mississippi claim an established county health department in all eighty-two counties with at least one full-time public health nurse serving each county. Accomplishment of this vision had been a long time in the making and now all citizens found greater opportunity for improved health care.
The acute nursing shortage in the state was finally being addressed by the mid 50's, as well as a focus on the availability of higher education for nursing. In 1948, organized nursing had pushed for passage of legislation to appropriate funding for the establishment of a Department of Nursing at the University of Mississippi in Oxford. The baccalaureate program accepted students in 1949 and would be the first nursing program in the state to provide basic concepts of public health nursing. The School of Nursing was relocated to the University of Mississippi Medical Center campus in 1956. Other baccalaureate programs followed, allowing for the preparation of public health nursing at the level recommended by the National League For Nursing.
Another significant event occurred on April 11-12, 1957, when the Mississippi League For Nursing and the Mississippi Association of Student Nurses sponsored a two-day conference on "The Role of the Junior Colleges in Nursing Education." Dr. Mildred Montage from Teacher's College, Columbia University, the guest speaker, provided overviews for the establishment of nursing schools within the statewide community college network. Presidents from every junior college in Mississippi and many hospital administrators attended the conference. Shortly thereafter, the first community college program for nursing opened at Northeast Junior College in Booneville. The impact of these nursing education programs through the 1950's marked a water-shed effect on nursing education, nursing practice, and the availability of nursing personnel (Keyes, 1984).
By the mid 1950's, 223 public health nursing positions were budgeted. The increased number of nursing positions also raised the issue of adequate nursing supervision for staff nurses to assure quality and efficient services.
Holmes cited staff development as an essential component of assuring quality public health nursing services. Edna Roberts, Field Advisory Nurse in the northern part of the state during this time, proposed in 1948 that regular in-service education be implemented. This proposal was well received and by the 1950's in-service education was well established, consisting of eleven two-hour monthly district meetings over the state within each year. The average attendance per nurse was eight sessions per year, equating to two working days per year. The Field Advisory Nurses carried out these educational programs with assistance from selected resources. These efforts strengthened and facilitated the expansion of all public health programs.
These educational opportunities proved effective and strengthened the nursing abilities of both new and veteran nurses.
Pauline O'Keefe, R.N., accepted a staff public health nursing position in Coahoma County in 1958 following several years of experience in military and private duty nursing. O'Keefe related the uniqueness of public health nursing interventions to meet public health goals in an oral account as follows:
"Coahoma County was large with eight public health nurses, each assigned districts within the county to hold clinics, to home visit, and to develop community relationships. Roundaway was a rural farming community and consisted largely of poor farm laborers. Clotee Hill was the community midwife, who had practiced in the area since the 1930's. She knew most everyone in the community and was a leader within the county midwife group. Hill assisted at the weekly clinic at Roundaway and often home visited with me as she was first to know who was expecting, who had delivered, and who in the community was ill. Hill convinced a young woman named Freddie to come to the weekly clinic. Freddie, in her early 20's, was in her fourth pregnancy and her three children were less than school age. Her medical history revealed she had been born with congenital syphilis and received treatment at a rapid treatment center in the 1940's. Complicating physical and social factors from the congenital syphilis were evident, however. Hill had already discussed family planning with the patient, who then asked me how to help her not to have anymore babies.
"I made arrangements with a local obstetrician to evaluate her and he agreed to a hospital delivery and to perform a tubal ligation at no charge to the patient. All of the doctors in the community helped when indigent care was needed. Hill assisted the patient in getting to the hospital at the onset of labor. About 10 the morning of the delivery, the physician called me and told me he had delivered a healthy baby but he could not tie her tubes as she was not married. I asked the doctor to give me four hours to see what I could do. I made a fast trip to Roundaway and picked up the patient's sister, who led me to the patient's common law husband who was on a tractor in a cotton field in Tutwiler. I explained the situation to him and he readily agreed for me to take him to the courthouse to apply for a marriage license. There was no three day waiting period then. The three of us got to the hospital after lunch that day. A notary public in the hospital signed the marriage license.
"I left the hospital and came to my home to get a white gown and robe for Freddie to get married in. Headed back to the hospital, I went by Yazoo Street to get a local minister who often helped me with my nursing service in his community. He agreed to accompany me to the hospital to perform the marriage. Before the ceremony began, I called the doctor to advise him to post the surgery for the next morning. The hospital nurses helped to arrange a waiting room for the ceremony and agreed to serve as witnesses.
"Freddie had a tubal and, with no other means to get home, I carried her and the baby home two or three days later. I had contacted the local Welfare Department to assist the family with basic food and clothing needs. I continued to visit this family for several years to assure that basic health services such as immunizations for all of the children were provided."
This account is representative of public health nurses in action over and over again, demonstrating compassion and total family health care.
Dr. Felix J. Underwood retired as State Health Officer on July 1, 1958, after 38 remarkable and pioneering years of public health service. Dr. Underwood held a high regard for public health nurses and supported the expansion of public health nursing positions and activities throughout his tenure.
Dr. Archie Lee Gray, M.D., M.P.H., became State Health Officer immediately following Dr. Underwood's retirement. Dr. Gray had been associated with the Mississippi State Board of Health since 1933 in general public health and preventable disease. The public health philosophy and mission in Mississippi was well established and carried forward with the administration change. During this period, however, emphasis was placed on other disciplines such as disease intervention specialists and sanitarians and on communicable disease, Dr. Gray's primary area of interest.
New challenges were brought forth for public health nursing as changes in administration occurred. The State Board of Health, accepting the responsibility for mental health services, initiated a federal grant proposing follow-up care in the community for a pilot project. The proposal defined public health nursing's role in the community to care for mental health patients being discharged from state institutions.
The Division of Preventable Disease Control established the Chronic Disease Control unit to initiate programs for diabetes case finding and care and to provide home nursing services to the aging population. An Accident Prevention Program was also initiated and integrated with general public health nursing services. Many health promotion and teaching activities for accident prevention were developed within basic child health services.
During the 1950's, public health nursing services shifted significantly from the field to clinics, a trend that had been noted since the mid 40's. A shift from family health to more technical, disease oriented services occurred as a result of limited medical coverage and increased demands for nursing services. The relationship of quality and quantity were certainly being tested through this era. Many dilemmas are noted in the historical review of public health nursing through the 1950's; yet public health nursing had met their challenges head-on.
1960-1969: Changing Times
Mississippi, along with the nation, continued to flourish economically as the 1960's era began. Social and political events and people's attitudes were changing dramatically.
The Civil Rights Act of 1964 outlawed discrimination in employment and public accommodations and provided for universal voter registration, generating improved opportunities for many citizens. Lyndon Johnson, U.S. President from 1963-1968, guided national legislation for what he termed the New Society. One component of the New Society was the "War on Poverty," designed to expand social programs and enhance educational and employment opportunities. Another significant factor of the 1960's was the continuation and escalation of the Vietnam War, which, though begun in 1957 with public support, resulted in much public outcry and opposition by the mid 60's.
Most disturbing in review of this decade, however, was the dramatic increase in such crimes as murder, robbery, and rape. Illicit drug use also increased dramatically in this decade. Sociologists have attributed the increased crime rate and drug abuse to many factors, including the weakening of the family,poverty, mental illness, drug addiction, and a feeling of hopelessness and alienation. The impact of these social changes would eventually force public health nursing to focus on new issues and refocus on old issues to continue the public health mission "to provide for the protection of life and health and to prevent the spread of disease."
According to the Biennial Report of the Mississippi Board of Health, 1959-1961, between 1960-1961, forty-six branch health department clinics were constructed in twenty-nine counties. This greatly improved access to public health nursing in more rural areas of the state and discontinued the need for nurses to carry the large brown Field Bag. That report summarized the improved health status of Mississippians and identified the significant changes in mortality and morbidity rates. Tuberculosis and several other infectious diseases were no longer the leading causes of death. Typhoid fever, diphtheria, malaria, smallpox, and pellagra had caused 2,440 deaths in 1930-1931; by 1959-1960, only sixteen deaths were reported from these diseases. Heart disease, circulatory diseases, cancer, accidents, and diabetes had become leading causes of death in Mississippi.
Rural Electric Power Associations had expanded throughout the state. Farmers Home Administration (FHA) loans enabled large and small land owners to build better houses at low interest rates. At the same time, FHA loans enabled rural communities to develop community water systems which met standards established by the State Board of Health. These progressive measures brought conveniences and amenities throughout Mississippi. Safe drinking water and approved waste disposal were becoming a reality for rural Mississippi. Yes, improved sanitation, health promotion, and vaccine campaigns were paying off!
This evaluation of morbidity and mortality in Mississippi indicated that public health needed to develop new strategies and programs to continue its mission. In 1960, Louise Holmes persuaded the State Health Officer and other necessary authorities to create a position as Assistant Director of Public Health Nursing to support the development and integration of adult health services into general public health nursing services. Holmes promoted long time staff nurse Zona Jelks, R.N., M.P.H., as her assistant. In her tenure with the Mississippi Board of Health since 1941, Jelks had worked as a county public health nurse since 1941 in both Washington and Harrison counties, as a county nursing supervisor, and as one of the four Field Advisory Nurses.
In 1962, the Division of Chronic Disease was established under the direction of Dr. Alton B. Cobb. Jelks worked closely with Cobb to establish the goals, objectives and activities to be carried out through the public health nursing service system.
One of Jelks' first initiatives was to evaluate the contents of the nurses' black bag. Changes included a newer aneroid sphygmomanometer and the addition of new items including several catheters, thumb forceps, scissors, and a variety of improved venipuncture supplies.
Public health nurses conducted community-wide diabetic screening projects to find undiagnosed cases of diabetes. Between 1965 and 1967, they identified approximately 1,300 previously undiagnosed patients. Referrals were made to local physicians to initiate a treatment plan to be carried out by the public health nurse. The patient care process between the local physician and the public health nurses became known as joint management and proved to be an effective and cost efficient means of delivering care in the community. About 30,000 public health nursing visits were made to 4,300 diabetic patients in these same years. Public health nursing interventions included education, dietary counseling, and instruction in the administration of insulin to prevent acute and chronic complications and improve overall health status.
In addition, Papanicolaou's tests to screen for cervical cancer were integrated with existing services. Efforts were also underway to address hypertension, another disease determined to contribute significantly to high morbidity and mortality rates in Mississippi.
Through the 1950's, the nursing home industry had begun to emerge, with licensure requirements for standards of operation developed to assure quality of services and care. Communities were accommodating an increase in the number of elderly persons living with chronic and degenerative diseases. A public health nursing consultant was employed to assist in the licensure and re-licensure process, specifically to evaluate patient care. Public health nurses provided training courses for nurses' aides employed in nursing homes.
Mary Lester, R.N., one of the four Field Advisory Nurses, conducted a research study on staphylococcal infections in all nursing homes in the state in the early 60's to evaluate the extent of staph infections and to determine nursing interventions to eliminate this infectious disease.
Through these types of nursing initiatives, more rigid standards were developed, improving the quality of life for nursing home residents. County public health nurses regularly visited the nursing homes within their communities, providing TB skin testing, administering flu vaccine, and providing technical assistance in nursing care. A nutritionist and physical therapist employed by the Mississippi Board of Health provided additional expertise to improve care processes and support public health nurses in the areas of rehabilitation and nutrition.
Mental health services remained an integral part of public health service delivery through this decade, with new activities enhancing the community focus. A national trend had begun in the 1960's to release psychiatric patients from institutional care as improved psychotropic drugs and treatment modalities were available. Inadequate staffing at the state mental health institutions due to the nursing shortage was a complicating factor. In 1959, the Mississippi Department of Health entered a cooperative relationship with the state mental institutions to do a demonstration project. This project was funded by the National Institute of Mental Health.
Janet Amendt, R.N., was employed as a mental health nurse consultant to spearhead the research efforts of the project. The project's public health nursing activity was defined as "aftercare" and was designed to determine the effectiveness of integrating follow-up services to mental health clients and their families into general public health nursing service. Scott, Newton, Jasper, and Smith counties were selected as the pilot sites for the project.
In-service programs were conducted by Amendt and consulting psychiatrists for all public health nurses participating in the project. Public health nursing services included case finding and referral, hospital discharge planning, home and family assessments prior to and following discharge to the home, and medication supervision to these patients. Teaching and health promotion were basic nursing interventions included in these mental health activities.
The project proved successful, and six new counties implemented aftercare services in the remaining months of 1963. Evaluation of the aftercare project indicated that additional public health nursing positions would be required to provide the increasing demand for this service. This effort eventually resulted in statewide service availability.
Great emphasis was placed on child health, growth, and development in the early 1960's. Communicable disease, intestinal parasites, and physical defects that had been so prevalent in the school age population were greatly diminished. Evaluations of this population found the new concerns to be dental and oral defects, vision and hearing defects, mental and emotional disturbances, accidents, and serious nutritional deficiencies. Continuing education was provided statewide to enhance public health nurses' skills in observation, assessment and nursing interventions in the care of children.
Child health services provided by public health nurses included screening for physical defects, administration of immunizations, follow-up to correct physical defects, referral for mental health evaluations, consultation to teachers, and health promotion in nutrition, accident prevention, and mental health.
Public health nursing experienced a major transition as Louise Holmes retired as Director of Public Health Nursing on June 30, 1963. Holmes had strengthened the standards of professional public health nursing established by Mary D. Osborne. Zona Jelks, promoted from Assistant Director to Director of Public Health Nursing on July 1, 1963, brought knowledge and experience as she assumed her new role.
Immunizations administered by public health nurses were proving effective. Yet surveys showed that many preschool and school-age children were not completely immunized. The Mississippi Board of Health, continuing its vigilance of Mississippi's health status, received a federal grant under the Vaccination Assistance Act. In 1965, public health nurses administered 1,500,000 immunizations. Oral polio, known as Sabin vaccine, had became available in a sugar cube administration form. Measles vaccine became available in 1966 and rubella in 1969. Following mass initial immunization campaigns for both measles and rubella, the new vaccines were incorporated into routine immunization schedules for children.
By the mid 1960's, federal funding for maternal/child health services had required the incorporation of contraceptive information and general reproductive health into public health services. The objective was to reduce maternal and infant mortality and to improve the health and well-being of mothers and children generally.
Dr. Underwood had, in the early 1930's, recognized the health problems associated with multiple unplanned and unwanted pregnancies and had been an early leader in efforts to repeal federal and state laws restricting birth control services. By 1944, Dr. Underwood had successfully integrated family planning counseling and issuing of select supplies with maternity and postpartum services into about one third of the county health departments. Contraceptive supplies at that time included condoms and diaphragms. However, due to the wide divergence of public opinion, the development of the program was slow and unpublicized.
By 1965, every county health department provided contraceptive counseling and supplies. Oral contraceptives were also available by this time and gave women more convenient and accepted method choices. Public health nurses promoted family planning and were key in identifying those women at highest risk and need for such services. Approximately 160,000 family planning nursing visits were made between 1967 and 1969.
Landmark legislation in 1965 amended the Social Security Act of 1935 by establishing Medicare, a health insurance plan for people 65 years and older and for those with long term disabilities. The insurance plan included reimbursement for intermittent skilled nursing services provided to homebound persons. The purpose of home health services was twofold. Health care costs were beginning to skyrocket; home care would reduce costly hospitalization stays with the added benefit of patients being in familiar home settings, enhancing quality of life. The goal of the program was to rehabilitate patients to their maximum potential and to teach families to care for the physical and emotional needs of patients.
The Health Care Financing Administration (HCFA), the federal agency responsible for program administration, established the conditions of participation providers must meet to receive reimbursement.
Public health nursing seized the challenges of this opportunity to enhance public health nursing service delivery within their communities. With approval of State Health Officer, Dr. Archie Lee Gray and the State Board of Health, public health nursing set about to implement home health services in Mississippi.
Public health nurses had been providing home nursing services on a limited basis since the inception of public health nursing in the 1920's, but this would be the first reimbursement established for direct nursing services within the Mississippi Board of Health. Additionally, the reimbursable home health nursing services to be provided would require public health nurses to learn new assessment and rehabilitative technical skills.
Jelks, without an assistant director since accepting the director position in 1963, orchestrated the implementation of Home Health Services. Federal regulations established for certification were monumental, however. Continuing education for the nurses and nurses' aides directly providing care was just one of the regulations that in itself would be an immense task once statewide service delivery was fully implemented.
Federal grants through the U.S.P.H.S. were made available to support the implementation of home health. The Field Advisory Nurses and select supervising and staff nurses attended university-supported educational offerings in rehabilitation care and techniques. Educational workshops were provided throughout the state to upgrade nursing skills and techniques in rehabilitative care and on the conditions of participation for home health services. Additional workshop topics included documentation of skilled care and nursing care plans, medication administration and side effects, and the disease process of many chronic health conditions. Jelks and the Field Advisory Nurses wrote policy manuals for standard operating procedures and nursing procedure manuals required for certification. Counties were initially selected for implementing home health based on demographic data such as the percent of population over 65 years. Between 1966-1967, twelve counties were providing home health. Skilled nursing care was the primary component of home health services.
Jelks set forth justification and successfully reestablished an Assistant Director of Public Health Nursing. Grace Ferguson, R.N., M.S., one of the Field Advisory Nurses, accepted the position of Assistant director of Public Health Nursing in January 1967. Ferguson assumed the responsibility of integrating home health into general public health nursing services and for many of the administrative conditions of participation requirements.
The tremendous task covered a period of four-to-five years, but by 1969, all eighty-two counties were certified home health providers. Only two other home health agencies, both hospital based, obtained certification at this time. Home health was well received as staff public health nurses marketed home health nursing services throughout their communities to hospitals, physicians, nursing homes, and other community organizations.
Though tuberculosis was no longer one of the ten leading causes of death, tuberculosis morbidity continued to be one of the greatest challenges in public health. The tuberculosis case rate had dropped significantly from forty-three in 1955 to twenty-eight in 1964. With the lowered case rates, new public health initiatives were initiated in January 1968 under the title "Chemoprophylaxis '68." Recognizing the value of early detection of persons susceptible to tuberculosis and providing prophylactic treatment was a major, advanced endeavor by the Mississippi Board of Health to attain a long-term goal to eradicate tuberculosis. Public health nurses identified contacts to active cases and those persons with positive TB skin tests. Following identification, public health nurses coordinated medical evaluations and initiated plans of care for further diagnostic measures and administration of INH medication. Approximately 8,500 patients were placed on prophylactic treatment between 1968-1969.
The unexpected death of Dr. Archie L. Gray in March 1968 led to the appointment of Dr. Hugh B. Cottrell, M.D., M.P.H., as State Health Officer on July 1, 1968. Cottrell began his public health career in Mississippi as the county medical director of the Sunflower County Health Department and gained additional experience and expertise as the supervisor of the Field Unit of County Health Work and associations with several programs. His mission and philosophy were well grounded with the public health standards set by Underwood. Though the administration change was abrupt and unplanned, programs and services continued.
Mississippi was again faced with disaster when, on August 17-18, 1969, Hurricane Camille struck the Gulf Coast. The devastation and havoc caused by this storm left 256 dead, 68 missing, and hundreds homeless. Camille is classified as one of the greatest disasters to have hit the continental United States.
Emergency Health Service units of the State Board of Health with cooperation of Civil Defense units utilized "Package Disaster Hospitals" to assist local hospitals. Public health nurses from throughout the state were detailed to the coastal area. Home visiting, assisting homeless, assessment of persons in shock, and providing skilled care in the home environment were assets and skills that public health nurses brought to the victims of this natural catastrophe. Dr. Cottrell, State Health Officer at the time, best summarized the valiant effort of public health workers in his Biennial Report of 1969-1970. Dr. Cottrell reported, "Conditions that might have touched off an epidemic of monstrous proportions abounded on the 28-mile long Gulf Coast in August 1969 in the wake of Hurricane Camille...Yet not one case of communicable disease occurred in the state attributable to Camille and her aftermath, silent testimony to the capabilities of the State Board of Health to meet catastrophic emergencies through a team effort. It was a large public health team made up of 235 engineers, doctors, nurses, sanitarians, health technicians, and other personnel from the state and county health departments who moved into the stricken area to render services and were backed up by many other workers who stayed at their desks and contributed to the emergency effort in a supportive role."
In times of disaster, healing knows no barriers. Mississippi was on the road to recovery, and public health nursing had participated in the both the preventive and healing processes.
Evaluations of public health nursing by Jelks in the late 1960's indicated concerns over the number of nursing positions to carry out the quality and quantity of services being provided. The national standard for the ratio of public health nurse to population was 1:2,500; Mississippi's ratio of public health nursing positions to its population in 1969 was at 1:9,000. Mississippi needed about four times the number of existing public health nursing positions to meet the national standard.
But additional nursing positions were difficult to come by through the Merit System as legislative appropriations did not include funding for new positions. The increase in nursing positions between 1967-1970 were made possible by earnings generated through reimbursable home health nursing services.
The 1960's did bring change and recognition of needs in public health nursing. Public health nurses remained persistent despite the obstacles of inadequate staffing and increases in quantity and types of activities. Jelks wrote in a 1969 Division of Public Health Nursing memorandum that "the work of public health nurses in all health programs is perhaps the greatest force in delivering health services to the citizens of Mississippi."
But public health nurses' greatest contributions during the period included the mass oral polio administration campaign, statewide aftercare to mental health patients and families, increased patient utilization of family planning services, and the certification of all 82 counties as home health care providers. All of these accomplishments were made with only 290 public health nurses.
1970-1979: Public Health Nursing Expands
The social and political unrest of the 1960's bled into the 1970's. Public outcry at the continued U.S. involvement in the Vietnam War grew louder. Illicit drug use had escalated and was reaching more rural areas and younger populations. Mississippi's public schools initiated the court-ordered integration of schools. School integration resulted in required bussing of students. Simultaneously, the nation was being faced with inflation and a gas war. Higher gas prices hit everyone's pocket, including the State Board of Health's.
More liberal social values emerged and the 1960's era became known for having spawned a sexual revolution. These effects were being recognized by the early 1970's. Communities were faced with tremendous increases in sexually transmitted diseases and teen pregnancy rates. Social programs initiated in the 1960's were being formalized in public and community health efforts in all states. The establishment of Medicaid through the amendment to the Social Security Act, Title XIX, enhanced the delivery of health care services to a wider range of recipients. The federal monetary match for Mississippi was four to one. A large proportion of families and individuals in Mississippi met the federally established poverty guidelines and were entitled to Medicaid, but the state needed to strengthen the public and private mechanisms to provide health care to this medically indigent population in the state.
By the early 1970's, Mississippi had 309 public health nursing positions. The quantity and variance of activities in public health nursing continued to increase. Dr. Hugh B. Cottrell, State Health Officer, reported in the annual agency report that "never in its history had the State Board of Health been charged with the implementation of more new programs than in the 1970-71 fiscal year."
And all the while, the traditional programs of health protection and disease control went forward, many with an accelerated pace. Collaboration with other agencies, institutions, and groups continued at a high level in an effort to coordinate resources to achieve the best possible public health service delivery in Mississippi.
Legislative enactment transferred Crippled Children's Service from the Department of Education to the State Board of Health in 1970. The association of this service to the State Board of Health increased the utilization of medical and nursing services. The Medicaid Program enhanced the expansion of Crippled Children's Services as a payment mechanism for many previously uncovered services. Additional screening and specialty treatment clinics for neurology, heart, and orthopedics were established throughout the state.
Other initiatives centered around the delivery of child health services. The State Board of Health, continuing its vigilance of the infant mortality rate, entered a cooperative agreement in 1970 to establish a public health nursing position at the University of Mississippi Medical Center, Newborn Intensive Care Unit. The goal was to improve the communication, referral and follow-up mechanisms for these high-risk infants following discharge from the hospital to home. Mary Cobb, R.N., accepted the position and soon became a familiar name to all public health nurses throughout the state. Cobb continued in this position until her retirement in 1993.
According to Highlights: Maternal and Child Health and Crippled Children's Service 1935-1985, Title XIX of the Social Security Act (Medicaid) established Early Periodic Screening Diagnosis and Treatment (EPSDT) in 1969 to improve the access of preventive and primary health care for low income children. The State Board of Health captured this opportunity to strengthen the delivery of well child services. These physical screenings were made available primarily by public health nurses and were reimbursable nursing services, another recognition of the value of public health nursing service.
The Denver Developmental Screening Test (DDST) was incorporated into the physical assessment, giving public health nurses a new dimension to find potential developmental delays and provide early intervention in the newborn to six-year age groups. Workshops and in-services were conducted in select regions of the state to teach the DDST standardized procedures.
Medical technology was continuing to advance rapidly, including advances in genetic diagnostics and treatment. Routine screening for sickle cell anemia was introduced about the same time and was integrated with EPSDT services. Other genetic technological advances determined that a contributing factor to the high incidence of mental retardation resulted from genetic disorders such as hypothyroidism and phenylketonuria. Medication and dietary treatments had been developed for these genetic disorders that would improve the quality of life and life expectancy. Public health nurses in the northern counties of the state were beginning to receive referrals from the University of Tennessee Medical Center. Nursing interventions included a home assessment, treatment modalities ordered by the attending physician, provision of dietary supplements, and teaching basic child health care and special health care based on the diagnosis.
In 1972, the University of Tennessee Child Development Center hosted a nursing conference, and many of Mississippi's public health nurses had the opportunity to attend. The conference objectives were to increase the knowledge and skills of public health nurses in the identification and management of selected genetic disorders and other developmental disabilities. The conference incorporated a wide range of conditions including early mothering, failure to thrive, retardation as a result of genetic disorders, and neurological problems. An outgrowth of the conference was a document published by the Child Development Center entitled "The Identification and Management of Collaborative Selected Developmental Disabilities: A Guide for Nurses."
Public health nurses were again participating in research, early detection, field follow-up, family counseling, and treatment.
The Mississippi public health nurses who attended these conferences gained new nursing perspectives to care for children with special health care needs. By sharpening observational and assessment skills and using new screening tools, the public health nurses could provide more and better nursing service to the child health population. Clinic visits continued to grow in importance, with home visits made only on a select basis. The following account, however depicts the relevance for public health nurses' continuing vigilance in making select home visits to care for infants and children.
In Tate County, a three year old child was referred to the University of Tennessee Child Development Center by the public health nurse. The child was in the low range of height and weight for her age. She clung to her mother, and her verbal skills were limited. The family kept the appointment in Memphis, but the Child Development Clinic asked the public health nurse to make a home visit to do the Denver Developmental Screening Test in the home setting. The clinic situation had been too much for the child; clinic staff requested a detailed family and home environment assessment.
Armed with her nursing bag, portable scales, and the Denver Developmental kit and scoring sheet, the nurse proceeded to the home. The family lived in an old, three room tenant house in the hills, located about one-eighth of a mile off the blacktop road, secured with a fence and gate. The nurse chose to walk the short distance. The yard was neat, with a beautiful flock of Rhode Island Red chickens pecking at the green grass, jonquils blossoming profusely, and plum trees in full bloom. The grandmother who was caring for the child was cordial and knew the nurse making the visit. Two older children would soon arrive home from school on the bus. The mother worked in a garment factory as a seamstress and the father was a pulp wood hauler.
The home environment was neat and clean but there were no toys noted inside or outside. The grandmother was assessed to be kind but not active. A radio was playing. The public health nurse explained her mission and began engaging the child in the "Denver games."
The older children arrived and were eager to "show sister" how to accomplish the tasks. They were asked to just watch and cooperated. The child was noted to have deficits but loved the praise given for her efforts. The nurse encouraged interaction with the older children at this point, asking that they show her pictures from their books and let her tell them what things were. She could emulate their playing with a ball.
The mother came to the health department following the home visit to talk with the nurse. The nurse had, in the meantime, collected a few toys including a ball, a doll, and some picture books which she gave to the mother. A report was made to the Child Development Clinic, with future appointments to continue the evaluations of the child. The child was also enrolled into Headstart the following year. Progress was being made. Examples like this were the challenges, opportunities, and satisfaction of public health nursing in the early 1970's.
By 1971, a national concern emerged over the limited availability of physicians to provide primary care services. The U.S. Department of Health, Education, and Welfare supported the concept of expanding the scope of nursing to include primary health care. Federal funds became available to support educational programs for nurse practitioners. Mississippi, along with several other states, recognized the value of this concept and revised the state nurse practice act to accommodate the expanded role for practice.
The Mississippi State Board of Health, having selected three public health nurses to attend nurse practitioner training programs in 1972, cited this effort as a major innovation in its 1972-1973 annual report. Nurse practitioner programs specialized in pediatrics, family planning, and certified nurse midwifery. The University of Mississippi Medical Center initiated an educational program for registered nurses to become certified nurse midwives in 1975. This effort was in part due to the planned phase-out of the lay midwives. Select medical providers in the state supported this initiative. Dr. Ed Hill of Hollandale contracted with several certified midwives to support the high volume of high-risk, medically indigent maternity clients in the Delta area. By 1973, only 262 lay midwives continued to deliver, attending 1,504 births that year.
The effects from the sexual revolution that had begun in the 1960's were beginning to be revealed in public health in Mississippi, with dramatic increases in teen pregnancy and in the incidence of both syphilis and gonorrhea. With the State Board of Health providing family planning and maternity services to a large proportion of women at high-risk, routine gonorrhea cultures became a standard of care to screen asymptomatic females. Routine screening for syphilis had previously been incorporated as a standard of care. Public health nurses, along with disease intervention specialists, located clients found to be infected, accessed treatment services, and worked in contact identification.
The Mississippi State Board of Health established a Division of Family Planning Services in 1971. Due to a national emphasis with federal financial incentives, states began to expand family planning services. The employment of nurse practitioners enhanced an increase in the provision of family planning services as medical coverage was limited. From June 1971 to June 1972, the number of family planning patients enrolled for service increased from 21,000 to 40,000. Approximately 63,000 patients received family planning services by 1976. Mississippi continued to have a high percentage of births to teenagers, 29 percent of all births in 1976; therefore, priority was given to enrolling teens into family planning. Procedures for follow-up to teens to assure continuity of care were developed.
Dr. Hugh B. Cottrell retired as State Health Officer in 1973, and Dr. Alton B. Cobb, M.D., M.P.H., was appointed by the State Board of Health to assume the position of State Health Officer on July 1, 1973. Dr. Cobb brought varied public health experience which included his holding of positions as county health officer in Sunflower County beginning in 1957, medical director of the Division of Chronic Disease, and director of the Mississippi Medicaid Commission for four years. His experience and associations with the previous State Health Officers gave the State Board of Health the ability to continue established public health philosophy and goals that were proving effective in meeting its mission.
Difficult economic times hit again in the early and mid 70's. Nursing time and activities were evaluated and another move, as had occurred in the 1950's, shifted nursing services from the field to clinics and from family health to more technical and program-related services. The gas war had adversely impacted travel budgets for all agency staff. The addition of nursing activities and services also influenced this decision. Categorical federal funding defined program services, and counties had established clinic schedules by program. Public health nurses would make less home visits and be less visible in their communities.
In 1973, the infant mortality rate in Mississippi was 28 per 1,000 live births, continuing as the highest among the 50 states. In spite of the continued high rate, the infant mortality rate was declining and at a faster rate than the national decline. Continued vigilance was in order, and evaluations of the causes of the continued high infant mortality rates revealed new areas of concern for public health and its nursing force. Teen pregnancy, a higher incidence of premature birth among the poorer women in the state, and frequent, multiple pregnancies were found to be areas that public health nurses could provide interventions.
The Division of Public Health Nursing became the Bureau of Public Health Nursing, according to a 1974 file memorandum by Zona Jelks, who continued to serve as Director of Public Health Nursing. In evaluating public health nursing during the early 1970's, Jelks cited that nurses were often excluded from initial and ongoing planning as well as implementation of programs designed to provide nursing services. Communication among the field, programs, and nursing was needed to strengthen service delivery. With Bureau status, public health nursing could function in planning and policy making of programs that involved nursing services.
Jelks revised the Public Health Nursing Manual in 1974 and incorporated the definition of public health nursing. The definition, published in the 1974 edition of the Standards of Community Health Nursing by the American Nurses' Association, reads as follows:
"Community Health Nursing is a synthesis of nursing practice and public health practice applied to promoting and preserving the health of populations. The nature of this practice is general and comprehensive. It is not limited to a particular age, or diagnostic group. It is continuing, not episodic. The dominant responsibility is the population as a whole. Therefore, nursing directed to individuals, families, or groups contributes to the health of the total population. Health promotion, health maintenance, health education, coordination and continuity of care are utilized in a holistic approach to the family, group, and community. The nurse's actions acknowledge the need for comprehensive health planning, recognize the influences of social and ecological issues, give attention to populations at risk and utilize the dynamic forces which influence change."
The national emphasis on mental health had increased in the mid 1970's. In 1974, Mississippi legislation created the Mississippi Department of Mental Health and rescinded the authority vested in the State Board of Health relating to mental health. Regional mental health facilities were strategically located throughout the state to address the growing numbers of illicit drug users, alcoholics, domestic violence victims and offenders, and chronically ill mental health patients. Therefore, some of the mental health nursing services such as the aftercare program initiated in the 1960's were transferred from the State Board of Health to the Mississippi Department of Mental Health. Mental health assessment and referrals, however, remained an integral part of all aspects of public health nursing.
In 1975, the State Board of Health began the federal WIC (Women, Infants and Children) Program, a special supplemental food program to enhance the nutritional status of mothers and children. The program was designed to provide supplemental food to at-risk and high-risk pregnant women and children. Additional nutritionist positions were created with the federal funding. Public health nurses who have been working since that time report that the infants they care for now are healthier, and many credit WIC services and improved overall nutrition with healthier babies and toddlers.
Adult preventive services were being expanded in the 1970's. One of Dr. Cobb's goals had been to establish services for the identification and treatment of hypertension. Hypertension screening and control programs were implemented in 1975. Public health nurses identified hypertensive clients through screening programs, referred clients for medical evaluation, and provided health promotion. Guidelines for nursing management of hypertensive clients were developed which included periodic blood tests, nutritional counseling, and medication administration. Many hypertension clients were jointly managed, with private physicians giving the medical treatment orders to the public health nurse to execute. The joint management of hypertension proved to be a successful method of providing care to an indigent population in a state that continued to have inadequate medical coverage.
Jelks' prior evaluations of public health nursing indicated concern for an insufficient number of supervising nurses to plan, direct, and evaluate nursing services at the local level. In recognition of Jelks' and other public health administrative evaluations, the State Health Officer proposed in 1973 that a district organization system be implemented to strengthen the local system of service delivery. Dr. Cobb initiated this major reorganization of the public health agency into eleven public health districts in 1975. A District Supervising Nurse was assigned to each district to serve as the front line supervisor and manager for nursing. Communication and directions related to nursing practice and nursing activities would be managed through regular staff meetings with the Director of Public Health Nursing and the District Supervising Nurses.
Due to lack of funding, the original plan for eleven districts was redesigned for nine districts. This organization system has proven to be a very successful system for planning, directing, and evaluating public health nursing services at the local level. Program coordinating nurses for maternal and child health, home health, and TB were beginning to be added at the district organization level during the late 1970's.
By the close of the decade, midwifery supervision by public health nursing was beginning to cease. Since the Emergency Maternity and Infant Care legislation in 1943, the role of the midwife in maternal and infant care had been diminishing. The hospital construction act of 1946 and continued population shifts out of the state and to urban areas within the state had made it possible for many midwives to find more lucrative positions in industry and personal service jobs. Younger women had opportunities for better education. From a roster of about 3,000 midwives in 1940 to a roster of less than 300 in 1974, the number of midwives with permits to practice was 20 by the close of the decade.
Public health nursing otherwise remained focused on maternal and child health, tuberculosis, communicable diseases, immunizations, and home health. Renewed interests in the value of public health nursing in communicable disease control resulted in the designation of a state-level immunization nursing consultant. District TB nurses were designated to support the control of disease as the TB Sanatorium had closed in 1976. Home health services were rapidly expanding. Within these areas of focus, however, additional activities were continuing to be added to the public health nurse's workload. And, for the first time, public health nurses were, at times, seeing priorities established based on the reimbursement for the service.
Appropriately closing this busy decade, the Public Health Nursing Section of the Mississippi Public Health Association established an annual award in recognition of Mary D. Osborne. The first award would be presented at the 1980 annual Mississippi Public Health Association meeting. The Mary D. Osborne Public Health Nurse of the Year recognizes significant contributions and service in public health nursing through quality patient care and strengthening the professional public health nursing image.