超级英雄也能成为专家：护士对公共卫生政策的重要性

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The COVID-19 pandemic has inflicted structural damage to public health systems that we cannot yet fully comprehend. Although much attention is now paid to COVID-19 issues of social and economic upheaval, public health nurses remain focused on the cracks in health care’s foundation—such as the slow drip of resignations, revenue loss, and rural clinic closures—that are steadily undermining our country’s ability to provide health services to all citizens. Nurses, the “health care heroes” celebrated at the start of the pandemic, remain “inside the house,” and they can see the direct causal relationships between health system breakdowns and the global disruptions making headlines today.

Frontline heroes can be system experts too. And yet, the visibility of nurses in public health policy remains woefully lacking. Despite nursing being the largest health care profession, chief nursing officers account for only about 0.8% of voting power on hospital boards, and nurses make up about 2.3% of voting power on community health boards.1 The National Academy of Medicine’s 2021 Future of Nursing Report 2020–2030 (https://bit.ly/3NhiuJh) highlights this staggering dichotomy between nurses’ presence in health systems and their representation in roles of influence. The National Academy of Medicine underscores the needs not only to invest in nursing education and practice but to cultivate the leadership potential of nurses as well.2

Two articles in this special issue of AJPH (Zauche et al., p. S226; Morone et al., p. S231) describe the public health leadership roles nurses assumed during the pandemic, and both reach similar conclusions: the visibility of public health nurses must continue to grow. Florence Nightingale is widely acknowledged for her leadership both in the design of care and in measuring population health outcomes and instituting public health interventions. Despite Florence’s legacy, the contributions of public health nurses have been largely overshadowed by prominent figures in medicine and epidemiology. A key focus of this special issue is to understand why.

Morone et al. argue that the lack of nursing appointments to policy boards and committees is entrenched in historical, structural, and social factors associated with a predominately female workforce. Male-dominated structures and institutions continue to preside over decisions affecting a health care workforce composed primarily of female nurses. The COVID-19 pandemic amplified nursing voices, yet nursing leaders are seldom present among policy groups addressing COVID-19–related issues, such as vaccine hesitancy and the deployment of services to underserved communities. When policies do not reflect the nursing perspective, critical oversights are bound to occur: Although physicians and epidemiologists offer a remarkable knowledge base, nurses lead in carrying the trust of people and communities. Nurses alone bring insights from human touch points across the lifespan and in every care setting imaginable.

Zauche and her colleagues from the Centers for Disease Control and Prevention (CDC) illustrate this point. This stellar group of nursing leaders in the CDC aims to highlight the impact of the organization’s nursing workforce, which has gone largely unnoticed throughout CDC history. From nurses’ central role in malaria surveillance in 1947 to the more than 200 nurses working in research, epidemiology, public health, clinical care, and communications today, CDC nurses have played a pivotal role in safeguarding the health of US populations.3 Nurses holding doctorates frequently serve in the Epidemiology Investigation Service, and nurses comprise the largest membership of the Commissioned Corps of the US Public Health Service. Together, these nurses offer a diversity of expertise that should be considered invaluable from a health care policy perspective.

Nurse leaders such as those at the CDC must be called on when national groups assemble in response to large-scale threats such as COVID-19. It is imperative to include nurses on committees deliberating the financing of public health infrastructure in particular. Likewise, funding bodies need to allocate substantially more direct public funding to community and public health nursing (including competitive nursing salaries). Real change starts at the policy level, where decisions are made on what we pay for and how much is spent. It is time for nursing to own the influence that they have earned.

全文翻译（仅供参考）

COVID-19大流行病对公共卫生系统造成的结构性破坏，我们还不能完全理解。尽管人们现在非常关注COVID-19的社会和经济动荡问题，但公共卫生护士仍然关注医疗卫生基础的裂缝--如缓慢滴落的辞职、收入损失和农村诊所的关闭--这些都在不断地破坏我们国家为所有公民提供医疗服务的能力。护士，这些在大流行病开始时被颂扬的 "卫生保健英雄"，仍然在 "屋内"，他们可以看到卫生系统的崩溃和今天成为头条新闻的全球破坏之间的直接因果关系。

一线英雄也可以是系统专家。然而，护士在公共卫生政策中的能见度仍然严重不足。尽管护士是最大的医疗保健职业，但护士长只占医院董事会投票权的0.8%，护士占社区卫生委员会投票权的2.3%。1 美国国家医学会2021年《2020-2030年护理工作未来报告》（https://bit.ly/3NhiuJh）强调了护士在卫生系统中的存在和他们在有影响力的角色中的代表性之间这种惊人的对立关系。美国国家医学院强调，不仅要投资于护理教育和实践，还要培养护士的领导潜力。

本期AJPH特刊中的两篇文章（Zauche等，第S226页；Morone等，第S231页）描述了护士在大流行期间承担的公共卫生领导角色，并都得出了类似的结论：公共卫生护士的知名度必须继续提高。弗洛伦斯-南丁格尔在护理设计、测量人口健康结果和制定公共卫生干预措施方面的领导能力得到了广泛认可。尽管弗洛伦斯的遗产，公共卫生护士的贡献在很大程度上被医学和流行病学的杰出人物所掩盖。本专刊的一个关键重点是了解原因。

Morone等人认为，在政策委员会中缺乏护理人员的任命，这与女性劳动力占主导地位的历史、结构和社会因素有关，是根深蒂固的。男性主导的结构和机构继续主持影响主要由女护士组成的卫生保健工作队伍的决策。COVID-19大流行放大了护理的声音，但在处理COVID-19相关问题的政策小组中，如疫苗犹豫不决和向服务不足的社区提供服务时，护理领导人却很少出现。当政策没有反映出护理的观点时，必然会出现严重的疏忽。尽管医生和流行病学家提供了一个了不起的知识库，但护士在承载人们和社区的信任方面发挥着主导作用。只有护士才能从人的一生中的各个接触点和可以想象到的各种护理环境中获得洞察力。

Zauche和她在美国疾病控制和预防中心（CDC）的同事说明了这一点。这个由CDC的护理领导人组成的明星小组旨在强调该组织的护理队伍的影响，在CDC的历史上，这些影响基本上没有被注意到。从1947年护士在疟疾监测中的核心作用，到今天在研究、流行病学、公共卫生、临床护理和通讯领域工作的200多名护士，CDC的护士在保障美国人民的健康方面发挥了关键作用。这些护士提供了多种多样的专业知识，从卫生保健政策的角度来看，应该说是非常宝贵的。

当国家团体为应对COVID-19这样的大规模威胁而聚集在一起时，必须求助于像CDC这样的护士领袖。尤其是在审议公共卫生基础设施融资的委员会中必须包括护士。同样，资助机构需要为社区和公共卫生护理工作分配更多的直接公共资金（包括有竞争力的护理人员工资）。真正的改变从政策层面开始，在政策层面上决定我们支付什么和花多少钱。现在是时候让护理工作拥有他们所赢得的影响力了。

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