公共卫生护士家庭访问中的信任、转化和透明度

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Evidence over the years has demonstrated the clear impact of public health nurse (PHN) home visits on outcomes of those raising infants and children: PHNs save lives and improve health and social outcomes—not just in the short term, but for decades to come.1–3 The family home visiting articles in this special issue of AJPH (Ballard et al., p. S298; Huling et al., p. S306) extend and advance intervention effectiveness knowledge for PHN family home visiting practice. They also demonstrate that PHNs are ready and willing to do whatever it takes to provide effective, high-quality, life-changing care and transparently document outcomes to prove quality and effectiveness.

In this era of extreme accountability and transparency for health care professionals, PHNs serve as leaders and exemplars of what can be done with nursing data to demonstrate effectiveness and value. PHNs have been generating useful, valid, and reliable data through routine documentation for more than two decades—consistently validating positive family home visiting outcomes in program evaluation and research.3–5 Based on an extensive body of literature across home visiting programs, translations of PHN family home visiting evidence to practice in everyday public health have been highly successful and should continue. Indeed, the public health system would be well advised to add PHN family home visiting to any population of interest to enhance outcomes and reduce downstream social and financial costs. What, then, is preventing the widespread deployment of PHN family home visiting to address the complex health and social needs of those at highest risk for poor outcomes?

First, consider that although we affirm PHN family home visiting’s effectiveness, we are slow to acknowledge and trust that it is the PHN—who is highly educated, emotionally available, and greatly connected—who makes the intervention effective.4,5 Instead, we put our trust in “evidence-based programs” that diminish the role of the PHN to that of a technician who delivers a scripted intervention. Expanding PHN family home visiting programs depends on trusting and respecting the capability of skilled PHNs and supporting their ability to tailor interventions to each person. This is fundamental to expanding the availability of PHN family home visiting, simply because funding mechanisms require PHNs to be prepackaged in expensive, restrictive evidence-based programs rather than embedded as expert interventionists acting in the fabric of the public health system to improve the public’s health.

Second, let us question the notion that evidence-based PHN family home visiting services should be available only as replicated evidence-based research programs. Such replication is a costly process often accompanied by burdensome requirements of accreditation and oversight as well as extensive, time-consuming data collection protocols. This results in siphoning of resources away from the PHNs and public health agencies and into the external programs, thereby reducing funds available to pay PHNs to do the work. Furthermore, such models have restrictive eligibility requirements that are in opposition to the mission of many public health departments: to serve those who need services in their jurisdictions. In fact, PHN family home visiting is effective for a broad range of family home visiting groups and needs,1–5 and to deny effective services to those who are in need in the name of program fidelity is unethical.

Finally, let us acknowledge the truth in the data generated by PHNs and support the most trusted profession to practice to the full extent of its licensure in our communities. PHNs are equipped and ready to do so, but the systems in which PHNs must function need to take a hard look at political assumptions and willingness to act on the evidence PHNs have provided. PHNs have long accepted the responsibility of demonstrating intervention effectiveness; this is the message that the Ballard et al. and Huling et al. articles affirmed once again. It is time to listen.

全文翻译（仅供参考）

多年来的证据表明，公共卫生护士（PHN）的家访对抚养婴儿和儿童的结果有着明显的影响。公共卫生护士拯救了生命，改善了健康和社会成果--不仅仅是在短期内，而是在未来的几十年里。1-3 本期AJPH特刊中的家庭访问文章（Ballard等，第S298页；Huling等，第S306页）扩展并推进了公共卫生护士家庭访问实践的干预效果知识。它们还表明，PHN准备并愿意不惜一切代价提供有效的、高质量的、改变生活的护理，并透明地记录结果以证明质量和效果。

在这个对卫生保健专业人员极度负责和透明的时代，公共卫生护士作为领导者和典范，可以用护理数据来证明有效性和价值。二十多年来，公共卫生护士通过日常记录产生了有用的、有效的和可靠的数据--在项目评估和研究中不断验证了积极的家庭访问结果。3-5根据家庭访问项目的大量文献，将公共卫生护士家庭访问的证据转化为日常公共卫生的实践是非常成功的，应该继续下去。事实上，公共卫生系统最好在任何感兴趣的人群中增加PHN家庭访问，以提高结果并减少下游的社会和财政成本。那么，是什么阻碍了PHN家庭访问的广泛部署，以解决那些最有可能出现不良结果的复杂健康和社会需求？

首先，尽管我们肯定了PHN家庭访问的有效性，但我们却迟迟不承认和相信是PHN--受过高等教育、情感丰富、关系密切--使干预有效。扩大PHN家庭访问计划取决于信任和尊重熟练的PHN的能力，支持他们为每个人量身定做干预措施的能力。这是扩大PHN家庭访问可用性的基础，仅仅是因为资金机制要求PHN被预先包装在昂贵的、限制性的循证项目中，而不是作为专家干预者被嵌入公共卫生系统的结构中，以改善公众的健康。

其次，让我们质疑以证据为基础的私人医生家庭访问服务只应作为复制的以证据为基础的研究项目来提供的概念。这种复制是一个昂贵的过程，往往伴随着繁琐的认证和监督要求，以及广泛的、耗时的数据收集协议。这导致了资源从初级保健医生和公共卫生机构被抽走而进入外部项目，从而减少了可用于支付初级保健医生工作的资金。此外，这种模式有限制性的资格要求，与许多公共卫生部门的使命背道而驰：为辖区内需要服务的人服务。事实上，PHN家庭访问对广泛的家庭访问群体和需求是有效的，1-5，以项目忠实度的名义拒绝为那些有需要的人提供有效的服务是不道德的。

最后，让我们承认PHNs所产生的数据的真实性，并支持这个最值得信赖的职业在我们的社区中充分行使其许可权。PHNs有能力并准备好这样做，但PHNs必须在其中发挥作用的系统需要认真审视政治假设，并愿意根据PHNs提供的证据采取行动。PHNs早已接受了证明干预有效性的责任；这是Ballard等人和Huling等人的文章再次肯定的信息。现在是倾听的时候了。