Home visiting as public health nursing intervention: How 19th-century policies limit 21-st century care outcomes

For almost 125 years nurses have employed home visits to deliver services to individuals and families where they live. Research evidence underscores both cost-effectiveness of the home visit, and positive patient/family and societal outcomes. Despite the utility of the home visit intervention, health department/agency retrenchment has reduced home visit funding and utilization. Absolute reductions in resources and the dilemmas of resource distribution have played a part. Less visible is the enduring policy legacy of nineteenth-century social welfare opposition to non-institutional service delivery. Using practice vignettes illustrating public health nurses work in home visiting practice from the 1930s Depression to the present, this paper will illuminate factors that operate behind contemporary discourse to influence American assumptions about appropriate health care structure and delivery, including: bias against public expenditures for community-residing individuals; opposition to nurse-patient partnerships; a focus on disease-specific, rather than family-targeted services; and discomfort with long-term services to less-worthy or stigmatized individuals/families. Understanding these less-visible influences on nursing practice will assist public health nurses to design advocacy strategies to secure effective policies for home-visiting to improve the health of individuals, families, and communities. This paper is based on primary historical research in archived records of several public health nursing agencies; the microfilmed records of the National Organization for Public Health Nursing; federal documents relating to home visiting from 1930 to the present; and the secondary literature about public health and visiting nurse history.