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Ideally, public health nurses focus mainly on primary prevention, while community health nurses focus on secondary and tertiary prevention, said Margaret Avila, MSN, MS, NP, RN, nursing director of public health administration for the county department.

Public health nurses also operate at three levels of practice: the individual, the community and the system as a whole, Smith said. They don't see themselves as being the sole remedy, but as being part of a multifactored approach that involves other community disciplines.

When asked what was most challenging about public health nursing, "It's all a challenge," House said. She said it was sometimes a challenge to develop relationships with families and have them be receptive to visitors and information.

Also, the issues clients deal with can be overwhelming, Acosta said, and sometimes it's hard to know where to start.

The need to improve public health in most jurisdictions is enormous, and the resources are limited, Smith said. Because of limited resources, public health nurses must prioritize and focus on providing services that no one else addresses.

Also, the potential workforce is limited because of the nationwide nursing shortage.

Most jurisdictions in California prefer to hire nurses with both a BSN and a public health nursing certificate from the California Board of Registered Nursing, Avila said. However, because of the nursing shortage, jurisdictions have hired nurses without a BSN who appear to have comparable training, such as nurses who have received the public health nursing certificate from California State University, Dominguez Hills.

To compensate for the nursing shortage, some jurisdictions have contracted out their disease control activity, while others have developed a team approach that involves public health nurses, social workers and paraprofessionals.

California's requirements for PHNs, however, are stiffer than most states', Avila said. To work for Maine's statewide system, for example, a public health nurse needs only an associate degree, according to Beth Patterson, MN, RN, Maine state director of public health.

In the past, Schmidt said, the epidemics that public health nurses dealt with were communicable diseases. Today's epidemics, such as violence, substance abuse and mental illness, are more insidious, she said, and it's harder for nurses to demonstrate theyhad an effect.

Public health nursing is a constant educational process, Schmidt said, in that public health nurses are always having to learn about new nationwide and worldwide concerns such as smallpox, SARS and the West Nile virus.

Not surprisingly, federal and state budget crunches have resulted in less money for public health.

Most public health resources have gone toward bioterrorism and emergency and disaster planning. With more emphasis on bioterrorism during the past couple of years, public health organizations have encountered more demands. Nurses also have to be in a constant state of readiness, Avila said.

The Los Angeles County department's bioterrorism program has grown tremendously since Sept. 11, according to Los Angeles County public health nurse Jennifer Rivera, MSN/MPH, CNS, RN. Nurses in this program often train hospital staff in how to prepare for bioterror attacks.

Despite the challenges of public health nursing-as well as the reality that the everyday life of a public health nurse may not be as dramatic as an "ER" episode, Schmidt doesn't regret her career choice.

She said she often enters a situation with an idea of what the major problem is, only to have her preconceptions shattered. But even in these situations, she has succeeded in helping families and communities solve their problems.

"There's strength in every situation," she said. "In every family or community, you can usually find some strength to build on."

Contact Rebecca Ray at rebeccar@nurseweek.com