We discuss the upstream approach, one-on-one work, and policy development with two chief nursing officers in Ontario. We’ll learn what they love about public health and why they’ve stayed in this field for a combined 44 years. Listeners will gain an appreciation for the difference that public health nurses can make within their communities.
We discuss the upstream approach, one-on-one work, and policy development with two chief nursing officers in Ontario. We’ll learn what they love about public health and why they’ve stayed in this field for a combined 44 years. Listeners will gain an appreciation for the difference that public health nurses can make within their communities.
Stories from the Field is hosted by Maureen Cava and Susan Blue. This series is produced by Katie Jensen and Sabrina Brathwaite of Vocal Fry Studios for the University of Toronto Lawrence S. Bloomberg Faculty of Nursing.
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Nicole Welch [preview]:
I’ll maybe tell a quick little story that’s often used in public health. If you can imagine a picture of a stream, the story is often told of an individual going for a walk and hearing some shouts, and they realize that someone is in the river and is needing help. So they rush over to the edge of the river, realize that someone is struggling, and they quickly get into the water, and pull that person out, and provide them the support they need to be okay.
As they’re doing that, they hear someone else calling for help. More and more people start coming down the stream. And they start asking for passerbys to help, because they can’t keep up with all of the work that’s needed to get these people into safety—until someone comes along and makes the suggestion that, “Maybe we should go upstream to see what’s causing those individuals to fall into the water in the first place.”
And so it’s really about focusing on reducing risk factors and on enhancing and increasing and strengthening the protective factors—those things that protect people from chronic disease, from other types of infectious diseases, from injury. So that’s kind of how I would explain “upstream.”
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Susan Blue:
Hi, I’m Susan Blue.
Maureen Cava:
And I’m Maureen Cava.
Susan Blue:
This is Stories From The Field: Public Health Nursing in Ontario…
Maureen Cava:
… a six-part series talking with talented and passionate public health nurses about the work they do each and every day, and the difference they’ve made in the lives of so many Ontarians.
Susan Blue:
We’re both recently retired public health nursing managers from Toronto Public Health. And combined, we have over 70 years of public health nursing experience.
Maureen Cava:
And we’ve worked in areas of child, reproductive, and mental health, seniors’ health, and public health education—always with a focus of advocacy and community capacity-building.
Susan Blue:
And we know that public health nursing is often misunderstood, and understated, or even unknown. And for many, this field of nursing is overlooked as a possible career choice.
Maureen Cava:
If these short episodes, highlighting the work of public health nurses, help you to think of the opportunities in this dynamic field, then we will have succeeded in our goal.
We hope to see you in the field.
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Maureen Cava:
Today we’re meeting two public health nursing leaders. First is Heather Lokko.
Heather Lokko [preview]:
I’m the Director of the Healthy Start division and the Chief Nursing Officer for the organization.
Maureen Cava:
Heather has worked for the Middlesex-London Health Unit for about 24 years, mainly in the areas of prenatal and postpastum. She also has a strong interest in health equity. She’s the Director and the Chief Nursing Officer.
In Ontario there are 34 health units. Each has a Chief Nursing Officer. They provide nursing leadership. They support organizational effectiveness. And they ensure that nursing practice issues are raised at the management table.
Susan Blue:
We’re also meeting Nicole Welch.
Nicole Welch [preview]:
I work at Toronto Public Health. I am one of the Directors at Toronto Public Health. And I’m currently in the COVID response, leading our liaison and school response teams.
Susan Blue:
I had the good fortune to work with Nicole at Toronto Public Health for a number of years. In her 20 years with the organization, it was wonderful to see how Nicole moved up the organizational ladder. She started as a public health nurse, and then over the years moved through a succession of management positions. During the past six years, she has worked as a Director—initially as the Director of Healthy Communities, to more recently also taking on the role of Director of Child Health and Development, a very large portfolio. Nicole’s current role includes being responsible for the extensive variety of programs and services, and the work of almost 600 staff and managers—quite a tall order, actually. And yet, Nicole handles it all with diplomacy, patience, vision, and strong leadership.
Maureen Cava:
So let’s get started and hear from Nicole and Heather.
But first, we’d like to acknowledge and thank both the Lawrence S. Bloomberg Faculty of Nursing and the University of Toronto. Funding from the Verna Huffman Splane Endowment Fund enabled us to produce the podcast series. A public health nurse who lived to be 100, Verna’s legacy donation supports education that promotes public health nursing.
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Maureen Cava:
We started by asking Heather to shed some light on the public health nursing role.
Why is it that perhaps public health nursing isn’t well understood in the healthcare arena, as compared to, perhaps, hospital-based nursing?
Heather Lokko:
Wow, if I could answer that definitively, I’d be famous, or rich, or something. (laughs) You know, it’s a challenging role to explain, partly because of the diversity of the role. If you talk about one area of public health nursing, that doesn’t give the full sense of what the role is like.
Public health nurses focus on assessing, and supporting, and providing nursing interventions to families, individuals, groups, communities, and populations. So the scope of the work of a public health nurse is very broad in terms of who they are engaging with.
The types of interventions that a public health nurse engages in are also as broad—from facilitating a group, to working one-on-one with a mum in her home, to engaging in policy work with decision-makers, working with city planners on environmental health. There’s also a lot of disease follow-up that needs to happen. And nurses are often the staff that are following up on those diseases. So many different types of interventions.
I think another challenge is that many people think of nurses as clinical. And there are clinical aspects to public health nursing: there are assessments that are done; immunizations that are given. There are clinical pieces to the work, but the assessment and intervention is done at such a broad comprehensive level that can be hard to explain to people who don’t engage in that type of broad work.
Susan Blue:
We asked Nicole to give us a run-down of some of the key programs and services that public health nurses provide.
Nicole Welch:
Public health nurses do a little bit of everything. So we have programs where public health nurses can be working in our sexual health clinic. Public health nurses that do home-visiting programs in our Healthy Babies, Healthy Children program. Public health nurses also do parenting programs in the community for families with young kids right up into teens. Working with our school health program.
We do access and equity work. TB management. Case investigation. We have a supervised injection site where public health nurses and other staff will provide services to very vulnerable clients. We have homeless at-risk prenatal program, which is another excellent program where the nurses go right out into the community and meet clients, wherever they’re at, to provide services to them, so that they can have a healthier child and improve their own health. We also have our Vulnerable Adults and Seniors, ah, Team that provides work with very vulnerabe seniors, who are often homebound and isolated. And you know, direct service is one part of public health.
I think another key part, and something that we worked on developing further over the last few years, is the population-health approach. So how do we work on different policy decisions, advocacy—so that we can improve the health of the whole population. So it’s really getting at: what are the root issues and the causes of some of these wicked situations that people are subjected to that really are preventable? So looking at things such as poverty, housing, opportunities for better education, reducing, ah, racism, which would improve the health of all.
Susan Blue:
Nicole brought up access and equity work. So, I asked her to explain the concept of health equity, as it shapes a lot of the work that public health nurses do.
Nicole Welch:
So, when we use the term “health equity,” what we’re really talking about is the social determinants of health. So it’s things such as: housing, income, racialization or racism, child health and development. And these are areas that we can do quite a bit of work on, as public health and as society as a whole, to ensure that people have a good basic income, good access to housing, and the resources they need to ensure that they can improve their health, and reduce their risk of chronic diseases and their risk of mental health, and just not having a good sense of, ah, overall health and well-being.
Susan Blue:
So, in a nutshell, Nicole has clarified that health equity is created when everyone has opportunities to be as healthy as possible. So for marginalized and disadvantaged people, that means removing obstacles to health—such as poverty and discrimination—and improving their access to resources that really can influence their health—things like quality education, a good job with good pay, having a safe environment to live and play and work in, having access to good health care, among other things.
We asked Nicole to describe for us how public health nurses can actually influence the development of healthy public policy.
Nicole Welch:
So, I think the public health nurses have such a key role in being the connector between the community and the policy development pieces. So any time we’re developing policy within public health, we do have to be closely aligned to, and in tune with, the needs of the community. Because public health often is about behaviour change. Like how do you get people to eat healthier, exercise more, reduce smoking? These are all things related to behaviour. And it’s often our infrastructures around us are so important.
So when public health nurses are working with the community, working with community groups, organizations, and agencies, they can identify what’s in the environment. So is this a neighbourhood, or a community, that’s in a food desert? So they don’t have an opportunity to eat fresh vegetables and fruits, because it’s just not readily available. So what policies do we put in place that could help the community access these resources?
Walkable communities. Safety is a huge issue, as well, in some communities. And, ah, where families and young children may not feel safe to just use the playground, because there was a shooting there a few months ago. So how do you work with the community to learn from their knowledge and wisdom of what they need in their environment to help improve their health overall?
So I think it’s really making that connection, and understanding, and listening. And all those great nursing skills that we do learn with active-listening but expanding it to a community level. So how do you open your ears and your eyes to take that not-knowing approach and learn from the community as a whole? And it is challenging, because there’s many different voices, and we have to hear from all voices, not just the vocal minority, but for those that don’t feel empowered to speak up.
Maureen Cava:
As we’ve just heard from Nicole, influencing policy is a very important role for public health nurses. Heather expands on how the development of policy work in public health happens.
Heather Lokko:
Looking at health from a public health perspective is not just about physical health. It’s also about “Are you getting food to eat?” “Do you have a home to live in?” “Do you have a job?” “Do you have social support from your community?” Public health’s role is critical in providing the information needed to those decision-makers to help them make policy decisions that will impact in a positive way the health of the community.
There are often many, many years of work that are done to gather data, highlight the issue, understand the issue, identify priority populations, think through all the different policy options and the implications of those options, to build relationships, to be able to have the conversations that you need to have with who you need to talk to, to shift that policy. So it can be years and years of background work.
The fascinating thing about policy work is that you need to be ready to slip in at a moment’s notice when there’s a policy window—when a certain person has been elected in, or there’s a certain issue on the table, to be able to slip in with that information at the time that there’s that receptivity.
So it’s a very long process.
Susan Blue:
We wanted to know why Nicole chose to pursue public health nursing as a career.
Nicole Welch:
Well, it’s interesting, because I did my Nursing degree, and entry to practice, and Masters of Science degree at McGill University, in nursing. And they have a different public health system there. So I had a little bit of experience with that in a placement. When I did come back to Ontario—because I am from Ontario, born in Toronto, raised in Oakville—I applied for different jobs.
My first job was in a hospital, at Brampton Memorial Hospital, which doesn’t exist anymore. And then I went to Mount Sinai Hospital. I did apply for public health—it took, ah, some time before I heard back from public health—and got an interview, and kind of discovered what public health was, through just learning about it through the interview, and then started off in our Healthy Living area, and then moved over to our, what was called, Healthy Families or Child Health and Development
I do recall when I first started as a public health nurse, and going out and working in the community—in schools, different community groups—doing postpartum classes, etc. in the community, thinking, “Okay, this is good, I like it.” A little nervous when I was first out on my own. Not sure how long I was going to stay with public health. You know, it seemed pretty good at the time but I—I thought I would move on, within that first year.
But, much to my surprise, 20 years later I am still with public health. And it’s really the joy of working with the community, and the staff, and the management to really improve the health of the whole population and—and looking at it strategically.
You know, public health, sometimes it’s tough to see that immediate response. Because it’s not like working in the hospital where somebody may come in close to death and literally see them turn around and lives saved right in front of you. The work is long-term. So the decisions we make now, the policies that we put into place, and the advocacies is to improve, you know, the health of the next generations and the generations to come, and really looking at reducing the health inequities in our society.
So it’s the long-term gain. And 20 years is a long time. And I’m like, wow, it just seems like yesterday I was starting off and meeting all the wonderful staff and management I’ve had the opportunity to work with in—in supporting the community.
So lots of opportunity within public health to learn many, many different things. So I’ve always felt challenged and, ah, motivated to, ah, come to work. So I’m quite pleased with that.
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Maureen Cava:
Heather’s path to public health started in her university nursing program. And she describes what she liked about public health then, and what’s kept her inspired.
Heather Lokko:
I was so intrigued and inspired by the upstream approach to health and well-being, and to the ability of public health nurses to focus on the whole person, the whole family, the whole community, the whole population. So that focus of public health nursing very much inspired and attracted me.
Secondly, in fourth year, I remember we took a leadership course. And I loved that course and felt again so inspired to move into leadership, and to be a leader and a nurse. I actually did not want to be a manager; I never intended to be a Chief Nursing Officer. But I wanted to be a leader, and so I felt like public health nursing would give me many opportunities to provide leadership.
The other thing, I would say, that really drove me to public health nursing was the autonomy and independence of practice. As a public health nurse, one has the chance to very much be autonomous in their practice—always, of course, conferring with supervisors when you get into difficult situations you’re not sure what to do with but—there is a lot of independence.
You’re out there in the community working with families, problem-solving, assessing, linking and referring, providing nursing interventions in the home and in other contexts in the community. And so that independence and autonomy was certainly attractive to me.
Maureen Cava:
Do you think it’s important for new graduates to have some hospital acute care experience before they enter public health?
Heather Lokko:
That’s a loaded question. And I know that there are different perspectives on that. I would say, from my own experience as a nursing student that did a practicum in public health because it was my intention to get into public health, and as in my experience as doing some teaching at the university, and in my experience as a recruiter actually interviewing, looking through résumés and interviewing potential candidates, I would say that if someone is interested in public health, it is not essential for them to do hospital practicums or—or to—to really focus on building that part of their career. In fact, I would say, as someone looking through résumés and recruiting, there’s a huge benefit if a student has actually done a practicum in public health. That is very attractive to someone who is hiring, looking at candidates for—for positions after graduation.
Nicole Welch:
I personally did have acute care experience, which I valued. I enjoyed that work as well. Is it absolutely necessary? I don’t think so. I’ve worked with colleagues who have not had acute care experience, and they’ve been excellent public health practitioners.
I think it’s just one of those experiences. And that has built my, ah, repertoire of a nurse in understanding what nursing looks in different environments. But I don’t think it’s—it’s a must-do.
Maureen Cava:
But are there other skills that students should acquire first?
Heather Lokko:
I think change within the community—whether it’s building capacity amongst community partners to more effectively support a particular population, or whether it’s bringing in new policies, or advocating for particular services within a community—all of that change happens at the speed at which trust is built. So I think one of the really critical skills for public health nurses is to know how to interact with others, and how to engage and conduct themselves in a way that builds trust.
Being able to work with a group to identify what goals they can agree on and work on together—where’s the common ground? So identifying common ground. Negotiating differences around the table. Public health nurses are often in the position where the ones that are helping to navigate those differences and help the group come to consensus—so consensus-building.
And then to take that idea and that passion and turn it into specific actions that can be moved forward. So planning, and helping to take those ideas and—and help the community think about how they could be moved into concrete action.
Those are a few of the many skills needed in that community collaborative kind of work.
Susan Blue:
Collaboration is also a big part of Nicole’s work.
Nicole Welch:
Probably all the work that we do, we’re collaborating with different sectors within the healthcare sector, different community groups and organizations. So collaboration is such a key piece of our work. And I do feel very proud of our ability to collaborate. And it’s done in a way where there’s a lot of respect for the community, a lot of understanding. And you know, bringing the knowledge we have—the evidence, the scientific data—but really letting the community be their voice and speak for themselves.
I’ve often seen excellent collaboration when I was doing work with our Toronto Indigenous Health Advisory Circle, where the Toronto Public Health, as the representative there, the Medical Officer of Health would be sitting there, as an ex de facto member, and really listening to the community and understanding. And I supported a lot of that work. And it was so important to take the not-knowing approach—not coming in there as the expert and telling people what to do but listening to them, and hearing what their needs are, and asking how best can we support this. “How can we help?” “What is needed from the system to move these things forward?”
So collaboration is absolutely key to any of the work that we’re doing if we actually want to change behaviour to improve health outcomes.
Susan Blue:
I think that as I hear you speaking of that, an underpinning of that is relationship-building and trust-building. And ah, no wonder things take a long time.
Nicole Welch:
Especially when you’re working with groups that have historically been—what’s the right word to say but not—there has not been a trusting relationship with government. That trust has been broken, you know, year over year by certain atrocities that have happened to them. When you look at, you know, with our indigenous folk, residential schools. The Indian hospitals that were, you know, doing experimentation. We often see that in the Black community, too, where trust was broken with government for many, many reasons. And we’re very well aware of what’s happening, even today, within these communities.
So it takes a long time to be a representative of government—because we do work for local government in public health—and build that trust with the community. And it’s easy to break that trust too. And it’s such a hard thing, because we want to do well, we want to help, and that’s what our role is, and it does take quite some time to maintain that relationship, respect that relationship, and move things forward.
Susan Blue:
Listening to Nicole describe the many professions and people that public health nurses interface with day-to-day, the multi-disciplinary aspect of public health nursing becomes very apparent.
Nicole Welch:
We definitely work with many different professions. And that’s like a great thing about nursing. As a whole, like, we can do so many different things. Like, a nurse can be in a healthcare setting, could be in an insurance company, could work at the city in a different division. And the skill sets we bring are excellent and, I think, serve us well for, ah, doing a variety of jobs.
In public health we work with just about everybody. You know, we work with accountants because we have to buy (laughs) and do budgets. And—and so we’re doing that. We’re working with other healthcare professionals—with physicians, or Associate Medical Officers of Health, our public health inspectors, which, you know, are—are working in the community as well. Our promoters. Family home-visitors. Our outreach workers. So I do look at it as, you know, public health being a community of different members whose opinions, and vantage point, and experience improves our ability to advocate at the larger population-health level.
And years ago I attended a conference. They talked about the “Scallop Principle.” The person who was presenting that was a gentleman from California named John Ott. And a scallop has, you know, eyes all around—the 360-view. And in order to keep that scallop safe, in the environment, keep that 360-view to keep that scallop safe. And I think that’s how I look at public health, and us working in community, that everybody’s vantage point may see something a little bit different, but when we take all those ideas and put them together and use that collective wisdom, then it improves the outcomes for all.
And I think, you know, often sometimes it’s hard, because we tend to gather or associate with people that are like us. I’ve always, throughout my career, tried to encourage that lone voice. If you have a different perspective, a different experience, based on whatever—the way maybe you were raised in a family up north that had a very different experience than somebody living in the urban environment, or from a different country—that we have to hear all those experiences, because it’s going to lead us to make better decisions, and advocate, and hopefully include more voices as we move forward with policies. Because it’s so easy to develop policies, and the unintended consequences of—of those policies can actually further and widen the gap between the Have’s and Have-not.
Susan Blue:
Nicole shared some thoughtful insights on self-reflection, including awareness of her own personal bias.
Nicole Welch:
We have to take an inventory of ourselves when we come into this work, understand what our biases are, what are privilege is in relation to others in community—and really take an acknowledgement of that—so that when we approach our work, we can situate ourselves, understand what we bring to the table, and really then approach individuals, different communities, as we’re planning programs, delivering programs, from a not-knowing space where they are the experts on their own life and have a good understanding of what they need to improve their life and health.
It takes a lot of work. And although I’m a racialized individual—being Black—I had a lot of work and growth to do. I had to acknowledge where my position of privilege was. Being a lighter-skinned Black person. Being a women. So then, you know, I do get treated, ah, differently than my sons do. I was able to achieve a high level of education, which also gives me a certain position and privilege in our society. So I have to acknowledge that, coming to the table, that I’ve had opportunities that others may not have had.
Maureen Cava:
Before we wrapped up our conversation with Heather, we wanted to know if she had any past examples where a public health nurse made a real difference in the community.
Heather Lokko:
I can give an example that I heard about from one of the nurses that was visiting a family in our community. So, the nurse spoke with the client—and it was the postpartum client—and identified that she needed some support with breastfeeding. She was having some challenges. So the nurse did provide some support over the phone, and virtually now that we’re in COVID, and then also arranged for a home visit. Went out to do the home visit, and on the home visit things deteriorated fairly quickly within the home. It became apparent that the woman was not feeling safe in her home with her partner who was there at the time.
So in consultation with the client, the nurse suggested that they might finish their home visit outside. So they went out and finished the visit on a walk, and did talk about the breastfeeding challenges she was having and also then had an opportunity to explore issues around her safety.
After conversation with the client, asking questions to better understand the situation and what the client’s needs, and wants, and goals were, made a suggestion, and the client accessed some services from a shelter.
The nurse followed up again the next day to help her figure out what her goals were and what her needs were for her own self and her child, did support that client to move into a safer location in a different community even. And this was a very, very young mum who really needed that support.
So that nurse made a massive difference in that woman’s life, and in the life of that infant. That’s an example at the—at the individual level.
At a community level, I can give a really quick example of, ah, a situation in which a nurse was providing leadership for an issue that was really prevalent at the time, where there was a real need for additional education and awareness about perinatal mood disorders.
And so, this nurse, ah, reached out to key partners, and proposed that they get together and talk about the issue in the community, and see if they wanted to work together to try to address this.
So over a series of meetings, and building relationships, and helping to understand—each other helping to understand the issue, that nurse worked for several years with that group, providing leadership. There was education done to healthcare providers all across the community. There was a communication campaign that was done with individuals, like women and their family members, different target populations for that campaign. There were new screening processes put in place. There was a new referral system created, so that public health nurses could refer directly to a psychiatrist. There were assessment tools clarified, so that everyone is using the same thing, and everyone is on the same page, and many other aspects.
So it was a total community approach to addressing an issue that would make a difference to many, many families across the whole community, and make a difference to the practice of healthcare providers across the community.
Maureen Cava:
After all these years, what keeps Heather’s passion as a nursing leader alive?
Heather Lokko:
The reason I stay in public health nursing is because of the opportunity that I feel I have to have a positive influence in the lives of individuals and in the health of our community broadly. I tend to be a big-picture thinker. And public health nursing gives me the opportunity to feel like I am making a difference in the big picture. And that absolutely motivates and inspires me.
The other piece that keeps me is that upstream approach that I talked about at the beginning. That feeling like I can be involved in preventing people from experiencing health challenges, family challenges, social challenges, whatever it may be, to give them the opportunity for better health—however that health is defined for them—it inspires me and keeps me going.
Susan Blue:
And for Nicole?
Nicole Welch:
One of the areas of my work that I really enjoy, as management, is the coaching and mentoring of staff. But I know over the years some of the nurses have felt very disempowered. Some of the Black nurses have come to me and said they don’t feel that there’s opportunities for movement within the organization. And I remember, it was—it was quite profound when I did get, ah, my first senior-level position—it was as an Associate Director—people literally said to me—and I was kind of taken aback, because it was a little intimidating for me to think of myself like this but—they were like, “We feel like you getting this position was like when Obama won.”
I realized that they hadn’t seen a lot of that movement happen within the organization, and the feeling that opportunities weren’t there for them. That it was you had to look a certain way in order to get into senior management. You had to be a certain age, because (laughs a little) that—that was a thing, too. I was too young. And I wasn’t really that young, I just looked younger (laughs). Because I wasn’t young. But people thought, you know, I was like 30, 34. I was in my 40s, right? But, you know, and that feeling of so it’s the age, you have to be a certain age, you’ve got to look a certain way, and it wasn’t the way I looked.
And I think just telling people to challenge the system. Put yourself forward. Go for opportunities. Keep on trying. Look for mentorship throughout the organization—informal and formal mentorship. All you can do is if you connect with a manager, ask, “Can I—can I come meet you?” or, you know, “Would it be okay that we connect once in a while?” You have to step out of your box and make the opportunities for yourself. You can’t wait for them to be given to you.
I think things are changing more now, as, you know, our communities have changed over the years.
But it is an added pressure I do feel as being a woman of colour. Sometimes you feel like scrutiny is a little bit more on you and if you fail it has a—a broader impact on—on more.
So it—it’s a lot to handle, but I just think we just gotta keep on working, being authentic, being true to ourselves. And I really believe on being kind and respectful to people, and that has really served me well. Like I just treat people as I want to be treated, which sounds corny, like my grandmother would say (laughing), but it—it’s—it’s the truth.
If we meant were meant to do it alone, we wouldn’t have this big team around us. So.
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Susan Blue:
Thank you for listening to Stories From The Field, hosted by me, Susan Blue…
Maureen Cava:
… and me, Maureen Cava.
We are so grateful to the Ontario Public Health Nursing Leaders Association, and the Chief Nursing Officers, for their support in identifying public health nurses willing to share their stories.
Susan Blue:
This series is produced by Katie Jensen and Sabrina Brathwaite of Vocal Fry Studios.
If you enjoyed this episode, we’d love if you shared it with a friend and subscribed wherever you listen to your podcasts, because we have more stories on the way.
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