From Crisis to Collaboration: Pima County Public Library partners with Health Department for Library Nurse Program

by Kenya Johnson, Amber Mathewson, & Karyn Prechtel on February 28, 2014

All customers of the Pima County (Ariz.) Public Library system are important community members regardless of race, domiciled status, age, gender, sexual orientation, or physical ability. It is the goal of the Library Public Health Nurse to improve the physical and mental health of library patrons through education, referral, crises prevention, nursing intervention, and disease management nursing care models.—Library Nurse Program Mission¹

As one of twenty-seven libraries in the Pima County (Ariz.) Public Library (PCPL) system, the Joel D. Valdez Main Library serves a wide array of patrons who represent every sector in this community of nearly 980,000 people. Located in the heart of downtown Tucson in the 85701 zip code, the 96,000-square-foot library opens its doors to government employees, tourists, students, families, business owners, retirees, and residents who live or work nearby. In 2012, there were more than 648,000 visitors at the Main Library alone.²

Like many urban and rural libraries, Joel D. Valdez Main Library also serves many patrons with significant social service needs. The staff here is accustomed to referring patrons to outside community agencies regarding housing, medical care, food resources, and other basic needs.  However, they also handle incidents involving behavioral health issues, traumatic crisis episodes, medical emergencies, loitering, substance abuse, and volatile physical or verbal confrontations that occur inside and outside the facility. When necessary, staff will call 911 for  assistance with these incidents.

While traditional library service provides for information and referral to people in crisis, librarians and library associates do not receive special training in making referrals to social service agencies and seeing someone in need through that process. When situations escalate, the protocol involves onsite security guards or calling law enforcement or emergency medical services to the scene. PCPL’s systemwide procedure also requires staff to document serious incidents—especially those involving 911 calls—in the library’s online incident report tracker.

What can a public library system do when faced with the challenge of having an unsafe and unwelcoming environment for the community and staff, and at the same time, helping patrons get connected to the critical services that they need? How could we minimize the number of calls to 911 for non-medical emergencies and free up law enforcement resources?

An Idea Sparks

For most people in this community, the library is the place to go for books, programs, events, information, and learning. For others, the library means refuge, free public computers, and help.

Various government and community organizations in Pima County identify the 85701 zip code as being plagued by homelessness, poverty, and mental illness. With an increase of incidents that coincided with the economic downturn, PCPL staff was concerned for the welfare of the individuals with behavioral health issues and the well-being of the general public that visited any of our libraries.

We were looking for ways to better serve our patrons with exceptional social service and mental health needs when staff  learned at a workshop in 2010 that San Francisco Public Library (SFPL) had partnered with the San Francisco Department of Public Health to hire a social worker. SFPL inspired us to “think outside the library.” Our goals to mitigate the situations at Main Library were straightforward:

• offer more options to help the public;
• reduce calls to 911 for behavioral health related issues;
• improve the community health overall; and
• create an environment that was more comfortable for all patrons and staff.

In 2011, PCPL Library Associate Nicole Huggett (also a graduate student in social work at the time) completed an in-depth white paper that included an analysis of the incident reports at Main Library, a literature review about homelessness in public libraries, and an interview with SFPL’s Leah Esguerra, the nation’s first full-time social worker employed in a public library.³ Huggett’s research also involved data from a voluntary survey completed by Main Library staff to identify gaps and barriers in library services and community needs.

Lastly, the white paper proposed a program plan to hire a full-time social worker at the Joel D. Valdez Main Library. The components of this position initially included one-on-one consultation with patrons, staff training, workshops and programs, outreach to community members, and outreach to community agencies.⁴

With an opportunity to make a significant change in how libraries addressed patrons with critical needs, we needed a solution that was more than just doable; we wanted a program that would be effective and sustainable.

Making It Work

“Pima County Public Library is addressing conditions that have long existed in nearly every urban and rural library in the country.”—Maureen Sullivan, 2012-13 American Library Association president⁵

After getting the approval from PCPL’s Executive Team to move forward with the proposal, we approached the Pima County Health Department. They were a natural partner to help determine how we could create a social worker position similar to the one that SFPL had implemented.

In talking with the Health Department, library staff learned that a public health nurse (PHN) would be a better fit for the library’s needs. PHNs are population-focused, and their work in the community highlights health promotion and disease prevention. Moreover, PHNs provide nursing assessment, education, and case management to patrons of all ages.⁶

Together, PCPL and the Pima County Health Department (PCHD) outlined the scope of what would become the Library Nurse Program. The PHN position was located within the library department, PCPL funded the full-time position, and the PHN would be stationed at the Joel D. Valdez Main Library. PCPL and PCHD would co-supervise the position, with PCHD providing clinical oversight of the program. Both departments would be involved in the hiring process.

In January 2012, PCPL hired the first PHN to work in a public library. The forty hours would be divided among six library locations (Joel D. Valdez Main Library, Eckstrom-Columbus Library, Martha Cooper Library, Sam Lena-South Tucson Library, Santa Rosa Library, and Woods Memorial Library). These were the libraries that staff identified as not being safe and welcoming for patrons and staff. It was clear that the difficulties were primarily due to other patrons with traumatic crisis episodes and behavior issues.

The PHN works closely with library staff and security staff to intervene during traumatic episodes and provide crisis intervention to patrons with social, behavioral, health, and emotional problems. The PHN also conducts assessments for social, medical, and related services; helps individuals access services and information provided by community agencies; and make referrals.⁷

Although the responsibilities for this newly created library position were expansive, they directly addressed what our libraries needed.

Helping the Human Condition

“Suspending judgment goes a long way.”⁸

Homelessness, personal hygiene, domestic violence, unemployment, detoxification, psychiatric crisis, arguments, substance abuse, nutrition, injury, medication education, and acute or chronic illness were just some of the many issues that patrons in our libraries faced in 2012.

Initially, the Library Nurse Program concept involved hiring one full-time PHN. Six months after the Library Nurse Program began, however, we determined that the work load was too much for one nurse to handle. Instead of sharing one PHN among six libraries, PCPL and PCHD developed a different staffing model that was more sustainable. We were able to come up with a work plan that would distribute the forty-hour position among five PHNs. Members of the team were assigned to work at the six libraries. One nurse, the team lead, worked twenty-four hours between the Main Library and a second library (Woods Memorial Branch Library).

The day-to-day experience for a PHN can vary, but there is a routine that the program has developed. As part of their work, PHNs chart their interactions and communications with patrons, library staff, and security personnel. They walk through the library wearing a stethoscope around their neck to let people know that they are there, and offer blood pressure checks as a comfortable way to engage patrons in conversation. A regular workday also includes checking on the status of established patients and educating library patrons about the PHN’s role, schedule, and contact information.⁹ Daniel Lopez, the PHN assigned to Joel D. Valdez Main Library and the Woods Memorial Library (and the program’s team lead), makes a point to ask patrons to come back to tell him how things worked out. He believes that having good relationships with agencies is the key to his ability to help people who need it the most.

For Lopez, the feedback from patrons is an important part of the evaluation process. “I want to know who in the community is taking care of people,” he said.¹⁰

Successes

@pimalibrary Congratulations on this story and the entire program! Working toward a similar program here—you inspired us!¹¹

In 2012, the PHNs had a total of 2,181 encounters with patrons over 180 visits at the six libraries. The impact of the Library Nurse Program at the Joel D. Valdez Main Library is especially palpable among the library staff. Overall, 911 police calls were reduced by six percent in 2012, and 911 medical calls decreased by 20 percent.¹² Today, we have a team of PHNs that have regular visit hours scheduled at seventeen of PCPL’s libraries and on our bookmobile as well.

The PHNs are coordinating trainings for library staff on relevant topics, mentoring interns and nursing students, and attending meetings with library staff. The University of Arizona, for example, has become a part of the program by sending nursing students to the library for their community health rotation. The students work with the PHNs to conduct community assessments, health education classes, and targeted community interventions, such as an awareness program that was aimed to prevent people from falling. Another group of nursing students developed a project to address hunger.

PCPL workers, on the other hand, are the eyes and ears for the PHNs and now feel supported to have onsite professionals to handle patron issues that may have resulted in 911 calls in the past.

PCPL, however, is not the only one excited about the program’s success. We receive positive feedback from patrons, the community, and other public libraries in the United States, Canada, and overseas. PCHD staff is also presenting the program at national conferences, and stories have been published in professional library and nursing publications as well as on library, nursing, and health-related websites and blogs. Local and national media have brought attention to PCPL by highlighting our unique program and collaboration as the first of its kind.

But when we hear from the people who are being directly helped because of the Library Nurse Program, we know that what we are doing is making a difference. In 2012, we received a letter from one such patron who took the time to let us know the impact the library and the PHN has had on his life:

I would like to especially thank the Library Nurse Emily. As she provided me with shaving razors to have a clean shave on the date of my interview. In addition she provided me with deodorant and lip balm so that I’d feel good/confident going to my interview. These things may sound simple, however without the self confidence that they brought me, I wouldn’t have gotten the position.¹³

PCPL was recognized by the Urban Libraries Council (ULC) as one of its ten 2013 Top Innovators at the ULC Annual Forum in Chicago. The Library Nurse Program was selected by a panel of expert judges from more than 140 applications for the fourth annual ULC Innovations Initiative and was recognized in the category of health, wellness, and safety.

Looking Forward

In late 2012, PCPL was invited to be a part of the Community Health Assessment Taskforce in Pima County and was given the lead to help address the need for health education and literacy in our community.

The taskforce identified five priorities that would make a significant positive impact on the health status of Pima County residents. These priorities include (1) obesity, (2) access to healthcare, (3) economy, (4) quality of care, and (5) health education and literacy.¹⁴ PCPL has created a Health Information Literacy Team of library staff members to take on this project, which will improve the lives of even more people. The success of the Library Nurse Program is evidence that a public library can and does play an important role in building the overall well-being of a community with a population as diverse as ours. The Pima County Board of Supervisors and county administration are both strong supporters of the library’s programs and services and have included PCPL in several literacy outreach efforts, as well as the county’s  economic development plan.

When we first initiated the program, our main goal was to increase the safety and welcoming environment of the library for our patrons and our staff. As we were able to find out more information about the people the PHNs were working with at our libraries, we added some  additional goals. Childhood hunger, for example, was identified by the PHNs as a key issue at the Santa Rosa and the Eckstrom-Columbus Libraries.¹⁵ As a result, PCPL staff worked with the PHN at the Santa Rosa Library and a University of Arizona nursing student to create an after-school healthy snack program in the fall of 2013. Twenty-two children participated on the first day of the new program.

The people we are helping through the Library Nurse Program represent every sector of our community in Pima County. They range from the young pregnant woman who is homeless, to the recently laid-off university employee without health insurance, to the underemployed senior citizen facing age discrimination, to the mentally ill veteran who sleeps on the streets. In some cases, they are gainfully employed, yet facing some challenges that, unbeknownst to them, are compromising their health.

The commonality is that all of these people are experiencing some sort of individual hardship. Many of them come to the library because it is a safe place, and a place where they know they can get good information. By having a PHN in our libraries, PCPL is providing both a compassionate presence and a path toward wellness through education, connecting people to community resources, and direct intervention.

Three years ago when we first learned about the social worker at SFPL, we did not have a clear vision of what we needed at our own library. We did know, however, that we had to do something. Because of the Library Nurse Program, PCHD staff is forging good relationships with community and government agencies that can provide the support and services to library patrons in need. Our collaboration with PCHD has increased our resources and our ability to help more people in our community. Yes, we are a public library; but we are—in many ways because of this program—so much more.

As a librarian for over thirty years, I have come to cherish the social role of libraries. We spend a lot of time protecting and building collections of books and other resources, and I hope that will always be the case. But today you and your colleagues in the Pima County Library System have built on the concept of library as a social crossroads, and you have stepped forward to serve the community in an innovative and daring manner.¹⁶

References and Notes

1. Pima County Public Library, Library Nurse Program Mission Statement, 2012.
2. Pima County Public Library, Activity Measures, 2013, accessed Feb. 10, 2014.
3. Nicole Huggett, “Changing Community, Changing Needs: Fusing Social Services and Information Referral for Revolutionary Library Services” (white paper, Pima County Public Library, 2011).
4. Ibid.
5. Eun Kyung Kim, “More than Just Books: Arizona Libraries Add Public Health Nurses,” TODAY.com, Mar. 28, 2013, accessed Jan. 21, 2014.
6. Pima County Health Department, Community Health Services Division, Library Nurse Project 2012 Annual Report.
7. Memorandum of Understanding, Pima County Public Library and Pima County Health Department, Oct. 24, 2011.
8. Daniel Lopez, personal interview with the author, Oct. 17, 2013.
9. Daniel Lopez, “The Public Health Library Nurse” (presentation at the Pima County Library Advisory Board Meeting, Nov. 5, 2012).
10. Lopez, personal interview with the author.
11. Albuquerque Bernalillo County Library, Twitter, Mar, 28, 2013.
12. Pima County Health Department, Community Health Services Division, Library Nurse Project 2012 Annual Report.
13. Personal letter to Joel D. Valdez Main Library, May 31, 2012.
14. Pima County Community Health Improvement Plan, 2013-2017.
15. Pima County Health Department, Library Nurse Project 2012 Annual Report.
16. Amy Rule, personal letter to the authors, Oct. 22, 2012.