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Abstract Public health nurses make up the largest single category of public health manpower, but confusion over where and how public health nurses should function continues. The purposes of this study were to describe the current structure of public health nursing in state health departments in the United States, and to note whether this structure had changed over the last 5 years. Data were collected through a survey sent to each of the 50 U.S. State Health Departments. Forty-eight percent of the 50 states responded to the survey. From the results, we can conclude that there is currently no uniform description of what states expect of their state nurse directors, even though these individuals lead the largest portion of the public health workforce. The public and the public health system place a large, but often unwritten and unspoken, expectation on public health nurse leaders, but in recent years erosion has occurred in public health nursing in many states. Public health nursing is well positioned to provide leadership under health care reform. The challenge now facing public health nursing leaders is to maintain or create the infrastructure, as well as the organizational culture, to maximize these opportunities.