[SOLVED] 3 part assignment – Health Medical

Review the agenda priorities of the current/sitting U.S. president and the two previous presidential administrations.Select an issue related to healthcare that was addressed by each of the last three U.S. presidential administrations.Reflect on the focus of their respective agendas, including the allocation of financial resources for addressing the healthcare issue you selected.Consider how you would communicate the importance of a healthcare issue to a legislator/policymaker or a member of their staff for inclusion on an agenda. The Assignment: (1- to 2-page Comparison Grid, 1-Page Analysis, and 1-page Fact Sheet) Part 1: Agenda Comparison Grid Use the Agenda Comparison Grid Template found in the Learning Resources and complete the Part 1: Agenda Comparison Grid based on the current/sitting U.S. president and the two previous presidential administrations and their agendas related to the public health concern you selected. Be sure to address the following: Identify and provide a brief description of the population health concern you selected and the factors that contribute to it. Describe the administrative agenda focus related to the issue you selected. Identify the allocations of financial and other resources that the current and two previous presidents dedicated to this issue. Explain how each of the presidential administrations approached the issue. (A draft of Part 1: Agenda Comparison Grid should be posted to the Module 1 Discussion Board by Day 3 of Week 1.) Part 2: Agenda Comparison Grid Analysis Using the information you recorded in Part 1: Agenda Comparison Grid on the template, complete the Part 2: Agenda Comparison Grid Analysis portion of the template, by addressing the following: Which administrative agency would most likely be responsible for helping you address the healthcare issue you selected? How do you think your selected healthcare issue might get on the agenda for the current and two previous presidents? How does it stay there? Who would you choose to be the entrepreneur/ champion/sponsor of the healthcare issue you selected for the current and two previous presidents? Part 3: Fact Sheet or Talking Points Brief Based on the feedback that you received from your colleagues in the Discussion, revise Part 1: Agenda Comparison Grid and Part 2: Agenda Comparison Grid Analysis. Then, using the information recorded on the template in Parts 1 and 2, develop a 1-page Fact Sheet or Talking Points Brief that you could use to communicate with a policymaker/legislator or a member of their staff for this healthcare issue. You can use Microsoft Word or PowerPoint to create your Fact Sheet or Talking Point Brief. Be sure to address the following: Summarize why this healthcare issue is important and should be included in the agenda for legislation. Justify the role of the nurse in agenda setting for healthcare issues.Atleast 3 resources used, please try to only use resources that I provide only. The first attachment is the grid you will need to add to and I will send 5 sources to use and 3 other sites that will be listed below. Please do not use other ones. USA.gov. (n.d.). A-Z index of U.S. government departments and agencies. Retrieved September 20, 2018, from https://www.usa.gov/federal-agencies/a USA.gov. (n.d.). Executive departments. Retrieved September 20, 2018, from https://www.usa.gov/executive-departmentsThe White House. (n.d.). The cabinet. Retrieved September 20, 2018, from https://www.whitehouse.gov/the-trump-administration/the-cabinet/DeMarco, R., & Tufts, K. A. (2014). The mechanics of writing a policy brief. Nursing Outlook, 62(3), 219–224. doi:10.1016/j.outlook.2014.04.002Kingdon, J. W. (2001). A model of agenda-setting, with applications. Law Review, M.S.U.-D.C.L., 2(331).Lamb, G., Newhouse, R., Beverly, C., Toney, D. A., Cropley, S., Weaver, C. A., Kurtzman, E., … Peterson, C. (2015). Policy agenda for nurse-led care coordination. Nursing Outlook, 63(4), 521–530. doi:10.1016/j.outlook.2015.06.003O’Rourke, N. C., Crawford, S. L., Morris, N. S., & Pulcini, J. (2017). Political efficacy and participation of nurse practitioners. Policy, Politics, and Nursing Practice, 18(3), 135–148. doi:10.1177/1527154417728514Institute of Medicine (US) Committee on Enhancing Environmental Health Content in Nursing Practice, Pope, A. M., Snyder, M. A., & Mood, L. H. (Eds.). (n.d.). Nursing health, & environment: Strengthening the relationship to improve the public’s health. Retrieved September 20, 2018.I will also need a draft of Part 1 only on Wednesday please. It does not have to be perfect, just need to submit for review.Copyright © 1995. National Academies Press. All rights reserved.
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i
Nursing, Health, & the
Environment
Strengthening the Relationship to Improve the Public’s
Health
Andrew M. Pope, Meta A. Snyder, and Lillian H. Mood, Editors
Committee on Enhancing Environmental Health Content in
Nursing Practice
Division of Health Promotion and Disease Prevention
INSTITUTE OF MEDICINE
NATIONAL ACADEMY PRESS
Nursing, Health, and the Environment, edited by AndrewWashington,
M. Pope, et al., NationalD.C.
Academies
Press, 1995. ProQuest Ebook
1995
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ii
National Academy Press 2101 Constitution Avenue, N.W. Washington, D.C. 20418
NOTICE: The project that is the subject of this report was approved by the Governing Board of
the National Research Council, whose members are drawn from the councils of the National
Academy of Sciences, the National Academy of Engineering, and the Institute of Medicine. The
members of the committee responsible for the report were chosen for their special competencies and
with regard for appropriate balance.
This report has been reviewed by a group other than the authors according to procedures
approved by a Report Review Committee consisting of members of the National Academy of Sciences, the National Academy of Engineering, and the Institute of Medicine.
The Institute of Medicine was chartered in 1970 by the National Academy of Sciences to enlist
distinguished members of the appropriate professions in the examination of policy matters pertaining to the health of the public. In this, the Institute acts under both the Academy’s 1863 congressional charter responsibility to be an adviser to the federal government and its own initiative in
identifying issues of medical care, research, and education. Dr. Kenneth I. Shine is President of the
Institute of Medicine.
This project was supported by funds from the Agency for Toxic Substances and Disease Registry, the National Institute for Occupational Safety and Health, National Institute of Nursing
Research, National Institute of Environmental Health Sciences, Health Resources and Services
Administration, and the Environmental Protection Agency (contract number U61/ATU398777-01).
Library of Congress Cataloging-in-Publication Data
Nursing, health, and the environment : strengthening the relationship to improve the public’s
health / Andrew M. Pope, Meta A. Snyder, and Lillian H. Mood, editors ; Committee on Enhancing
Environmental Health Content in Nursing Practice, Division of Health Promotion and Disease Prevention, Institute of Medicine.
p. cm
Includes bibliographical references and index.
ISBN 0-309-05298-X
1. Environmental health. 2. Nursing. 3. Industrial nursing. I. Pope, Andrew Mac Pherson,
1950- . II. Snyder, Meta A. III. Mood, Lillian H. IV. Institute of Medicine (U.S.). Committee on Enhancing Environmental Health Content in Nursing Practice.
(DNLM: 1. Environmental Health—nurses’ instruction. 2. Environmental exposure—
nurses` instruction. 3. Occupational Health—nurses’ instruction. 4. Nursing. WA 30
N974 1995]
RA566.N87 1995
610.73—dc20
DNLM/DLC
for Library of Congress 95-39601
CIP
Copyright 1995 by the National Academy of Sciences. All rights reserved.
Printed in the United States of America.
The serpent has been a symbol of long life, healing, and knowledge among almost all cultures
and religions since the beginning of recorded history. The image adopted as a logotype by the Institute of Medicine is based on a relief carving from ancient Greece, now held by the Staatlichemuseen
in Berlin.
Cover Photograph: 1910. Courtesy of Visiting Nurse Service of New York.
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iii
COMMITTEE ON ENHANCING ENVIRONMENTAL
HEALTH CONTENT IN NURSING PRACTICE
LILLIAN H. MOOD (Chair), Director, Risk Communication, Environmental
Quality Control, South Carolina Department of Health and Environmental
Control, Columbia
ELIZABETH T. ANDERSON, Professor, School of Nursing, University of
Texas, Galveston
HENRY A. ANDERSON, Chief Medical Officer for Occupational and
Environmental Health, Wisconsin Division of Health, Madison
NORMAN DePAUL BROWN, Associate Professor, College of Nursing,
University of Arkansas, Little Rock
GAIL F. BUCKLER, Clinical Instructor, Environmental and Occupational
Health Sciences Institute, University of Medicine and Dentistry of New
Jersey—Robert Wood Johnson Medical School, and Rutgers, the State
University of New Jersey; and Assistant Professor of Clinical Nursing,
School of Nursing, University of Medicine and Dentistry of New Jersey
ANN H. CARY, Associate Dean, School of Nursing, Louisiana State University
Medical Center, New Orleans
SUE K. DONALDSON, Dean, School of Nursing, Johns Hopkins University
GERALDENE FELTON, Dean, College of Nursing, University of Iowa
ELAINE L. LARSON, Dean, School of Nursing, Georgetown University
CAROLYN NEEDLEMAN, Professor, Graduate School of Social Work and
Social Research, Bryn Mawr College
DOROTHY S. ODA, Professor, School of Nursing, University of California,
San Francisco
RANDOLPH F.R. RASCH, Assistant Professor, School of Nursing, University
of North Carolina, Chapel Hill
KATHLEEN M. REST, Assistant Professor, University of Massachusetts
Medical School, Worcester
BONNIE ROGERS, Director, Occupational Health Nursing, University of
North Carolina, Chapel Hill
META A. SNYDER, National Center for Hazard Communication, University
of Maryland, College Park
Liaison to the Institute of Medicine’s Board on Health Promotion and
Disease Prevention
Jean Goeppinger, Chair, Department of Community and Mental Health, School
of Nursing, University of North Carolina, Chapel Hill
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iv
Study Staff
Andrew M. Pope, Study Director
Carrie E. Ingalls, Research Assistant
Michael A. Stoto, Director, Division of Health Promotion and Disease Prevention
Donna Thompson, Administrative Associate
Mona Brinegar, Financial Assistant
Laura Baird, Librarian
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PREFACE
v
Preface
In this time of local and global environmental concerns, people—as
individuals and communities—look increasingly to the health care system for
information and advice on identifying and reducing health risks associated with
environmental (including workplace) exposure to potential hazards, and for
diagnosis and treatment of the diseases caused by such exposures. Nurses are
often the first point of contact for patients and concerned individuals, and are in
positions to provide considerable support. However, most nurses have little, if
any, formal preparation in the field of environmental health.
In response to a growing awareness of the need to enhance occupational
and environmental health content in the practice of nursing, a workshop was
conducted by the Institute of Medicine (IOM) in May 1993 to assess the need
for an IOM study on the role of nurses in occupational and environmental
health and to clarify the associated areas of education, training, and research
that such a study would involve. It was an illuminating and successful
workshop, chaired by Bonnie Rogers, that provided resounding affirmation of
the need for the IOM to conduct a full-scale study of issues related to enhancing
environmental health content in the practice of nursing.
Following the workshop, and at the request of a consortium of federal
agencies, the IOM established the Committee on Enhancing Environmental
Health Content in Nursing Practice to carry out the study. Working from the
premise that the environment, including the work environment, is a
fundamentally important factor in determining the health of individuals
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PREFACE
vi
and populations, the committee defined essential competencies and curriculum
content in environmental health; recommended methods for developing nursing
faculty expertise in environmental health; developed strategies for enhancing
the dissemination and integration of environmental health content in nursing
practice; and identified research issues that would benefit from study by a
combination of environmental health and nursing investigators.
I have been privileged to chair the study committee; it is comprised of an
amazing group of experts in nursing and environmental practice, education, and
research, encompassing a variety of disciplines and diverse perspectives. We
particularly benefitted from a deliberate overlap in membership with the IOM
Committee on Curriculum Development in Environmental Medicine, which had
similar objectives yo ours, that is, enhancing environmental health in health
care delivery, only with a focus on physicians and medical education.
One of the hallmarks of the committee’s work was the mutual respect
present among the members. This group’s work was an example of true
interdisciplinary teamwork—the valuing of differences, openness to others’
ideas, a willingness to explore all options, an absence of jockeying for position
or recognition, and a generous giving of time, effort, and plain hard work.
The committee met several times during the course of a year, beginning in
May 1994, and worked hard at both identifying and resolving issues, and at
writing, rewriting, and revising segments of the report. We met as a whole and
in small groups with individual and group assignments. Our discussions were
held face to face and via conference calls, through FAX, and over the internet.
We assembled an even wider circle of opinion and expertise than that
represented by the committee through focus groups, surveys, guest
presentations, commissioned papers, and literature and research reviews.
Three themes emerged in the process of the study:
1.
The environment is a primary determinant of health, and
environmental health hazards affect all aspects of life and all areas
of nursing practice.
2. Nurses are well positioned for addressing environmental health
concerns of individuals and communities. Nurses are the largest
group of health professionals; they have great variety in their
settings and locations of practice; environmental health is a good fit
with the values of the nursing profession regarding disease
prevention and social justice; and nurses are trusted by the public.
3. There is a need to enhance the emphasis and awareness of
environmental threats to the health of populations served by all
areas of nursing practice. This will require changes in practice,
education, and research.
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PREFACE
vii
This study is not an exercise in defining a new nursing specialty. We
recognize that experts will be needed to guide the changes described, and ways
are suggested to facilitate the development of those experts. We also realize that
some nurses will choose to make environmental issues the primary focus of
their practice. Our emphasis, however, is on the role that every nurse can and
should play in addressing environmental health issues.
The competencies described for nurses are enhancements of content and
focus, as well as some new dimensions of nursing practice. The competencies
extend, but are continuous with, nurses’ existing roles as investigators,
educators, and advocates. The committee’s report indicates the need for change
for all practicing nurses. Change can seem overwhelming, but it can also be a
source of new energy and new interest. Through careful investigation and
thoughtful consideration, the committee has made recommendations and
proposed strategies for accomplishing these goals. It is not our intent to be
prescriptive, but rather to stimulate and challenge the thinking and action of all
nurses.
Finally, on behalf of the committee I want to acknowledge all of those who
assisted us along the way. A list of these people is presented in Appendix H, but
in particular I want to thank M. Virginia Ruth, Barbara Sattler, and Meta Snyder
(who also served on the committee) for their assistance in both initiating the
study and for providing thoughtful input throughout its tenure. In addition, the
workshop and focus group participants deserve recognition for helping us
clarify our objectives and the current needs in the field of nursing. The
sponsors, of course, are appreciated not only for their initiative and financial
support, but also for their substantive contributions and guidance. In particular,
we thank the following sponsors: from ATSDR, Max Lum, Diane Narkunas,
and Donna Orti; from NIEHS, Anne Sassaman; from NINR, Patricia Moritz;
from NIOSH, Bernie Kuchinski and Jane Lipscomb; from EPA, Gershon
Bergeisen; and from HRSA, Marla Salmon and Moira Shannon. Perhaps most
importantly, I want to thank the IOM for taking the initiative to develop this
activity, and for the staff’s tireless efforts in guiding us through the shoals of
committee work, and for making it an enjoyable, valuable experience.
It was a pleasure to work with such competent professionals on a topic of
such fundamental importance. I can only hope that our efforts will indeed
enhance the environmental health content of nursing practice and thereby
enlarge the indispensable contribution that nurses make to the health of the
public. Florence Nightingale would be proud.
Lilian H. Mood
Chair
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PREFACE
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viii
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ACRONYMS
ix
Acronyms
AACN
AAOHN
ABOHN
ACHNE
ANA
ANCC
AOEC
APN
ATSDR
BLS
CAI
CD-ROM
CDC
CFCs
CPHF
DHHS
DoD
HRSA
ICN
American Association of Colleges of Nursing
American Association of Occupational Health Nurses
American Board for Occupational Health Nurses
Association of Community Health Nurse Educators
American Nurses Association
American Nurses Credentialing Center
Association of Occupational and Environmental Clinics
advanced practice nurses
Agency for Toxic Substances and Disease Registry
Bureau of Labor Statistics
Computer-assisted instruction
compact disk read-only memory
Centers for Disease Control and Prevention
chlorofluorocarbons
California Public Health Foundation
Department of Health and Human Services
Department of Defense
Health Resources and Services Administration
International Council of Nursing
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ACRONYMS
IOM
IRB
LPN
MFS
NACNEP
NANDA
NBCSN
NCEH
NCLEX
NCSBN
NIEHS
NIJ
NINR
NIOSH
NLN
NP
OSHA
PPRC
RN
STTI
TRI
x
Institute of Medicine
institutional review board
licensed practical nurse
medical fee schedule
National Advisory Council for Nurse Education and Practice
North American Nursing Diagnosis Association
National Boards for Certification of School Nurses
National Center for Environmental Health
National Council Licensure Examination for Registered Nurses
National Council of State Boards of Nursing
National Institute of Environmental Health Sciences
National Institute of Justice
National Institute of Nursing Research
National Institute for Occupational Safety and Health
National League for Nursing
nurse practitioner
Occupational Safety and Health Administration
Physician Payment Review Commission
registered nurse
Sigma Theta Tau International
Toxic Chemical Release Inventory
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CONTENTS
xi
Contents
EXECUTIVE SUMMARY
1
1
INTRODUCTION
Defining Environmental Health
Environmental Health as a Core Function of Nursing Practice
Moving to a Population-Based Perspective
The Nursing Workforce
Origin, Purpose, and Organization of the Report
13
14
15
17
18
20
2
OVERVIEW OF ENVIRONMENTAL HEALTH HAZARDS
Classifying Hazards
Air, Soil, and Water
The Workplace Environment
The Global Environment
Vulnerable Populations
Environmental Health Priorities
Conclusion
23
25
25
29
30
31
34
35
3
NURSING PRACTICE
Nursing Practice and Responsibilities in Environmental Health
Factors that Influence Nursing Practice
Case Study
39
40
51
57
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CONTENTS
xii
Nursing Competencies in Environmental Health
Conclusion
Recommendations
4
5
A
B
C
D
E
F
G
H
I
NURSING EDUCATION AND PROFESSIONAL DEVELOPMENT
Factors Affecting Nursing Curricula
Nursing Education Pathways
Model Program Development
Methods for Enhancing Dissemination of Environmental
Health Content in Nursing Education at All Levels
Role of Federal, State, and Local Health Agencies
Methods for Evaluating Effectiveness of Curriculum
Recommendations
62
62
63
69
70
72
78
86
92
95
98
NURSING RESEARCH
Nursing Research Perspective
Multidisciplinary Research Base for Nursing Practice
Review of Nursing Research in Environmental Health
Meeting the Need for Nursing Research in Environmental
Health
Recommendations
103
104
105
106
112
References
121
APPENDIXES
Position Statement from the International Council of Nurses:
The Nurse’s Role in Safeguarding the Human Environment
Environmental Hazards for the Nurse as a Worker
Environmental Health Curricula
Environmental Health Resources: Agencies, Organizations,
Services, General References, and Tables of Environmental
Health Hazards
Focus Group Summary and List of Participants
Nursing Advocacy at the Policy Level: Strategies and
Resources
Taking an Exposure History
Acknowledgments
Committee and Staff Biographies
INDEX
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118
131
134
142
148
239
253
263
271
273
279
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Nursing, Health, & the Environment
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NURSING, HEALTH, & THE ENVIRONMENT
‘An Angel of Mercy.” Florence Nightingale at a soldier’s bedside at Scutari.
Mezzotint engraving (1855). Property of Duke University Medical Center
Library, History of Medicine Collections, Durham, NC.
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xiv
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EXECUTIVE SUMMARY
1
Executive Summary
Every day sanitary knowledge, or the knowledge of nursing, or in other
words, of how to put the constitution in such a state as that it will have no
disease, or that it can recover from disease, takes a higher place.
—Florence Nightingale, 1860, Preface
ABSTRACT
Environmental health hazards, including those in the work environment,
are ubiquitous, often insidious, and generally poorly understood. As such, they
are of increasing interest to the general public and of fundamental importance to
health care providers.
Among health care providers, registered nurses occupy a unique position.
In both rural and urban settings, nurses are often the initial, and sometimes the
only, point of contact for people seeking medical care. They are also the largest
group of professional health care providers in the United States: an estimated
2.2 million. In occupational health practice, nurses outnumber physicians by six
to one. Yet the vast majority of nurses have had no formal training in
occupational or environmental health.
If environmental health hazards and health effects are to be recognized and
dealt with effectively, it is of fundamental importance that all health care
providers have a clear understanding of the association between the
environment and health. Toward that end the committee makes a series of
recommendations for the integration and enhancement of environmental health
in nursing education, practice, and research.
INTRODUCTION
The environment is one of the primary determinants of individual and
community health. And, whether it is justifiable or not, there is
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EXECUTIVE SUMMARY
2
growing public concern and apprehension about the potential adverse health
effects associated with exposure to substances in the home, the workplace, and
in the other community settings. Unfortunately, most health care providers,
including nurses, are inadequately prepared to identify or respond appropriately
to such hazards or conditions.
A comprehensive approach to nursing practice (as well as other health care
professions) requires the awareness, recognition, and treatment of critical
factors that affect individual and community health, even if these factors are not
obvious at first to patients or providers. A child who has a behavior problem in
school because of lead poisoning; a young adult who has respiratory problems
due to the inhalation of solvents while working in the garage at home; a worker
who is exhibiting neurological symptoms related to handling chemicals on the
job; and a retired person whose rash is caused by a garden pesticide are all
examples of people who have been affected by environmental health hazards in
ways that could easily be misinterpreted in the absence of information about the
origin of the problem.
Nurses are well positioned to address environmental health hazards, both
on an individual and community level, for a number of reasons: They are the
largest group of health care providers in the United States (2.2 million), and
generally speaking, they have more opportunities than other health care
providers to talk in-depth with patients. In addition, they are often the only
health care providers who visit patients in their homes, workplaces, and local
communities, thus gaining firsthand knowledge of the potential environmental
hazards present in these settings. The close interaction of nurses with patients
and the “on-site” aspects of nursing care provide tremendous opportunities for
nurses to detect previously unrecognized health problems, including those
related to environmental exposures, and to initiate appropriate interventions.
Finally, there is a good fit between environmental health concerns, the historical
development of the nursing profession, and core nursing values.
DEFINING ENVIRONMENTAL HEALTH
The committee recognizes a need to distinguish between issues of
environmental health and issues more specific to the science of ecology. The
primary focus of this report is on the adverse health outcomes that may be
associated with exposure to environmental hazards rather than efforts to
conserve natural resources. This focus is in no way intended to diminish the
importance of ecological issues.
The environmental hazards of concern in this report fall into four widely
accepted classes: chemical, physical, biological, and psychosocial. Such hazards
may be naturally occurring, such as radon or ultraviolet
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EXECUTIVE SUMMARY
3
light from the sun, or they may be manmade (or “constructed”), such as
particulates and gases released into the environment from automotive exhaust,
industrial sources or tobacco smoke. As these examples demonstrate,
environmental hazards may be encountered in the home, workplace, and
community environments. Thus, adverse health outcomes related to
environmental conditions include worker and childhood lead poisoning,
childhood and occupationally induced asthma, and repetitive motion injury,
among many others. Taken in this context, use of the term environmental health
throughout this report refers to freedom from illness or injury related to
exposure to toxic agents and other environmental conditions that are potentially
detrimental to human health.
ENVIRONMENTAL HEALTH HAZARDS
Since 1950, more than 65,000 new chemical compounds have been
introduced into common use in the western world, the majority of which (84
percent) have not been tested for human toxicity. The post-World War II era
brought major technological advances that were accompanied by the release of
an unprecedented number of new synthetic chemicals onto United States
markets. New chemical compounds continue to be introduced into the
environment each year; presently, 72,000 chemicals are used in commerce in
the United States, and most have had limited testing for their effects on human
health. Furthermore, the U.S. Environmental Protection Agency (EPA) reports
that more than 40 million people live within 4 miles of a Superfund site,1 and
approximately 4 million people reside within 1 mile of a site, further increasing
their risk of exposure.
In the home, other environmental hazards have well-documented adverse
human health effects. These include radon, environmental tobacco smoke,
pesticides, carbon monoxide and airborne particulates from wood-burning
stoves, nitrogen dioxide from natural gas stoves, formaldehyde and other
chemicals that are released as “off-gases” from new carpets, blown-in foam
insulation, and the synthetic materials that cover the indoor surfaces of many
mobile homes.
Environmental hazards in occupational settings can be substantial, and
workplace injuries and fatalities are the best-documented environmental effects
on health. More than 2.25 million work-related illnesses
1 Superfund sites are hazardous waste sites designated by the EPA to be a threat to
human health; these may include leaking underground storage tanks or inactive
hazardous waste sites such as municipal dumps and contaminated factories or mines and
Nursing, Health, mills
and the(Chiras,
Environment,
editedp.
by462).
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EXECUTIVE SUMMARY
4
and injuries were reported to the U.S. Department of Labor in 1993, the most
recent year for which data are available.
Finally, in addition to community, home, and workplace exposures, global
environmental conditions may adversely affect human health. The global
warming trends experienced over the last century may have numerous untoward
health effects should they continue. For example, it has been estimated that
mortality in U.S. cities during prolonged heat waves may increase by 30–50
percent if current warming trends continue. Depletion of stratospheric ozone
due to the release of chlorofluorocarbons, which has occurred over the Arctic as
well as over the Antarctic, leaves large populations of people in other parts of
the world at risk for adverse health effects from overexposure to ultraviolet
radiation.
In summary, a large spectrum of environmental agents are potential health
hazards. Some of these agents are common, others are not; some are easily
detected, others are not. All of these hazards are important, however, and nurses
need to be aware of them in their daily practice to improve the level of health
care that they provide.
NURSING PRACTICE
With environmental influences on health so widespread and so
consequential, an understanding of environmental health is important in all
areas of nursing practice, including assessment, diagnosis, planning,
intervention, and evaluation. This is already recognized to a large extent in
community and public health nursing and in occupational health nursing. For
example, occupational health nurses routinely take environmental influences
and concerns into account when assessing a patient’s health status. The same
approach needs to be used more widely in other areas of nursing practice.
It is not the intent of this committee to encourage the creation of a new
environmental health specialty within nursing, particularly because closely
related specialties already exist. Rather, the committee supports the importance
of increasing environmental health awareness and content for all nurses,
regardless of their particular field of practice or educational preparation. There
is a fundamental need for the entire nursing community to develop a greater
understanding of environmental health hazards and the skills needed to
incorporate environmental health into practice. The essential skills include a
basic understanding of common environmental and occupational health hazards,
prevention and abatement methods, and the resources available for referral and
assistance (see Box 1, “General Environmental Health Competencies for
Nurses”).
If environmental health concerns are to be included in practice in
meaningful ways, nurses will need to function as members of professional
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EXECUTIVE SUMMARY
5
teams. For effective teamwork, the educational preparation of all health
professionals—nurses, physicians, and allied health professionals—need to
place a greater emphasis on skills needed for interprofessional collaboration,
such as negotiation, critical thinking, and mutual problem solving. In addition,
there must be opportunities for interdisciplinary interaction throughout
professional education and clinical practice, and existing barriers to
interdisciplinary practice must be removed.
BOX 1 GENERAL ENVIRONMENTAL HEALTH
COMPETENCIES FOR NURSES
I. Basic knowledge and concepts
All nurses should understand the scientific principles and underpinnings of
the relationship between individuals or populations, and the environment
(including the work environment). This understanding includes the basic
mechanisms and pathways of exposure to environmental health hazards, basic
prevention and control strategies, the interdisciplinary nature of effective
interventions, and the role of research.
II. Assessment and referral
All nurses should be able to successfully complete an environmental health
history, recognize potential environmental hazards and sentinel illnesses, and
make appropriate referrals for conditions with probable environmental etiologies.
An essential component of this is the ability to access and provide information to
patients and communities, and to locate referral sources.
III. Advocacy, ethics, and risk communication
All nurses should be able to demonstrate knowledge of the role of advocacy
(case and class), ethics, and risk communication in patient care and community
intervention with respect to the potential adverse effects of the environment on
health.
IV. Legislation and regulation
All nurses should understand the policy framework and major pieces of
legislation and regulations related to environmental health.
Interventions in environmental health problems often require nurses and
other health care professionals to assume the roles of advocate, activist, and
policy planner on behalf of an individual patient or population of patients.
Patient advocacy, bringing a patient’s concerns to the attention of the physician
within the health care setting, is familiar to most, if not all, nurses. However,
advocacy that goes beyond the confines of the health care system is a new kind
of activity for many nurses, who may feel ill equipped for translating research
and practice issues into health policy terms.
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EXECUTIVE SUMMARY
6
Advocacy that goes beyond helping an individual patient and enters the
realm of health policy is not yet acceptable and expected nursing practice for all
nurses. To prepare the profession for a broader range of advocacy activities,
nursing curriculum and continuing education programs may come to include
content on such skills as lobbying, use of the media, mediation, expert
testimony, and community organizing. In the meantime, whether with
institutional support or on their own, nurses who are stretching the definitional
boundaries of advocacy practice will need to build skills in areas that were
likely not part of their basic nursing education.
NURSING EDUCATION
The majority of nurses confronting environmental health problems have
not received adequate basic preparation to recognize and respond to them, will
not attend graduate school, and must rely on continuing education programs to
sustain and augment their level of knowledge. A national survey of
occupational and environmental health content in baccalaureate nursing schools
indicated that only one-third included occupational and environmental health
factors as part of routine patient assessment. In addition, in its Seventh Report
to the President and the U.S. Congress, the U.S. Department of Health and
Human Services noted not only significant shortages of occupational and
environmental health personnel but also a serious deficit in nurses’ educational
preparation concerning basic theories, principles, and methods of public health.
Lacking the training and education necessary to recognize the health effects of
environmental agents, nurses cannot begin to intervene appropriately to prevent
further illnesses, injuries, or fatalities.
Opportunities for nurses to learn about, obtain experience in, and otherwise
develop expertise in environmental health are quite limited. Educational
resources intended specifically for training nurses in this area are almost
nonexistent. There are no nursing texts or professional nursing organizations
with a primary focus on environmental health issues, and there are no graduatelevel training programs in schools of nursing that focus on environmental
health. One indicator of nursing education’s lack of emphasis on environmental
health is the limited content included in nursing textbooks. Federal support for
nursing programs in environmental health is currently limited to a small number
of graduate level training programs sponsored by the National Institute for
Occupational Safety and Health.
To better prepare nurses for the environmental aspects of nursing practice,
the environmental health curriculum content in all levels of nursing education
should be enhanced. The committee recognizes that integrating
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EXECUTIVE SUMMARY
7
environmental health content into an already crowded curriculum will require
creativity on the part of faculty, as well as commitment on the part of
educational administrators. Instead of viewing this content as completely new
and separate, nursing educators may find ways to emphasize the environmental
dimensions of existing courses.
The committee’s approach to enhancing education in environmental health
was not to develop a new curriculum or to dictate those elements that should be
part of basic nursing education. Rather the committee’s intent was to help
faculty in nursing programs think about and incorporate environmental health
content into existing courses (or curricula). To that end, this report deals with
four curricular concerns: (1) identifying the general competencies relevant to
environmental health in nursing, (2) suggesting where those competencies may
be addressed and integrated into the curriculum, (3) providing examples of
content areas conducive to the inclusion of environmental health in order to link
educational activities with the competencies to be achieved, and (4) suggesting
resources that will facilitate the teaching of environmental health issues. A
summary of the committee’s approach is presented in Table 4.1 in Chapter 4 of
the report which lists core courses commonly found in nursing programs.
Accompanying each course are the competencies that could be addressed
therein, an example of suggested content relevant to the course, and references
and resources.
The committee also recognizes that most nurses will continue to be
educated at less-than baccalaureate levels, where fewer opportunities exist for
including environmental health content. Moreover, nurses already in practice
will not benefit directly from curricular changes in basic nursing education.
Meeting the environmental health training needs of nurses in associate degree
and diploma programs, and of nurses already in practice will require the
development of continuing education opportunities and other kinds of
professional support. In other words, a range of different strategies will be
needed because of the widely varying education and employment circumstances
of registered nurses (RNs).
NURSING RESEARCH
Nursing research is geared to understanding human responses and behavior
in regard to health rather than to an elucidation of diseases and their treatment
or cure. Clarifying the complex relationship between human behavior and the
physical and biological effects of environmental hazards with the goal of
facilitating social and behavioral changes is a major focus of nursing research in
environmental health. The knowledge generated from nursing research shows
how people achieve health, respond to threats to their health, and cope with
disease and the treatment
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EXECUTIVE SUMMARY
8
of disease. In nursing research the view of people (seen individually or
collectively) is holistic, and a priority is the preservation of human autonomy in
the achievement of health. Thus, in the area of environmental health, nursing
research addresses (1) human responses to potential and real environmental
hazards and (2) interventions directed toward the prevention of exposure to
environmental hazards (primary intervention), the limitation of exposure to the
hazards (secondary intervention), and treatment or rehabilitation after exposure
to environmental hazards (tertiary intervention). Nursing research also
addresses the quality and safety of the physical environment from the
perspective of how people interact with their environment during the course of
their daily lives. An example of this type of research is the work-related
enhancement of person-environment compatibility through reductions of
ambient stresses such as noise levels. Nursing research is also directed toward
quality control of the physical environment and related public policy. Nursing
research thus spans the area from individual biological (e.g., physical symptoms
of lead poisoning) and behavioral (e.g., ingestion of paint chips) responses to
environmental hazards, to collective and group behavior (e.g., community
efforts or regulatory policy aimed at removing a hazard).
In order to assess the status of research in nursing, a survey of the literature
was conducted. The survey showed that there is, in general, a dearth of research
in environmental or occupational health related to the practice of nursing.
Overall, nursing research represents an extremely small component of the
portfolio of funded research of the agencies and organizations polled: 9 of 1,367
(0.6 percent) government grants and 12 of 3,124 (0.4 percent) grants from
professional and private research organizations. The reason for this
underrepresentation was not explored, but it likely reflects the small number of
people conducting nursing research. Thus, nurse researchers and nursing
research in the area of environmental or occupational health are
underrepresented both in terms of numbers and activity. Further, nonnurse
investigators in the area of environmental or occupational health do not appear
to be conducting studies directly related to the knowledge base for nursing
practice. Expansion of the research directly related to nursing practice in the
area of environmental or occupational health is most likely to be accomplished
by expanding the level of research conducted by nurse investigators.
Currently, nurse principal investigators in the area of environmental and
occupational health identified in the survey are mainly affiliated with schools of
nursing (48.6 percent). Interestingly, there is a larger proportion of nurse
principal investigators working in corporate settings (20 percent) than in other,
nonnursing university units (11.4 percent), such as in schools of public health.
This finding most likely reflects the predominant occupational health focus of
the studies captured in the literature
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EXECUTIVE SUMMARY
9
survey (91.4 percent). Schools of nursing and universities are the administrative
homes for the majority of the nurse investigators in environmental or
occupational health. However, the private sector is also active in nursing
research.
The scope of the research studies surveyed (grants and published papers)
was broad in terms of topics, subject groups, and health hazards or conditions
studied. In contrast, the type of design and total funding for nursing research
appear to be limited. Current nursing research in the area of environmental or
occupational health appears to be predominantly descriptive rather than clinical.
This is a serious limitation because the application of knowledge to practice
generally follows clinical intervention studies. To conduct research that can
serve as a basis for clinical nursing practice in environmental or occupational
health, it may be necessary to conduct some descriptive studies to identify
appropriate and valid biobehavioral models from which nursing interventions
could emanate. However, the highly descriptive research found in the survey
might also reflect an inadequate focus of the research on clinical intervention
strategies for nurses, even though it is conducted by nurse investigators. It is
difficult to ascertain information regarding the nurse’s role in multidisciplinary
team research where the nurse is not a co-investigator.
Regardless of the reason for the predominantly descriptive nature of
nursing research, it is clear that scant research supports the clinical practice of
nursing in environmental health. Because nursing, like other health professions,
strives to base its clinical practice and educational programs on knowledge
generated from research, the volume of relevant clinical data in environmental
health must be increased to support nursing practice in this area. To generate an
adequate knowledge base to support nursing practice in environmental or
occupational health, the numbers of nurse researchers and funded projects must
be increased, and the design of the work must be broadened to include
experimental and intervention studies.
SUMMARY OF RECOMMENDATIONS
Table 1 contains a listing of all of the recommendations presented in this
report. Each recommendation is elaborated on in its respective chapter with a
rationale and strategies for implementation.
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EXECUTIVE SUMMARY
TABLE 1 Summary listing of all recommendations in this report
Nursing Practice
Recommendation 3.1: Environmental health should be reemphasized in the scope of
responsibilities for nursing practice.
Recommendation 3.2: Resources to support environmental health content in nursing
practice should be identified and made available.
Recommendation 3.3: Nurses should participate as members and leaders in
interdisciplinary teams that address environmental health problems.
Recommendation 3.4: Communication should extend beyond counseling individual
patients and families to facilitating the exchange of information on environmental
hazards and community responses.
Recommendation 3.5: The concept of advocacy in nursing should be expanded to
include advocacy on behalf of groups and communities, in addition to advocacy on
behalf of individual patients and their families.
Recommendation 3.6: Conduct research regarding the ethical implications of
occupational and environmental health hazards and incorporate findings into
curricula and practice.
Nursing Education
Recommendation 4.1: Environmental health concepts should be incorporated into
all levels of nursing education.
Recommendation 4.2: Environmental health content should be included in nursing
licensure and certification examinations.
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EXECUTIVE SUMMARY
Recommendation 4.3: Expertise in various environmental health disciplines should
be included in the education of nurses.
Recommendation 4.4: Environmental health content should be an integral part of
lifelong learning and continuing education for nurses.
Recommendation 4.5: Professional associations, public agencies, and private
organizations should provide more resources and educational opportunities to
enhance environmental health in nursing practice.
Nursing Research
Recommendation 5.1: Multidisciplinary and interdisciplinary research endeavors
should be developed and implemented to build the knowledge base for nursing
practice in environmental health.
Recommendation 5.2: The number of nurse researchers should be increased to
prepare to build the knowledge base in environmental health as it relates to the
practice of nursing.
Recommendation 5.3: Research priorities for nursing in environmental health
should be established and used by funding agencies for resource allocation decisions
and to give direction to nurse researchers.
Recommendation 5.4: Current efforts to disseminate research findings to nurses,
other health care providers, and the public should be strengthened and expanded.
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EXECUTIVE SUMMARY
Portrait of Florence Nightingale in a hospital ward used on the cover of the
sheet music for a popular ballad written in her honor; ”The Nightingale’s
Songto the Sick and Wounded.”
Lithograph (1857). Property of Duke University Medical Center Library,
History of Medicine Collections, Durham, NC.
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INTRODUCTION
13
1
Introduction
I use the word nursing for want of a better. It has been limited to signify
little more than the administration of medicines and the application of
poultices. It ought to signify the proper use of fresh air, light, warmth,
cleanliness, quiet, and the proper selection and administration of diet—all at
the least expense of vital power to the patient.
—Florence Nightingale, 1860, p. 8
At its inception, the profession of nursing adopted a holistic approach
toward health promotion and the prevention of illness and injury. Florence
Nightingale founded modern nursing on the tenet that the role of the nurse was
primarily to modify the environment in ways that enhanced health and healing.
Her classic text Notes on Nursing (Nightingale, 1860), the first volume to
codify nursing practice, includes topics such as ventilation and heating, health
of houses, noise, light, food, and cleanliness. In Nightingale’s view, any factor
that can affect the health of the patient and the health of the public was relevant
to nursing practice.
At the time that nursing began to emerge as a profession, the interaction of
the environment and health was difficult to ignore. Nurses worked
predominately in the community, overseeing the care of the sick in homes, work
sites, and schools, where environmental threats to health were often extreme
and highly visible (DeWitt, 1990; Kalisch and Kalisch, 1986; Moore, 1990;
O’Reilly, 1990; Pierson, 1990; Scovil, 1990). In those early days, nursing care
included responsibility for “the construction, sanitation, and hygiene of all
places where people pass their waking hours or sleep” (Davis, 1990). However,
despite the good fit between environmental health concerns, core nursing
values, and the profession’s early history, over the years environmental factors
increasingly came to be treated as separate from the nursing domain. As
hospitals assumed a greater role in the health care system, more nurses were
employed in noncommunity-based settings (Kalisch and Kalisch, 1986).
Nursing care focused increasingly on the individual patient’s health,
specifically, the treatment of disease
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INTRODUCTION
14
and rehabilitation. Less emphasis was placed on preventive care in general,
including the elimination of harmful environments and the enhancement of
healthful environments.
This trend continues in nursing today. Environmental health currently
receives scant attention in nursing education and research (Rogers, 1991, 1994;
Snyder et al., 1994). Neither the present organizational structure of nursing
practice nor the reimbursement mechanisms presently in place for nurses favor
the development of nursing skills related to environmental health hazards. In
fact, numerous barriers discourage or prevent nurses from fulfilling their
potential in this regard. Environmental health hazards have come to be
perceived as something separate from the usual practice of nursing rather than
as a set of concerns integral to its mission.
Nevertheless, nurses remain well positioned to address the potential health
effects from environmental hazards at both the individual and community
levels. The 2.2 million registered nurses in the United States make up the
nation’s largest group of health care providers (HRSA, 1992). On a daily basis,
regardless of specialty or practice site, nurses meet people who are at risk or ill
because of hazards in the environment such as contaminated food or drinking
water, toxic waste, occupational exposures to harmful substances and
conditions, lead and radon in the home, and health-threatening conditions
related to poverty. The health benefits to patients from nurses’ better education
and fuller involvement in addressing environmental health concerns are
potentially enormous.
The intent of this report is to remind providers, planners, administrators,
observers, and receivers of nursing services that environmental health concerns
should not be left to others or relegated to a small group of nursing specialists.
On the contrary, these concerns are relevant to the entire nursing community,
being part and parcel of the holistic health approach that nursing at its best has
always championed.
DEFINING ENVIRONMENTAL HEALTH
The committee recognizes a need to distinguish between issues of
environmental health and issues more specific to the science of ecology. The
primary focus of this report is on the adverse health outcomes that may be
associated with exposure to environmental hazards rather than efforts to
conserve natural resources. This is in no way intended to diminish the
importance of ecological issues.
The environmental hazards of concern in this report fall into four widely
accepted classes: chemical, physical, biological, and psychosocial. Such hazards
may be naturally occurring, such as radon or ultraviolet light from the sun, or
they may be manmade (or “constructed”), such as
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INTRODUCTION
15
particulates and gases released into the environment from automotive exhaust,
industrial sources or tobacco smoke. As these examples demonstrate,
environmental hazards may be encountered in the home, workplace, and
community environments. Thus, adverse health outcomes related to
environmental conditions include worker and childhood lead poisoning,
childhood and occupationally induced asthma, and repetitive motion injury,
among many others. Taken in this context, use of the term environmental health
throughout this report refers to freedom from illness or injury related to
exposure to toxic agents and other environmental conditions that are potentially
detrimental to human health.
The committee includes the workplace in this definition because the
workplace is the locus of some of the most significant environmental exposures.
Moreover, many concepts and principles from the field of occupational health
and occupational health nursing are directly relevant and applicable to broader
environmental health issues.
Some health problems that nurses encounter fit easily into the definition of
environmental health given above (e.g., lead poisoning). There is heated debate
over others that exist in the overlap between health and social problems. For
example, interpersonal violence has not been traditionally regarded as an
environmental health issue. Some argue that violence is an environmental
health problem, because violence represents a major and growing threat to
health in the environments of many people (NRC, 1993a). The committee
wishes to underscore that all definitions of environmental health are socially
constructed, reflecting politics as well as science. Nurses and other health
professionals must remember that the conceptual boundaries of environmental
health are not set in stone and may expand or narrow as social priorities change
and as scientific knowledge increases.
ENVIRONMENTAL HEALTH AS A CORE FUNCTION OF
NURSING PRACTICE
As defined in this report, environmental hazards to human health affect all
areas of nursing practice. Nurses, often the first contact point in the health care
system and with responsibility for managing the care of individuals over time,
are well positioned to ask questions and make observations that can lead to the
accurate assessment of and prompt intervention in problems related to
environmental conditions and exposures. Pediatric nurses, for example, need to
be vigilant with respect to specific hazards for children, such as residential lead
paint, and knowledgeable of children’s unique vulnerabilities to environmental
agents caused by rapid growth and cell division, higher metabolic and
respiratory rates, and dietary patterns that differ from those of adults (NRC,
1993b). Gerontology
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INTRODUCTION
16
and oncology nurses need to understand that cancers and other diseases in older
people may be due in whole or in part to toxic exposures that occurred years
earlier in the workplace, home, or community. Nurses working in obstetrics and
gynecology need to be aware that many environmental hazards are known to
affect adversely reproductive health or are suspected of doing so (Paul, M.,
1993). Emergency department and trauma nurses need to know how to isolate,
decontaminate, and treat workers and emergency response personnel who are
exposed to toxic chemicals through transportation spills, industrial accidents, or
unsafe working conditions. Occupational health nurses, who already address
health hazards in the work environment, need to be wary of workplace
chemicals that can be carried into the community as effluent or into homes on
the clothing of workers, putting additional populations at risk.
In particular, any nurse caring for economically disadvantaged patients
should be aware that these populations often face an increased risk of exposure
to hazardous environmental pollutants. For example, low-income and minority
populations are more likely to live near or work in heavily polluting industries,
hazardous waste dump sites, and incinerators (EPA, 1992). They are more
likely to live in substandard houses with friable asbestos and deteriorating lead
paint and to have yards with contaminated soil. They are also more likely to be
exposed to toxic chemicals through diets that include seafood or fish taken from
local waters designated unfit for swimming and fishing. Thus, the
environmental burden is generally greater for minorities and the economically
disadvantaged because they are exposed to a greater number and intensity of
environmental pollutants in food, air, water, homes, and workplaces. Inequities
of this kind have generated sharp controversies, often cast in terms of
“environmental justice,” about legislative and regulatory measures that can be
used to decrease the burden of pollution on disadvantaged communities. The
environmental justice issue has special relevance to this report, because for
many disadvantaged populations, nurses represent the initial and most
consistent point of contact with the health care system. Because of their close
contact, nurses are well positioned to represent the environmental concerns of
members of these communities in discussions of health policy.
Individuals and communities often lack adequate information about
environmental hazards to enable them to act on their own behalf. There are a
variety of reasons for this lack of access to information, such as the use of
overly technical language in warning signs, illiteracy, and language
inadequacies. Nurses are responsible for responding to an individual’s or a
community’s lack of access to information.
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INTRODUCTION
17
MOVING TO A POPULATION-BASED PERSPECTIVE
At present, when the nursing profession addresses environmental health at
all, it is generally in the context of the individual patient or the patient’s family.
However, as in the case of health issues related to environmental justice, an
equally important dimension of environmental health is the community context.
Populations of entire neighborhoods and regions can be affected by industrial
pollution, waste disposal facilities, contaminated streams and soil, toxic
incinerator emissions, and other potential environmental threats to health.
The effects of environmental hazards on the health of the community often
generate public controversy, and concerned citizens organize their communities
to protect their health, legal, and financial interests. One of the most familiar
examples occurred at Love Canal, New York, in the 1960s when citizens
learned that their residential neighborhood was contaminated with potentially
dangerous industrial waste. They organized under the leadership of Lois Gibbs,
a resident of the community with no special training in environmental issues,
and sought professional help from local and state health department officials
and scientific experts. Their concern eventually grew into a major social
movement involving litigation, social protest, and government intervention.
Because of the national media attention that the movement received, Love
Canal became an important symbol for the national environmental movement.
Ms. Gibbs’ organization developed its own scientific expertise through selftraining with expert assistance. The organization subsequently developed into a
national resource center (see Appendix D), offering technical assistance to
communities facing environmental health threats. Other more recent examples
of community-based environmental health activism abound (Ashford, 1994;
Needleman and Landrigan, 1994). Some of these efforts occur on an entirely
local level. Others (for example, dioxin in the soil at Times Beach, Missouri,
and contaminated drinking water at Woburn, Massachusetts) have been covered
intensively by the national press and television networks and have become the
focus of major health research efforts.
In such situations, residents of the community tend to seek help from local
health professionals, including nurses. Residents will especially turn to nurses
working in public health, community health, and occupational health, but nurses
outside these specializations may also be drawn into the issue simply because
they reside in the area and are trusted by the community. Whether or not they
are prepared for the role, nurses in all fields of practice may find themselves
interacting with worried residents of the community. They may be asked to
assess, advise, and counsel pregnant women who are concerned about the
possibility of birth defects,
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INTRODUCTION
18
parents concerned about the safety of the drinking water or children’s play
areas, workers at high risk of cancer from occupational chemical exposures,
workers’ compensation claimants and community litigants seeking redress for
their injuries, and homeowners with questions about the health effects of
residential lead or radon, as well as questions about the costs of mitigating the
hazard.
In responding to citizen concerns of this kind, most nurses are at a distinct
disadvantage, because in general, there is a wide disparity between a public
health orientation and the way that nurses are taught to practice their profession.
Public health issues must be approached from a population-based, primary
prevention perspective. Yet, most nurses practice their profession from a
curative perspective that focuses on ill individuals. This mismatch creates
conceptual and practical difficulties for nurses involved with environmental
health issues. They may feel that they lack the authority to take a public health
approach or that they lack the skills to analyze health issues in population-based
terms. They may be interested in reconceptualizing the ways in which
environmental factors fit into their nursing practice, but they are too pressured
and busy to consider such a reconceptualization. In light of the controversy that
sometimes surrounds public health issues, nurses may feel safer caring for
individuals because this is the task with which they are more familiar; caring for
individuals allows nurses to stay solidly within the boundaries of the health care
system without stepping into the social, legal, and political arenas important for
disease prevention.
Tension between the paradigm of public health and the paradigm of
individual care, a serious concern in environmental health, also underlies many
other current debates in health care (Barnes et al., 1995). One goal of this report
is to provide realistic guidance and assistance to nurses in various practice roles
so that they can bridge the gulf between the two frameworks in relation to
environmental health.
THE NURSING WORKFORCE
Preparing nurses to respond more effectively to environmental health
problems raises complex professional issues, in part because nursing offers so
many different levels of training and routes to practice. The term nurse as used
in this report refers to registered nurses (RNs) who have graduated from an
accredited nursing education program and who have passed the licensure
examination. However, not all RNs are the same in terms of educational
background, clinical experience, or preparation. The entry-level professional
licensure examination (NCLEX, National Council Licensure Examination for
Registered Nurses) does not include content specific to environmental health or
general concepts of population-based
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INTRODUCTION
19
practice central to public health, which include the environment as a primary
determinant of health. The current curricular content relevant to environmental
health varies dramatically among professional nursing education programs.
Despite their common licensure status, not all nurses are trained to practice
in the same settings, with the same level of skill, or in the same roles. Most RNs
receive their basic nursing education in one of three programs: hospital
diploma, associate degree, or baccalaureate degree.1 Graduates with hospital
diplomas and associate degrees are prepared primarily as skilled members of
the team that delivers direct patient care services in institutional settings. Nurses
with baccalaureate degrees are likewise prepared primarily for patient care in
institutional or organized care settings, including community-based health care
facilities. However, they also serve in leadership roles and are expected to
revise nursing practice, conduct quality control analyses, and participate in
research.
Nurses with clinical graduate degrees and/or specialty certification are
commonly referred to as advanced practice nurses (APNs). These include
clinical nurse specialists, who are often employed in tertiary-care settings, and
nurse practitioners, who often work in the community (AACN, 1994). These
nurses are prepared for leadership roles in advanced practice and collaborative
roles with other health care professionals. Independent practice and practice in
partnership with physicians may require educational preparation at the master’s
level or higher as well as national certification. These nurses structure,
implement, and evaluate systems of health care delivery in hospitals or
community-based settings and provide continuing education to other staff to
improve practice. While some APNs may have received some formal
preparation in environmental health concepts through occupational health
nursing programs at the master’s or doctoral level, the supply of nurses with this
kind of training is meager.
One of the fundamental problems related to enhancing environmental
health content in nursing practice is the fact that only about one-third of the
nurses in community-based settings have formal training in public health or
environmental health concepts and the related clinical experience necessary to
deal adequately with the environmental aspects of health. This problem has
occurred because only nurses prepared at the baccalaureate level or higher are
likely to have formal training in basic public health and environmental health
concepts, and only one-third of the RNs in community-based settings have
training at the baccalaureate
1
A small number of nurses obtain their basic nursing preparation in master’s degree
Nursing, Health, programs.
and the Environment, edited by Andrew M. Pope, et al., National Academies Press, 1995. ProQuest Ebook
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INTRODUCTION
20
level or higher; the other two-thirds are largely graduates of associate degree
programs that provide only an observational experience in community care
settings (HRSA, 1992) (see Chapter 4).
This mismatch between the level of educational preparation of RNs and
their practice settings and roles in relation to environmental health is part of a
more general problem in the composition of the nursing workforce. In a recent
review of priorities for the health care workforce, Aiken and Salmon (1994)
concluded that in terms of sheer numbers, the aggregate supply of nurses
appears to be adequate for meeting national needs in the near term. However,
they noted that the mix of nurses by educational background is inadequate to
meet the increasing demand for nurses in leadership and advanced practice roles.
ORIGIN, PURPOSE, AND ORGANIZATION OF THE REPORT
At the request of a consortium of federal agencies (Agency for Toxic
Substances and Disease Registry, National Institute of Environmental Health
Sciences, National Institute of Nursing Research, Health Resources and
Services Administration, National Institute for Occupational Safety and Health,
Environmental Protection Agency), and as follow-up to a planning meeting
conducted by the Institute of Medicine (IOM), the IOM established the
Committee on Enhancing Environmental Health in Nursing Practice to address
issues related to the need for enhancing environmental health content in nursing
practice. The committee was charged with the following tasks:
• assess the current status of environmental health in the practice of
nursing and the need for enhanced education and research;
• provide guidance on the development of environmental health curricula
for nurses;
• identify barriers to the integration of environmental health content into
nursing education and the practice of nursing;
• develop implementation strategies for enhancing environmental health
in nursing education, practice and research, including methods and
resources for faculty development;
• describe methods for evaluating the effectiveness of an enhanced
environmental health curriculum; and
• identify and describe: (a) environmental health/nursing research issues,
(b) potential roles for government, industry, and academia in
supporting environmental health/nursing research and practice, and (c)
potential collaborative and interdisciplinary activities and research
initiatives that might be undertaken in addressing environmental health/
nursing issues.
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INTRODUCTION
21
The report offers some starting points for considering what kinds of
change are needed and what kinds of change are possible with respect to
enhancing the environmental health content in nursing practice, and should be
of interest to nurse educators, practicing nurses, and other professionals who
interact with nurses to promote the health of the public. First, it provides factual
information about the present status of the environmental health content in
nursing practice, education, and research. Second, it clarifies some of the
complex reasons for the present neglect of this subject area in professional
nursing. Third, it proposes some strategies for enhancing the training, skills, and
roles of nurses so that they are better able to make the connection between
environment and health and more empowered to help the patients and
populations affected by environmental health hazards.
Following this introduction, Chapter 2 outlines some of the environmental
health hazards of concern. The subsequent three chapters examine, in turn, the
complexities of enhancing environmental health content in nursing practice,
education, and research. The analysis and discussion in each chapter concludes
with some recommendations for change that would improve nursing by
enhancing the emphasis on environmental health. Eight appendixes are included
at the end of the report: (A) The Nurse’s Role in Safeguarding the Human
Environment (ICN, 1986); (B) Environmental Hazards for the Nurse as a
Worker; (C) Environmental Health Curricula (Lipscomb, 1994a); (D)
Environmental Health Resources: Agencies, Organizations, Services, and
General References; (E) Focus Group Summary and Lists of Focus Group
Participants; (F) Nursing Advocacy at the Policy Level: Strategies and
Resources; (G) Taking an Environmental Health History; (H)
Acknowledgments; and (I) Committee and Staff Biographies.
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22
”I was sick and ye visited me.”
Florence Nightingale at Therafia Hospital, near Constantinople, Turkey.
Photogravure (1855). Property of Duke University Medical Center Library,
History of Medicine Collections, Durham, NC.
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OVERVIEW OF ENVIRONMENTAL HEALTH HAZARDS
23
2
Overview of Environmental Health Hazards
The most difficult challenges for environmental health today come not
from what is known about the harmful effects of microbial agents; rather they
come from what is not known about the toxic and ecologic effects of the use of
fossil fuels and synthetic chemicals in modern society.
—DHHS, 1990, p. 312
Environmental health hazards are ubiquitous, affecting all aspects of life
and all areas of nursing practice. As noted by the National Research Council in
1984, more than 65,000 new chemical compounds have been introduced into
the environment since 1950, and new chemical compounds enter commerce
each year. The post-World War II era brought major technological advances to
society, accompanied by the release of an unprecedented amount of synthetic
chemicals onto U.S. markets. It is presently estimated that there are 72,000
chemicals currently used in commerce (excluding food additives, drugs,
cosmetics, and pesticides), the majority of which have had limited testing for
their effects on human health and the environment (INFORM, 1995). Even less
is known about simultaneous exposures to a number of different chemicals,
which is how most human contact with chemicals occurs.
As early as 1979, the Surgeon General’s Report on Health Promotion and
Disease Prevention noted, “There is virtually no major chronic disease to which
environmental factors do not contribute, either directly or indirectly” (DHHS,
1979, p. 105). Nevertheless, it is impossible to accurately quantify the burden of
morbidity and mortality related to environmental exposures for several reasons:
poor compliance with reporting requirements for occupational illness, long
latency periods between initial exposure and resulting disease, the inability of
health care providers to recognize environmental etiologies of diseases, and the
absence of national reporting systems for environmentally related illnesses. The
extent of the problem is further obscured by the multifactorial etiology of many
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OVERVIEW OF ENVIRONMENTAL HEALTH HAZARDS
24
environmentally related diseases (e.g., lung cancer caused by exposure to
asbestos is more likely to occur among people who smoke tobacco).
Nevertheless, the link between adverse health effects and exposure to
environmental hazards has been well established, and much can be done to
prevent or minimize environmentally rel…
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