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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Nursing Health, & Environment: Strengthening the Relationship to Improve the Public's Health 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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Nursing Health, & Environment: Strengthening the Relationship to Improve the Public's Health 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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Nursing Health, & Environment: Strengthening the Relationship to Improve the Public's Health 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 mills (Chiras, 1994, p. 462).

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Nursing Health, & Environment: Strengthening the Relationship to Improve the Public's Health 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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Nursing Health, & Environment: Strengthening the Relationship to Improve the Public's Health 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. 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. 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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Nursing Health, & Environment: Strengthening the Relationship to Improve the Public's Health 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 graduate-level 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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Nursing Health, & Environment: Strengthening the Relationship to Improve the Public's Health 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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Nursing Health, & Environment: Strengthening the Relationship to Improve the Public's Health 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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Nursing Health, & Environment: Strengthening the Relationship to Improve the Public's Health 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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Nursing Health, & Environment: Strengthening the Relationship to Improve the Public's Health 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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Nursing Health, & Environment: Strengthening the Relationship to Improve the Public's Health 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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Nursing Health, & Environment: Strengthening the Relationship to Improve the Public's Health 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 Song to the Sick and Wounded." Lithograph (1857). Property of Duke University Medical Center Library, History of Medicine Collections, Durham, NC.