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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Nursing Health, & Environment: Strengthening the Relationship to Improve the Public's Health 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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Nursing Health, & Environment: Strengthening the Relationship to Improve the Public's Health 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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Nursing Health, & Environment: Strengthening the Relationship to Improve the Public's Health 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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Nursing Health, & Environment: Strengthening the Relationship to Improve the Public's Health 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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Nursing Health, & Environment: Strengthening the Relationship to Improve the Public's Health 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 self-training 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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Nursing Health, & Environment: Strengthening the Relationship to Improve the Public's Health 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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Nursing Health, & Environment: Strengthening the Relationship to Improve the Public's Health 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 programs.

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Nursing Health, & Environment: Strengthening the Relationship to Improve the Public's Health 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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Nursing Health, & Environment: Strengthening the Relationship to Improve the Public's Health 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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Nursing Health, & Environment: Strengthening the Relationship to Improve the Public's Health ''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.