The purpose of this appendix is to provide guidance on the development of environmental health curricula by defining essential curricular content, competencies, and learning objectives in environmental health as they relate to existing specialty areas and educational levels. Before doing so, however, two caveats should be kept in mind when reviewing the proposed content.
First, if nurses are truly going to make a significant contribution in the area of environmental health, they will need to develop, at a minimum, an awareness, and, ideally, some expertise in the range of areas included in the specialty area of environmental and occupational health. This is particularly true for frontline health care professionals who may be the first and sometimes only contact with members of the public who have many informational needs regarding environmental hazards. As a result, the proposed essential curricular content is comprehensive and may appear to be resource intensive upon first review. However, if it is integrated successfully, the suggested content will not be burdensome but will result in an improved overall basic nursing education, one which will better prepare nurses for future practice within the context of health care reform.
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Nursing Health, & Environment: Strengthening the Relationship to Improve the Public's Health C Environmental Health Curricula* The purpose of this appendix is to provide guidance on the development of environmental health curricula by defining essential curricular content, competencies, and learning objectives in environmental health as they relate to existing specialty areas and educational levels. Before doing so, however, two caveats should be kept in mind when reviewing the proposed content. First, if nurses are truly going to make a significant contribution in the area of environmental health, they will need to develop, at a minimum, an awareness, and, ideally, some expertise in the range of areas included in the specialty area of environmental and occupational health. This is particularly true for frontline health care professionals who may be the first and sometimes only contact with members of the public who have many informational needs regarding environmental hazards. As a result, the proposed essential curricular content is comprehensive and may appear to be resource intensive upon first review. However, if it is integrated successfully, the suggested content will not be burdensome but will result in an improved overall basic nursing education, one which will better prepare nurses for future practice within the context of health care reform. * This Appendix was prepared by Jane Lipscomb, R.N., Ph.D., and was presented by her to the Committee on Enhancing Environmental Health Content in Nursing Practice at the committee's second meeting on August 4, 1994.
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Nursing Health, & Environment: Strengthening the Relationship to Improve the Public's Health Second, the current focus of this Institute of Medicine (IOM) initiative is environmental health. Although the committee's definition of environmental health encompasses occupational health, the two areas are not treated in parallel within this initiative, as in the 1988 IOM report on primary care physicians. This appendix is based on the committee's working definition of environmental health in its general approach to the curriculum. However, some of the content in the proposed curriculum is considered parallel between occupational health and environmental health, such as history taking and the regulatory framework. By way of introducing the recommendations for the specific content, a nursing curriculum that incorporates essential content in environmental health must be grounded in the basic principles of epidemiology and toxicology and must incorporate the concept of risk and its application to groups and individuals. Such curricula should be viewed not only as enhancing the environmental health content of the curriculum but also as preparing nurses to more successfully contribute to overall disease prevention and health promotion efforts. ESSENTIAL CURRICULAR CONTENT The essential curricular content can be grouped into the following four areas: nursing and the environment, legislation and regulations, exposure recognition and principles of control, and health consequences. The area of nursing and the environment includes a definition and framework for environment different from the current use of the term in nursing. This area also includes an articulation of nursing's role in promoting environmental health, for example, in areas of environmental justice and advocacy. The important area of risk perception and risk communication is also included within this category, although this content would be sequenced differently in an actual curriculum. Legislation and regulations must include an overview of major environmental and occupational legislation. Exposure assessment includes an understanding of the basic principles of toxicology, such as routes of exposure and dose (i.e., dose-response and time-dose characteristics). A basic understanding of the principles of controlling exposures is also included because this knowledge is essential to preventing environmental illnesses. Lastly, the area of health consequences includes the ability to take an environmental and occupational history, basic knowledge of sentinel environmental illnesses, and the ability to recognize when referral to a specialist is indicated. The length of the program of study (e.g., Bachelor of Science in Nursing [BSN] versus Associate Degree [AD]) and the presence of community health- and policy-focused course work will dictate the level of detail possible. It should be the goal of all basic nursing programs to incorporate
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Nursing Health, & Environment: Strengthening the Relationship to Improve the Public's Health some level of each of the essential content areas into their curricula through formal didactic course work, field experiences, and/or self-study. More specific recommendations for content in these four areas follow. Nursing and the Environment Definition of the environment (e.g., physical, chemical, and biological agents in air, food, water, and/or soil). Impact of the environment on the public's health and the epidemiology of major environmental illnesses. Role of nursing practice in promoting environment health. Role of advocacy in environmental health and environmental justice. Principles of risk perception and risk communication. Legislation and Regulation An overview of major environmental and occupational health legislation and regulatory agencies (e.g., Environmental Protection Agency [EPA], Toxic Substances Control Act [TSCA], National Institute of Environmental Health Sciences [NIEHS], Agency of Toxic Substances and Disease Registry [ATSDR], Occupational Safety and Health Administration [OSHA], and National Institute for Occupational Safety and Health [NIOSH]). Environmental health resources at the national, state, and local levels. Exposure Assessment Definitions and basic principles of hazard, exposure, and dose. Principle of dose-response relationship and time-dose characteristics. Routes of exposure to environmental contaminants. Process of hazard recognition and control (e.g., hierarchy of controls). Health Consequences Environmental and occupational health screening history. Criteria for the work or environmental relatedness of a disease or condition. Indications for more in-depth history taking. Indications for a referral to specialists. Basic knowledge of environmental sentinel health events and most prevalent conditions (e.g., lead exposure or poisoning, pesticide poison-
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Nursing Health, & Environment: Strengthening the Relationship to Improve the Public's Health ing, asbestos-related disease, environmentally induced or exacerbated asthma). The competencies and learning objectives related to this content are described in the following section. A discussion of where and how to integrate this content into existing curricula is presented in the final section of the paper. COMPETENCIES AND LEARNING OBJECTIVES The competencies and learning objectives related to the curricular content are as follows: To understand the framework for and major pieces of legislation and regulations in environmental and occupational health. To understand the potential and actual impacts of the workplace and general environment on the health of individual clients and communities in which nurses practice. To understand and be able to articulate the role of nursing practice in promoting environmental health. To demonstrate knowledge of the role of advocacy and justice in environmental health. To understand the principles behind how and why individuals perceive environmental risks as they do and to be able to incorporate these principles into a successful risk communication program. To understand the basic mechanism of exposure to environmental hazards. To demonstrate the ability to recognize and propose basic control strategies for common environmental hazards. To demonstrate the ability to recognize sentinel environmental illnesses. To demonstrate the ability to successfully complete an occupational and environmental health history. To demonstrate the ability to make a referral to a specialist practitioner or public health agency when a patient or group presents with a probable occupational or environmental etiology for their condition. SPECIALTY AREAS AND EDUCATIONAL LEVELS The essential curricular content, competencies, and objectives described above are proposed for basic nursing curricula in general. It should be possible to integrate most, if not all, of the proposed content into existing course work. A more in-depth and comprehensive approach
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Nursing Health, & Environment: Strengthening the Relationship to Improve the Public's Health to this content is possible in a baccalaureate nursing program. An associate degree or diploma program has more constraints on its curriculum and very little focus on community health nursing. Specialty courses or electives offer additional opportunities for more in-depth learning in environmental health. Graduate education offers the opportunity for more advanced training in all of the content areas. The following section contains recommendations for where to incorporate the proposed content into existing didactic course work. Note that in certain content areas the term must is used, whereas in other areas the term should be or could be incorporated is used. These terms were chosen to reflect the level of priority that the author believes is associated with incorporating the various elements of the content into existing curricula. Although no discussion of clinical or field experiences is included in this proposal, it should be highlighted that clinical experiences that incorporate these concepts and processes are essential for truly enhancing the environmental health content in nursing practice. Basic Nursing Education Legislation and regulations should be incorporated into existing leadership and/or policy course work. Principles of environmental advocacy could be taught in either leadership or community health course work. Environmental justice should be addressed in ethics and/or community health course work. Principles of toxicology (e.g., exposure and dose) should be incorporated into existing pharmacology course work. The effects of chemicals on organ systems (environmental illness) must be incorporated into pathophysiology and medical/surgery course work. Environmental and occupational history taking must be included in any physical assessment and/or nursing diagnosis course work. The impact of the environment and occupation on mental health and overall well-being should be incorporated into psycho-socio-cultural course work. Reproductive and childhood toxicants (e.g., prenatal and childhood lead exposure, pesticide exposure, and household chemical exposures) must be included within parent-child nursing course work. Hazard recognition and control should be included within existing community health course work. Specialty/Elective Course Work And Graduate Study More advanced education in the above areas should be incorporated
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Nursing Health, & Environment: Strengthening the Relationship to Improve the Public's Health into the following elective course work and graduate education in these specialty areas: Objectives and time in public health, community health, and primary health care nursing course work must be dedicated to health concerns related to air, food, water, and soil quality. Parent-child and family course work must include lecture content on prenatal and childhood lead exposure, pesticide exposure, environmentally induced asthma, health effects of environmental tobacco smoke, and household chemical exposures. Women's health course work must include lecture content on chemical, physical, and biological agents suspected of being reproductive toxins. Emergency room or trauma course work must include injuries and illnesses resulting from toxic chemical exposures, in particular, emergency chemical releases. Medical/surgery course work must include lecture content on the health effects of chronic exposure to chemical, physical, and biological agents on the job and in the environment (e.g., asbestos, pesticides, heavy metals, solvents, and radon). Oncology course work must include content on environmentally caused (or suspected of causing) cancer. Neurology specialty course work must include content on neurological conditions related to acute and chronic solvent and other neurotoxin exposure. Lastly, the author would recommend that all basic nursing education include content on the health hazards that nurses will face as health care professionals (e.g., chemotherapeutic agents, ethylene oxide, aerosolized drugs, tuberculosis, blood-borne pathogens, radiation, back injuries, stress, and shift work). Not only is this information critical to a successful career in nursing, but hazards in the health care setting can serve as very relevant case studies or examples for teaching the principles of hazard recognition and control.