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OCR for page 239
Nursing Health, & Environment: Strengthening the Relationship to Improve the Public's Health
E
Focus Group Summary and List of Participants
The following is a compilation of responses from focus groups that were convened by individual members of the IOM Committee on Enhancing Environmental Health in Nursing Practice. Twelve (12) focus groups were held with nurses in California, Iowa, Massachusetts, New Jersey, North Carolina, South Carolina, Texas, Washington, DC, and Louisiana.
Participants included specialists in the fields of occupational health, nurse practitioner and public health nursing faculty, practicing public health nurses, practicing family nurse practitioners, nursing doctoral students, nurses representing the American Organization of Nurse Executives, and representatives from the American Association of Colleges of Nursing.
1. What comes to mind with the words "environmental health (EH) issues"?
Responses to this question fell into eight major categories.
Nursing Practice Issues
Absence of EH in current scope of nursing practice, including primary care.
Issue of "jurisdiction" was commonly mentioned. Nursing not linked with public sector in addressing EH issues.
Reimbursement for EH services (how, by whom?)
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Recall early PHN practice, where health problems were related to poor sanitation
Detection, assessment, evaluation, treatment of hazardous substances' toxic effects
Accident prevention and elimination of hazards
Pollutants from health care industry
Practicing with the unit of analysis being the community rather than the individual
Psycho-social Issues
Inner city violence and poverty at epidemic levels (**mentioned by almost all)
Hostile, life threatening environments created by crime
Psychological effects of overcrowding, high density living (condos)
Cultural issues around food and water contamination
Environmental racism (burden of environmental hazards greatest on poor and minorities)
Violence—family, community and workplace
Public Awareness
Heightened public awareness about environmental hazards
Teaching kids to recycle, but not health effects
Media interest, expense
Legal and Ethical Concerns
Conflicts between business and well-being of community
EH legislation without funding to enforce
Control and dissemination of information
Conflict in consumer values—want technology, but not risks
Cost of intervention vs. prevention
Rights of the individual—to live in environment of choice, NRA and gun control
Refer and forget—lack of accountability and continuity in addressing these issues
Scientific/Research Issues
Cause and effect not often clear.
Problems identifying causative agent(s) for illnesses that appear environmentally related.
What is burden (or degree) of human illness/dysfunction that is associated with environmental conditions?
Interaction of various conditions that result in illness
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Mechanism of environmental hazards in causing or contributing to disease
Hazard control mechanisms inadequate
Emphasis is more (too much?) on toxicology than society and community environs.
Concern About Specific Environments
Hospitals and indoor air pollution
Housing, homelessness
Contamination of community by local industry
Urban problems—violence, stress, crowding
Rural health—lack capacity for assessments and referrals (lack of money)
Definition of environment needs to include concepts of economics and power
Concern About Specific Hazards
Sanitation
Air, water and waste management were primary concerns overall
Water and air pollution (indoor and outdoor) most frequently cited issues
Sanitation in general
Contamination of soil and play areas
Contamination of seafood and recreational waters
Contamination of drinking and recreational water by irrigation, farm chemical, and urban runoff
Other Hazards
All types: chemical, biological, physical, mechanical, psycho-social
Waste management and toxic waste (mentioned by more than half of groups)
Fleas, mosquitoes, and pesticides
Lead-based paint
Sick buildings
Farm safety
Electromagnetic fields
Noise (mentioned by more than half of the groups)
Ozone depletion and UV-B exposure
Natural disasters (tornadoes, fires, etc.)
Workplace technology creating hazards to health
Ergonomics
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Nursing Health, & Environment: Strengthening the Relationship to Improve the Public's Health
Deforestation
Foodborne disease
Strip mining and contamination of wells
Radiation exposures
Disease vectors and pest management
Specific Health Conditions
TB
Gulf War syndrome
Sick building syndrome
Legionnaires disease; childhood asthma; increasing incidence of allergic reactions
Carpal tunnel syndrome
2. How are nurses involved with EH?
Education (most frequently cited role)
Accessing and disseminating info. regarding EH factors in health and illness
Prevention oriented ed. on individual, worker, family and community basis
Keeping track of local resources and distributing this info (as go between)
Relaying standards and regulations to employers/employees
Hygiene, immunization, risks, injury control, pica appetite
Educate other team members/disciplines who are more narrowly focused
Advocacy
Work with community, environmental groups, local government
Legislative lobbying
Reporting community hazards
Ideally, all nurses should be advocates for safer environments
Involved in implementing policy
How/Where Involvement Occurs
Via referrals from public sector
Joint inspection of home, community, workplace
ER, OH, and CH practice centers
Involved in regulating teams
Nurse is first to get complaint, then becomes involved in case management
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Nursing Health, & Environment: Strengthening the Relationship to Improve the Public's Health
In Routine Practice and Research
First line problem identification; taking O/E histories
Identify link between illness and environmental condition
Recording and designing interventions, evaluation of outcomes
Implementing medical screening exams (e.g., childhood lead, worker exposures such as pesticides, solvents, pharmaceuticals). Individual and population based.
Demonstrate links between cost effectiveness and reducing hazards at work
Work as interdisciplinary team member (***many groups commented on this)
Focus on prevention, advocacy and as knowledgeable resource
Research in environmental science and technology
Suggest avenues of recourse, make recommendations to improve work conditions
Environmental Assessment
Although this is "routine practice" for some, it was mentioned so frequently and in such varied contexts, I made it a separate sub-section.
Assessment of patients' environment, via history taking and onsite
Identify exposures
Field assessments as component of other ongoing intervention
Extension of role into community and worker's family situation to identify problems related to community, home and workplace exposures
Other
Nurses are not involved if not OHN, PHN or CHN
Hospitals are poorest model of workplace safety/control of hazards. Hazardous but not viewed as such. Many "unempowered nurses," especially in hospital setting.
If EH issues raised at work (hospitals included), often get squelched by administration.
Nurses familiar with holistic approach, have advantage of interacting on personal level.
3. Other ways nurses could be involved?
Generating data systems for environmental assessment and outcomes
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Designing "critical paths" which include environmental assessment
Impact studies (consumer goods, land use)
Increase visibility of issues via PSAs, working with community groups
Work with professional associations
Push for inclusion in interdisciplinary discussions
More general education of public; publish in lay publications
More thorough home assessments
Become more involved with community, EH groups, corporate education
More collaboration within nursing, share information with each other, e.g., PHN could work with ER nurse on issues like violence
Move CH education to early part of nursing ed. so there is less separation between hospital and CH practice
Educate, but also move political system. Law changes behavior more effectively than public education, e.g., bike helmet and seat belt laws.
Revolutionize nursing ed. to focus more on social justice and critical thinking
Serve as role models, and develop role expectations such that attention to EH is routine
4. What would be gained with increased involvement and attention to EH issues?
Big change in HC delivery system, perspectives of medicine and community
Role of nurse would change, they would have some architectural input in HC system. Amplifier effect would occur: 1) make smarter consumer, voter, taxpayer and thus 2) shape behavior of industry and business.
Nurses and clients will be better able to think at a system level to effect change
Primary prevention would be enhanced
Decrease health care costs over long term, with earlier detection of "real" problem or etiology of disease, and interventions that address causative factors as well as medical symptoms.
More holistic approach
Nurses would become resource brokers
Increasing power of lay-groups, if nurses openly stand with them and educate them.
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Consumer would be more prevention oriented
Nurses would become a political voice for disenfranchised, at-risk peoples
Increase scientific knowledge base about environmental exposure and disease
More funding for EH practice, education and research—as knowledge base builds
5. Drawbacks to enhancing EH in nursing practice?
Will be difficult to change practice and education:
Nurses don't know "what they don't know," thus cannot understand impacts of enhancing knowledge base about EH issues
Nursing curricula already full
No faculty expertise in this area, and curricula is driven (in part) by this
Practicing nurses already spread too thin, no time to add new routine duties
Will require "revolution" or "new paradigm" of nursing education and practice based on systems level approach and/or critical thinking
May require redrawing the picture of nursing ed., rather than just adding content
No reimbursement structure for these activities
Be careful about creating expectations of quick fixes and easy solutions to EH problems.
Social and Economic Issues
Employers and employment may be threatened by nurses speaking out, drawing attention to issues
Turf battles rather than interdisciplinary collaboration may result.
Crusader image, can be portrayed negatively by peers, administrators, media
Backlash from political orientation: stereotyping and further division among nurses
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Nursing Health, & Environment: Strengthening the Relationship to Improve the Public's Health
6. What must be done to include EH in nursing practice?
Nursing Education Issues
Revamp nursing education: either add on EH piece, integrate it into other components, or include part of total revision of nursing curricula
Develop faculty expertise
Create new specialty in EH at graduate level (?)
"Market" or educate nursing faculty and administrators about magnitude of EH problems, and value of creating more knowledgeable nursing workforce in this area
Provide EH education at all levels of nursing education, and CE for current workforce.
CE must be ongoing as environmental health knowledge base expands
Begin to introduce earth science terms in (or in preparation for) nursing curricula
Two or three nursing schools need to take the lead, pilot revision of curricula
Nursing Practice/Professional Approaches
Educate administrators, CEOs, corporate officials about role nurses can take in resolution of EH problems
Demonstrate cost-benefit of interventions (e.g. primary prevention), to administrators, government officials, and legislators
Develop reimbursement structure for nursing EH interventions, e.g., working with insurance industry, change in NANDA codes
Amend ANA definition of nursing, NLN accrediting criteria
Amend credentialing/licensure exams to include EH content
Amend some specialty practice area definitions, e.g., CHN, PHN
Build coalitions with other disciplines for education and practice of EH
National Legislative Initiatives/Federal Government Role
Create national info. systems with data elements that trigger indepth examination of environmental exposures (e.g., for asthma, lead poisoning, birth defects)
Develop funding mechanism to support nursing expertise/faculty development in EH
Shift health care funding priorities toward preventive, public health interventions
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7. Barriers to enhancing EH in nursing practice?
Lack of time in routine practice situations
Lack of faculty expertise to teach content
Lack of administrative commitment to and knowledge about EH issues
Absence of EH content in credentialing, licensure, and accrediting systems
Lack of reimbursement structure
Nurses may have difficulty in employing non-traditional interventions. Want to know, why learn about something (EH issues) if there are no clear solutions, or clearly defined and proven nursing interventions to resolve problems.
Nursing job and role descriptions are often narrow, with discreet description of duties
Lack of funding to build nursing faculty and existing workforce expertise
Nurses are barriers; ''buying in" to EH as important to practice; need to see how knowledge will benefit them, help them do their job
Consequences of speaking out (social and economic)
8. How to overcome barriers?
Educate current workforce
Alter basic nursing curricula
Identify common threads and basics
Examine models of practice that are successful
Mandate competencies in accreditation of ed. programs
Include environmental risk in nursing assessment
Need some schools of nursing to test a new paradigm
Create new specialists and expertise
Educate nursing deans, faculty, preceptors
Funding and resource development
Make funding of health professionals a mandatory component of other federal funding related to EH
Federal and foundation funding
Work with national professional organizations to create initiatives in EH education
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Develop scientific basis of EH practice
Identify, characterize and control of EH hazards
Initiate national data collection systems to 1) Further document scope of problem, 2) Identify populations at risk and develop and evaluate interventions, 3) Provide quantifiable justification for funding (nursing) research and education in EH
Socialization of Nurses
Advocate EH for nurses on the job, before they even enter practice
Develop multidisciplinary programs, projects to address EH.
Collaborate
Empower nurses; impart knowledge and techniques for empowering community groups, workers, parents, etc.
Gain support from those with power to change funding, legislation, workplace policy
Educate govt. officials, consumers re. need for changes
Take more business oriented approach to EH; define what customer wants
Consciousness raising: family and peers, as well as public
9. Who needs to be involved?
(From most to least frequently cited)
Deans, faculty and schools of nursing and public health
Health care providers (nurses, MDs, related disciplines)
Policy makers, legislators, public officials
Industry, employers, CEOs
Nursing administrators
National nursing organizations, State Boards of Nursing, Accrediting Bodies
Federal sector, private foundations, insurers
Consumers, community activists, environmental groups (even extremists, because nurses mediate well, good brokers and coalition builders)
10. What educational methods appropriate for this content?
Traditional Methods
Classroom; integrate in health assessment courses; literature—update textbooks to include EH; merge PH with nursing content
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Critical Thinking/Problem Solving
Case Study
Systems paradigm that focuses on decision making
Specific Content on Environmental Risk
Site visits
Internships, precepting, role models, interdisciplinary, community groups
Multi-media
Telecommunication, interactive video, visual aids, newsletters, media (with subliminal messages?), the arts
Workshops/Seminars
Visiting workshops, professional conference topic, faculty education programs, lunch time seminars, CE, informal (fun) ways.
Make efforts specialized to cultural concerns and relevance to client
New view of world; view people in their context
11. At what level(s) of nursing education should EH content be included?
(Number in parenthesis indicates number of times cited by focus groups)
All basic nursing education—core component (8)
CE and Post-graduate (4)
Specialization at graduate level (3)
Baccalaureate and Masters (AD has no room) (1)
All specialties (1)
At ADN level teach assessment only (1)
CEOHN certification (1)
Sophisticated systems thinking and pop. based assessment may not be possible at basic baccalaureate level; perhaps nursing ed paradigm changes need to be made
12. Which nursing specialties might be involved in EH research?
(Number in parenthesis indicates number of times specialty was mentioned)
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PHN and CHN (7)
All nurses, all specialties (5)
Occupational Health Nurses (5)
Maternal and Child Health (4)
Primary Care (3)
Pediatrics
Oncology (2)
ER (2)
Mental Health/Psych (2)
School Nurses, Nurse Educators, Geriatrics, Home Health, Cruise Ship Nurses, Employee Health, Insurance Industry Nurses, Genetics (1)
FOCUS GROUP PARTICIPANTS
Gale B. Adcock, M.S.N., F.N.P., C.S.
SAS Institute Inc.
Christine Bolla, M.S., Ph.D. (candidate)
University of California, San Francisco
Carole A. Anderson, Ph.D.
Ohio State University
Pam Bromley, M.S.M., R.N.
Saint Alphonsus Regional Medical Center
Rhonda Anderson, M.P.A., R.N., F.A.A.N.
Hartford Hospital
Karen A. Brykczynski, R.N., C.S., F.N.P., D.N.Sc.
University of Texas
Mary Aquilino, Ph.D., R.N., F.N.P.
University of Iowa
Kathleen Clark, Ph.D., R.N., F.N.P
University of Iowa
Judith Baigis-Smith, R.N., Ph.D., B.S.N.
Georgetown University
Pat Clinton, M.A., R.N., P.N.P.
University of Iowa
B.J. Bartleson, M.S., R.N.
University of California, Davis
Joan Duran, B.A., M.A., B.S.N,
Contra Costa County, CA
Timothy J. Bevelacqua, M.N., R.N., C.N.A.
St. Luke's Episcopal Hospital
M. Louise Fitzpatrick, Ed.D.
Villanova University
Marjorie Beyers, Ph.D., R.N., F.A.A.N.
American Organization of Nurse Executives
Patty Franklin, C.P.N.P.
National Association of Pediatric Nurse Associates and Practitioners
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Grace Gainey, R.N.
Kershaw County, S.C.
Ann Marie McCarthy, Ph.D., R.N., P.N.P.
University of Iowa
Kristine Gebbie, R.N., Dr.P.H.
Columbia University School of Nursing
Judith McFarlane, Dr.P.H., F.A.A.N.
American Nurses Association
Barbara Goldrick, R.N., Ph.D.
Georgetown University
Robert Mehl, B.S.N., R.N., C.S.N.
National Association of School Health Nurses
Lisa Haley, R.N., B.S.N., C.O.H.N.
AT&T
Ellen S. Meyer, B.S., R.N., C.O.H.N.
Digital Equipment Corporation
Sue Hudec, M.S.N., R.N.
Veterans Affairs Medical Center
Virginia M. Minnicello, M.S., R.N., C.O.H.N.
Beth Israel Hospital
Phoebe Joseph, R.N., B.S.N.
Georgetown University Hospital
Marian Moody, R.N.
Clarendon County, S.C.
Alice Kamin, R.N.
Sumter County, S.C.
Wendy Myler, R.N., B.S., C.O.H.N., C.C.M
Digital Equipment Corporation
Carole Kelly, M.S., Ph.D. (candidate)
University of California, San Francisco
Martha Nelson, M.S., Ph.D. (candidate)
University of California, San Francisco
Nancy J. Krombach, R.N. M.S.N., F.N.P., C.S.
SAS Institute Inc.
Aroha Page, M.S.N., Ph.D. (candidate)
University of California, San Francisco
Jane Leonard, R.N.C., M.S.N.
University of Texas
Mary Ann Nugent, R.N.
Wateree Health District, S.C.
Andrea R. Lindell, D.N.Sc.
University of Cincinnati
Maureen Paul, M.D., M.P.H
Sally Lusk, Ph.D., M.P.H., F.A.A.N
Association of Community Health Nursing Educators
American College of Occupational and Environmental Medicine
Wendy J. Malone, B.S.N., P.H.N
Contra Costa County, CA
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Kathy Ras, R.N.
AT&T
Karen Van Varick-McGuire, R.N., B.S.N., C.O.H.N.
Johnson and Johnson
Libby Rembert, R.N.
Lee County, S.C.
Mary Lou Wassell, M.Ed., R.N., C.O.H.N.
American Association of Occupational Health Nurses
Carole Scott, R.N.
Sumter County, S.C.
Barbareta A. Welch, M.S.N., R.N., F.N.P., C.S.
SAS Institute Inc.
Willie Swanson, B.A., B.S.N.
Contra Costa County, CA
Joan A. West, M.A., P.H.N.
Contra Costa County, CA
Gale N. Touger, R.N., F.N.P., C.S.
SAS Institute Inc.
Dot Williams, R.N.
Patricia Travers, M.S., R.N., C.O.H.N. Digital Equipment Corporation
Sumter County, S.C.
Representative terms from entire chapter:
nursing curricula
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