3
Nursing Practice

In watching diseases, both in private homes and in public hospitals, the thing which strikes the experienced observer most forcibly is this, that the symptoms or the sufferings generally considered to be inevitable and incident to the disease are very often not symptoms of the disease at all, but of something quite different—of the want of fresh air, or of light, or of warmth, or of quiet, or of cleanliness, or of punctuality and care in the administration of diet, of each or of all of these.

—Florence Nightingale, 1860, p. 8

Environmental determinants of health and disease are pervasive and integral to the assessment, diagnosis, intervention, planning, and evaluation components of nursing practice. However, environmental factors that affect health are commonly overlooked in routine patient assessments. When environmental health concerns are missed, an opportunity for prevention is lost, and public health is less well served.

Although not every illness has an environmental etiology, nearly everyone will have a health problem related to an environmental hazard for which evaluation or advice is appropriate in terms of good nursing practice. It is important in nursing practice to identify not only the hazards that contribute to a current diagnosis (e.g., exposure to lead-contaminated dust resulting in elevated blood lead levels, and outdoor ozone or indoor allergens exacerbating childhood asthma), but also those that have not yet caused illness but are amenable to intervention (e.g., friable asbestos, radon, formaldehyde gases from building materials, and carbon monoxide and nitrogen oxides from poorly ventilated furnaces). By taking a proactive approach, nurses can initiate preventive actions to abate hazards before they manifest as disease. Thus, consideration of environmental health concepts as a core nursing function will vastly strengthen nursing's contribution to disease prevention.



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Nursing Health, & Environment: Strengthening the Relationship to Improve the Public's Health 3 Nursing Practice In watching diseases, both in private homes and in public hospitals, the thing which strikes the experienced observer most forcibly is this, that the symptoms or the sufferings generally considered to be inevitable and incident to the disease are very often not symptoms of the disease at all, but of something quite different—of the want of fresh air, or of light, or of warmth, or of quiet, or of cleanliness, or of punctuality and care in the administration of diet, of each or of all of these. —Florence Nightingale, 1860, p. 8 Environmental determinants of health and disease are pervasive and integral to the assessment, diagnosis, intervention, planning, and evaluation components of nursing practice. However, environmental factors that affect health are commonly overlooked in routine patient assessments. When environmental health concerns are missed, an opportunity for prevention is lost, and public health is less well served. Although not every illness has an environmental etiology, nearly everyone will have a health problem related to an environmental hazard for which evaluation or advice is appropriate in terms of good nursing practice. It is important in nursing practice to identify not only the hazards that contribute to a current diagnosis (e.g., exposure to lead-contaminated dust resulting in elevated blood lead levels, and outdoor ozone or indoor allergens exacerbating childhood asthma), but also those that have not yet caused illness but are amenable to intervention (e.g., friable asbestos, radon, formaldehyde gases from building materials, and carbon monoxide and nitrogen oxides from poorly ventilated furnaces). By taking a proactive approach, nurses can initiate preventive actions to abate hazards before they manifest as disease. Thus, consideration of environmental health concepts as a core nursing function will vastly strengthen nursing's contribution to disease prevention.

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Nursing Health, & Environment: Strengthening the Relationship to Improve the Public's Health NURSING PRACTICE AND RESPONSIBILITIES IN ENVIRONMENTAL HEALTH The practice of nursing is guided by standards and definitions established by leaders of nursing in professional associations and to some extent by governmental agencies such as the Public Health Service's Bureau of Health Professions. Systematic frameworks for the practice of nursing also guide nurses in actual nursing performance. The most widely accepted framework for nursing practice currently in use is the nursing process of assessment, diagnosis, planning, intervention, and evaluation. A model to guide medical and nursing practice specific to environmental health concerns established by the California Public Health Foundation (CPHF, 1992) consists of three roles: investigator, educator, and advocate. Awareness of the formal descriptions, definitions, and systems of nursing practice is useful for determining how environmental health concepts and related activities fit into nursing as it is currently practiced. A brief overview of the definitions and systems that guide nursing practice and their application to environmental health concerns is presented in the following section to demonstrate the "fit" between nursing practice and environmental health issues. The integration of environmental health concerns into nursing's scope of practice and the profession's philosophy of health and health care also illustrate nursing's historic and continued concern about environmental influences on human health. Definition of Nursing Practice The American Nurses Association (ANA) provides leadership in determining the goals, objectives, and professional practice of nursing. ANA defines nursing as " … a caring-based practice in which processes of diagnosis and treatment are applied to human experiences of health and illness" (ANA, 1994). ANA describes three basic nursing activities that explicitly include issues related to the environment and health, a preventive approach to health, and concern for populations as well as individuals: Restorative practices modify the impact of illness and disease. Supportive practices are oriented toward modification of relationships or the environment to support health. Promotive practices mobilize healthy patterns of living, foster personal and familial development, and support self-defined goals of individuals, families, and communities.

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Nursing Health, & Environment: Strengthening the Relationship to Improve the Public's Health Thus, major concepts and activities necessary to address environmental factors that can affect the health of individuals and populations are within the scope of practice and definition of nursing set forth by the ANA. The Nursing Process The nursing process, consisting of assessment, diagnosis, planning/outcomes, intervention, and evaluation, has been described as the core and essence of nursing, central to all nursing actions. It is a deliberate, logical, and rational problem solving process whereby the practice of nursing is performed systematically. The nursing process includes continuous input from patients, their families, or communities through all phases from assessment to evaluation. Diagnoses, planning, and interventions may be altered at any stage based upon new information from the patient or any other source. As far as possible, the patient should have an active and equal role in the nursing process, constricted only by physical or emotional limitations on their ability to participate. It is worth noting that the nursing process was developed for the care of individuals, and has since expanded to include a role in the care of families and communities. Application of the nursing process to environmental health issues may require nurses to employ various phases of the process in new ways. For example, the intervention may be recommending a change in the source of drinking water that affects a whole neighborhood or community. The process is compatible with the framework of investigator, educator, and advocate, established by the California Public Health Foundation (1992) to address nursing roles and responsibilities particular to environmental health issues. The CPHF framework augments rather than duplicates the nursing process. During the assessment phase of the nursing process, data are gathered to determine a patient's state of health and to identify factors that may affect well-being. This activity includes eliciting a health history to identify previous illnesses and injuries, allergies, family health patterns, and psychosocial factors affecting health. Environmental health components of history taking can be integrated into the routine assessment of patients by including questions about prior exposure to chemical, physical, or biological hazards and about temporal relationships between the onset of symptoms and activities performed before or during the occurrence of symptoms. During an assessment, the nurse should be alert to patterns of co-morbidity among patients, family members, and communities that are indicative of environmental etiologies. Nurses also conduct assessments during visits to patients in their homes and places of work, gaining first hand information about environmental factors that may adversely affect health.

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Nursing Health, & Environment: Strengthening the Relationship to Improve the Public's Health Diagnosis occurs with the culmination of objective and subjective data collection. In this phase of the nursing process health problems are identified and described. Depending upon their practice setting, nurses may use the diagnostic terms established by the North American Nursing Diagnosis Association (NANDA) or medical diagnostic terminology, as is often the case with APNs who are nurse practitioners. Routine consideration of environmental factors that affect health is essential in the diagnostic phase of the nursing process; without knowledge of such factors, problems may be misdiagnosed and subsequent interventions will address environmental issues haphazardly, if at all. Planning/outcomes is the phase of the nursing process in which optimal outcomes are identified. A range of interventions are identified to address the health problem, and plans for implementing those interventions are developed. The ability to establish interventions that address environmentally related illnesses depends on a nurse's ability to formulate diagnoses that include consideration of environmental factors. Without attention to environmental factors, intervention plans are likely to focus on secondary- and tertiary-level activities (care and cure) rather than primary prevention strategies. Intervention is the component of the nursing process in which the nurse implements activities to promote health, and prevent or alleviate illness and injury. The nurse may act as educator in this part of the nursing process, informing patients, families, workers, and communities about hazards in the environment and how to protect themselves. Effective interventions require a knowledge of resources, including texts, databases, and professional experts, and an ability to access these resources. Intervention also includes the role of advocate. Although nurses are familiar with the concept of advocacy on behalf of individual patients, often they have not been trained in techniques of advocacy for populations or in settings other than health care facilities. Nurses need to extend the concept of advocacy to include activities on behalf of communities and other groups and in settings such as the workplace or community meetings. This extension of nursing advocacy is often essential for addressing environmentally related health issues because they are frequently intertwined with social and political factors. Interventions focusing exclusively on the individual patient are rarely effective as primary prevention methods in matters of environmental health. Evaluation, the final step in the nursing process, can be conducted on numerous levels and frequently results in additional interventions. The health outcomes of an individual are one method of determining the effectiveness of nursing interventions. Another measure of effective intervention in environmentally related illness is an evaluation of hazard abatement methods. Has the hazard been contained or removed from the environment of the individual? Are others living in the area protected

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Nursing Health, & Environment: Strengthening the Relationship to Improve the Public's Health from exposure? Evaluation should also include an assessment of the effectiveness of interventions directed toward other populations at similar risk, for example, other family members, co-workers, and community members. Were the existence of the hazard and protective measures communicated clearly and consistently to those at risk? Was effective treatment provided to others at risk who experienced symptoms? Are measures being taken to prevent similar incidents of exposure in the future? Are the patient, work population, and community satisfied with the interventions used to identify and abate hazardous conditions related to the environment? Are those affected by the hazard satisfied with the health care that was provided, including educational interventions and medical treatment? These questions and the answers to them provide nurses and other health care providers with important information for determining the effectiveness of interventions undertaken in a particular incident and in identifying more effective measures for dealing with similar problems in the future. Application of the nursing process to environmental health concerns requires an expansion of the tools and processes used to assess patients, reason diagnostically, and develop treatments and interventions that consider environmental factors. Responsibilities for implementing clinical services relevant to environmental health will vary according to practice settings; however, the nursing process is a useful framework for applying environmental health concepts in all settings and roles. Scope of Responsibilities A nurse's role in addressing environmental health issues can be conceptualized in a variety of ways. The nursing process can be augmented or integrated with other models of practice, such as the CPHF model, which consists of three roles for the health professional: investigator, educator, and advocate (CPHF, 1992). The role of investigator supports the assessment and evaluation phases of the nursing process, while the roles of educator and advocate would be carried out as interventions. This framework incorporates a range of activities, including working with communities and on matters of public policy, that may be unfamiliar to nurses who structure their practice within the more traditional framework of the nursing process applied to individual patient care. Role as Investigator Nurses may act as investigators by taking careful environmental health histories and looking for trends in exposure, illness, and injury;

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Nursing Health, & Environment: Strengthening the Relationship to Improve the Public's Health being alert to environmental factors that influence health; working with interdisciplinary teams and with agencies to determine if an environmental exposure is affecting the health of a community; initiating or engaging in research to identify and control environmental exposures that adversely affect human health; and working with public and private institutions to perform risk and hazard assessments. In actual practice, this role may include home visits to look for peeling or chipping lead paint in the residences of young children or to identify the use of poorly vented wood stoves in the home of an asthmatic child. It may also involve entering a work site to assess conditions that affect worker health and safety, including ergonomic hazards, chemical exposures, or mechanical hazards such as poorly guarded conveyor belts. Moreover, the practice of nursing itself is uniquely hazardous. A discussion of the hazards to nurses (and other health care workers) is presented in Appendix B. One example of a nurse as investigator is a situation that occurred in 1992 in Brownsville, Texas, a town on the Mexican border. A nurse working in the labor and delivery department of a local community hospital noticed what seemed to be an unusual number of neonates born with a relatively rare but devasting birth defect, anencephaly. The nurse subsequently reviewed all birth records for the previous year and found that the incidence of children born with this defect in her facility was significantly greater than the national rate: 30 cases per 10,000 births versus 10 cases per 10,000 births, respectively. Further investigations suggested contamination of groundwater and surface water sources with chemicals known to cause adverse health outcomes of this nature (Suro, 1992) (see Box 3.1). Eliciting an environmental health history, another investigative activity, is one of the most important actions for enhancing the environmental health content in nursing practice, because information derived from the history is essential to all other nursing activities related to environmental health. Through the environmental history, a nurse may uncover exposures to hazardous substances that neither the patient nor the clinician had suspected as etiologic agents of existing symptoms or disease. Methods and tools for taking a complete environmental health history have been well described (Goldman and Peters, 1981; Tarcher, 1992). Sample forms for taking a comprehensive environmental health history are included in Appendix G. Three key questions to be included in all histories of adult patients are the following:

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Nursing Health, & Environment: Strengthening the Relationship to Improve the Public's Health Box 3.1 Sentinel Health Events and Disease Clustering Environmental health concerns often surface in a community when residents or others notice an unusual pattern of illness, for which an environmental cause is suspected. Perhaps residents notice ''too many" cases of childhood leukemia in a particular neighborhood near a waste dump. Perhaps local health professionals discover a common disease such as asthma or breast cancer occurring in a community at much higher rates than would normally be expected. Perhaps several cases of a relatively rare disease are detected among individuals who work at the same plant or live on the same street. Suspicion might be triggered by even a single case of illness that breaks the usual profile for that disease, such as a cardiac arrest in a 20 year-old when such an event would normally occur at an older age. This might occur following exposure to carbon monoxide, fluorocarbons, or hydrocarbons, for example. Such atypical patterns, whether in community populations or in individuals, are called sentinel health events (see Rutstein et al., 1983). When investigated, they may turn out to be coincidental, with no particular relationship to environmental factors, or there may have been misperceptions of the pattern in the first place (Schulte, 1988). However, they can also signal larger health problems related to environmental hazards, such as pesticide poisoning, heatstroke, lead and other heavy metal poisonings, or respiratory diseases triggered by poor air quality (DHHS, 1990). Detection of a sentinel health event should lead to investigation of the subpopulation of individuals who may be at risk for similar adverse health effects. This population-based approach to the tracking of environmental health concerns has been formally recommended by the U.S. Department of Health and Human Services (DHHS). In 1990, that agency recommended the establishment of 35 state plans to define and track sentinel environmental diseases (DHHS, 1990). Such tracking systems lead to early detection of disease and primary prevention through the control of hazards before they cause illness in others. However, the plan requires the assistance of a workforce adequately educated in environmental health. To contribute to this effort, nurses must adopt an orientation that is somewhat different from that currently provided in their education, roles, and practice activities. What are your current and past longest-held jobs? (For children and teenagers, the question can be modified to: Where do you spend your day, and what do you do there?) Have you had any recent exposure to chemicals (including dusts, mists, and fumes) or radiation? Have you noticed any (temporal) relationship between your current symptoms and activities at work, home, or other environments? The investigative role of nurses may extend to their being part of a community or interdisciplinary public health assessment team. The Assessment

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Nursing Health, & Environment: Strengthening the Relationship to Improve the Public's Health Protocol for Excellence in Public Health (NACHO, 1991) and ATSDR's Public Health Assessment process (Lybarger et at., 1993) involve identifying risk factors and exposures that affect the health of the community. Both processes also emphasize soliciting and incorporating community health concerns as part of the assessment. Nurses skilled in interviewing, active-listening, and group processes, as well as epidemiological methods, can be invaluable team members. Role as Educator Nurses have long served as patient educators; they teach patients how to get out of bed following surgery, how to change a dressing, the possible side effects of medication, and the importance of diet and exercise in maintaining health. This role can be expanded to include educating patients, families, workers, and communities about the possible adverse effects of exposure to environmental hazards and how to reduce or eliminate such exposures. This type of education is commonly referred to by public agencies and environmental health specialists as hazard or risk communication.(1) Nurses can further develop this role by providing information to create environmentally safe homes, schools, day-care settings, workplaces, and communities. As role models, nurses can conduct their practice and lives in an environmentally safe manner, that is, by limiting unnecessary exposure to chemicals or by carrying out routine duties in a manner that minimizes injury due to ergonomic hazards. Nurses can act as educators by speaking at community gatherings and becoming involved in community-level activities related to the environment and human health. They may also participate in risk or hazard communication for public health agencies. The original focus of risk communication was on developing and delivering a message from an expert or agency to the public, in order to help the public better understand a situation and its implications for their health and well-being. This definition is widening to incorporate a two-way dialogue between regulators or managers and the public (Cutter, 1993). The interactive process of exchanging information on technical hazards and the human response, both physiological and emotional, calls for professionals who can listen, interpret, clarify, and reframe questions and information in emotionally charged and sometimes hostile situations. The basic patient education role of nurses with individuals and families 1   In this report, when referring to the interaction between health professionals and individuals who are potentially affected by exposure to environmental hazards, the term risk communication will be used.

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Nursing Health, & Environment: Strengthening the Relationship to Improve the Public's Health will need expansion to include communication with entire communities and the general public if they are to fill an essential niche in environmental health. The ability to assess the target audience, develop a message that is meaningful and understandable, choose a method or media for conveying the message, and conduct community-level conflict resolution are skills beyond the current preparation of most nurses. The basic skills of linking individual needs with information and other resources will need to be broadened to include community linkages with environmental experts who may be outside the usual network of nursing referrals. The need to expand nursing's role in environmental health is not obvious to many nurses, for several reasons. First, no role models (faculty, supervisors) have alerted them to the potential hazards of environmental exposures. As a result, nurses are not aware that certain substances are highly hazardous to human health or that certain environmental conditions are contributing significantly, although insidiously, to the morbidity and mortality of the populations they serve. Second, nurses suspect, or are questioned by their patients about, the safety of certain conditions, but they do not know where to find accurate information about environmental hazards and measures to control them. Nurses who have attended NIOSH sponsored educational programs in occupational health can assist other nurses in learning about environmental issues by acting as guest lecturers in schools of nursing and as preceptors in the field of occupational health. Further support of this nature will enhance the ability of nurse generalists to educate their patient populations about environmental health issues. Role as Advocate In theory, the human health aspects of environmental problems can be isolated and dealt within traditional medical systems. In practice, these issues usually unfold in a highly charged social and political context. Nurses and other health care providers often need to help individual patients locate and secure access to specialized services for health problems related to environmental hazards. They may also be called upon to contact individuals, agencies, and organizations outside the health care system, working on behalf of patients or communities to change hazardous conditions and prevent future health problems. It is generally agreed that the interests of patients, workers, or community members are best served by empowering them to act as their own advocates. However, nurses' scientific knowledge and experience in speaking with scientists, physicians, and other authorities equip them to be effective advocates in some situations where individual citizens are likely to feel intimidated. This role is particularly important when advocacy

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Nursing Health, & Environment: Strengthening the Relationship to Improve the Public's Health involves communication with public health agencies and private industry, wherein inquiries by individual citizens sometimes meet with responses that fail to address their concerns. Establishing the legitimacy of advocacy activities as elements of nursing practice will require concerted effort among educators and leaders in the nursing profession. Environmental health issues are highly intertwined with social and political policies; thus, in the area of environmental health, advocacy is needed at the policy level as well as on behalf of individual clients. Advocacy as one component of the nurse's role is essential if a stronger, more prevention-oriented model of nursing practice is to be established. A more in-depth discussion of the practice of advocacy by nurses is provided in Box 3.2 and Appendix F. Interdisciplinary Aspects of Environmental Health Environmental hazards and their health effects rarely lend themselves to simple solutions applied from a single discipline. Effective interventions for environmentally related illness require collaborative efforts from many disciplines due to the complex nature of environmental health issues, the rapidly advancing science base in environmental health, and the need for primary prevention strategies that often must involve professionals from fields other than nursing. Such collaboration includes ongoing dialogue and fluidity of roles and responsibilities. Nurses are accustomed to working with members of other disciplines toward a shared goal, although it is often in a multidisciplinary manner, with members of each discipline performing their activities independently and with clear role delineation. Various nursing associations and other health professions advocate a more collaborative approach to health problems that is highly interactive and more likely to be termed interdisciplinary. This issue is important to consider in order to most effectively address environmental health issues. The ANA's draft Nursing Social Policy Statement notes that nursing has an "external boundary" that interacts with other professions in response to changing societal needs and the advance of scientific knowledge. The boundaries are fluid rather than firmly defined, with members of various professions cooperating in the exchange of knowledge, techniques, and ideas on how to deliver quality health care. Collaborative practice, with some overlap of function, enables members of various disciplines to interact with a shared overall mission (ANA, 1994). The National League for Nursing (NLN) has described several aspects of the complex nature of health care: technological advances that increase access to information, the need to educate professionals to recognize patterns and engage in innovative problem solving rather than simply

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Nursing Health, & Environment: Strengthening the Relationship to Improve the Public's Health BOX 3.2 Advocacy Practice 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 a single patient or population of patients. Patient advocacy within the health care setting is familiar to most, if not all, nurses; for example, bringing a patient's concerns to the attention of the physician. However, advocacy that goes beyond the health care system is a new kind of activity for many nurses, who may feel ill equipped to translate research and practice issues into health policy terms. Most nursing professionals are comfortable with the idea of case advocacy on behalf of an individual patient, even when it involves aggressive action in the interests of the patient. Where ambivalence occurs is over policy-level (class) advocacy aimed at changing environmental conditions that are detrimental to populations of patients. For some members of the profession, the latter kinds of activity will seem unprofessional, overly political, and inappropriate for nurses. Others will regard it as an expression of nursing's true mission, going back to the profession's origins as crusaders for social justice, as embodied in the practice Florence Nightingale and Lillian Wald. Nurses interested in advocacy practice will find many pressures and incentives encouraging them to define this activity around the needs of individual patients. Policy-level advocacy for structural change is not emphasized in nursing education, not fully legitimized by the field's professional associations (although it is popular among student members), and not welcomed by the majority of employers and hospital administrators. In the area of environmental health, however, nurses are likely to be drawn into a fuller range of advocacy activities whether they are prepared for these roles or not. Therefore, the issue is not whether to undertake policy advocacy, but rather how to do it in a way that is sophisticated, realistic, and constructive. Anxiety about advocacy roles can be lessened considerably by building familiarity with a wider range of advocacy techniques, not all of which are necessarily adversarial. There are many ways to conceptualize and practice advocacy in health and human services, and there are many heated debates about what true advocacy means. Different starting premises are possible. For example, who determines what is needed: the professional or those directly affected? Should professionals acting as advocates aim simply to solve the current problem, or should they, in addition, try to empower patients and communities to solve similar problems for themselves in the future? Is public conflict something always to be avoided in advocacy efforts, or is it sometimes useful? In thinking about such questions, nurses can draw on literature from other professional fields with advocacy dimensions such as social work, city planning, education, public health, law, and mediation. Based on a review of advocacy literature, Appendix F presents some useful conceptual frameworks for understanding different forms of advocacy and different advocacy strategies. Advocacy that goes beyond helping an individual patient and enters the realm of health policy is not yet acceptable and expected 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 lobbying, use of media, mediation, expert testimony, community organizing, and the like. 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 that were likely not part of their basic nursing education. Appendix F lists some of the self-training and support resources available for health and human services professionals interested in advocacy practice at the policy level.

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Nursing Health, & Environment: Strengthening the Relationship to Improve the Public's Health conduct a community assessment, and techniques for communication of risk. Types of Prevention Primary prevention focuses on the prevention of exposure and promotion of health. Secondary prevention occurs after a patient has been exposed to an environmental hazard and involves recognizing and reducing the adverse health effects resulting from the exposure. Tertiary prevention occurs after exposure to the environmental hazard has occurred and while the client continues to experience long-term health effects from the exposure. Interventions at the tertiary stage are rehabilitative and protective in nature. Figure 3.1 provides a diagrammatic description of the levels of prevention. In this case study nurses may have interacted with the family in a variety of roles and settings. The infant was probably born in an inpatient setting and discharged to the home with her family. She may then have been seen in an outpatient setting for well-child and acute illness care as mentioned in the case study. In all of these settings nurses practicing as generalists as well as advanced practice nurses would be responsible for assessing the infant, the family, and to some extent, the community in which they live. At birth, nurses in the inpatient setting are responsible not only for the care of the infant but for planning to discharge the infant and mother to the home. The health history of this infant should have included an assessment of any known environmental risk. At this point, the nurse would plan and implement primary prevention strategies with the family to reduce or eliminate environmental health risks, for example, by teaching appropriate procedures for handling food and water to prevent gastrointestinal problems. This should include information on the possible sources and routes of contamination of food and water. The nurse should also teach the family how to recognize the signs and symptoms of illness that require early medical attention. Following discharge from inpatient care, the infant was most likely seen for a well-child visit. The infant would be assessed by a generalist or advanced practice nurse for normal growth and development. In addition, anticipatory guidance and education for the care of the infant, including health promotion and disease prevention would be provided to the family. Among the possible causes of the infant's signs and symptoms was exposure to an environmental hazard, either biological or chemical. When the infant first developed symptoms at three weeks of age, the nurse should have included an environmental health history and assessed the need for secondary prevention. The exposure history may have identified

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Nursing Health, & Environment: Strengthening the Relationship to Improve the Public's Health FIGURE 3.1 Schematic representation of the natural history of disease and the related levels of prevention and modes of intervention. SOURCE: Adapted from Mausner and Kramer's, Epidemiology: An Introductory Text(1985).

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Nursing Health, & Environment: Strengthening the Relationship to Improve the Public's Health environmental hazards that would explain the cause of the infant's symptoms (contaminated drinking water). The nurse would then plan and implement secondary prevention strategies, focusing on protection of the infant and other family members from possible continued exposure. This includes parent education and referral to the local health department requesting further investigation of the home situation. This infant was hospitalized a second time. The deterioration of her condition was due to the failure of primary and secondary prevention efforts that were aimed at correcting the infant's symptoms without knowing the etiology of the illness. During the second hospitalization, nurses again had an opportunity for secondary prevention. Methemoglobin levels were obtained and exposure to an environmental hazard was strongly suspected. But what was the source? The nurse knew that private wells, especially in rural areas, may be contaminated with a variety of chemicals such as pesticides, nitrates, and bacteria. The nurse then contacted the local health department about the infant's illness, laboratory findings, and the diagnosis of methemoglobinemia. When one contaminant is identified or an illness that may result from water contamination occurs, it is important that the water be evaluated further. The public health nurse scheduled a home visit to investigate the possible sources of water pollution. The visit was coordinated with the local health department sanitarian or water supply specialists. The nurse noted that the home sits on a river bank near 100 acres of corn and alfalfa. Because of the public health nurse's knowledge of environmental hazards and health risks, the nurse knew that fertilizers are one of the most common causes of nitrate contamination of drinking water. During the visit, the public health nurse advised the family of the hazards and of ways to avoid further illness. Nitrates were the contaminant and the appropriate advice was to refrain from ingesting the water and to use only bottled water for drinking and food preparation. (In some rural areas domestic well-water nitrate concentrations are higher than 10 milligrams/liter measured as nitrogen in nitrate (ATSDR, 1991). Private wells should be tested for nitrate contamination a annually. A survey conducted in Iowa found that more than 18 of rural domestic wells contain concentrations of nitrate above the regulatory level established by the Environmental Protection Agency (ATSDR, 1991). Need for Broad Knowledge of Environmental Hazards Chemical contamination of the environment affects all communities and underscores the need for all health care professionals to be knowledgeable about the exposures and related health outcomes. In this case

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Nursing Health, & Environment: Strengthening the Relationship to Improve the Public's Health study it is important to recognize that the most common environmental cause of methemoglobinemia in infants in the United States is ingestion of water or reconstituted formula contaminated with nitrates from agricultural fertilizers, organic animal waste, and septic sewer systems (ATSDR, 1991). Nurses can take a proactive role in identifying these hazards and providing the public with information on how to avoid exposure to nitrate-contaminated drinking water. Community assessment by interdisciplinary teams would include assessment of potential as well as actual hazards. For the infant described in this case study, this episode of illness had a happy ending; nursing intervention and advocacy were successful. What about other infants in this community who may have been exposed to the same or similar environmental hazards? Even though the use of bottled water for the infant's formula offered a short-term solution to the immediate health threat, the nurse's role did not end at this point. The nurse had a responsibility to assist the family in seeking long-term solutions, for example, digging a deeper well or gaining access to a community water supply that had been tested for nitrate contamination. The nurse also needed to be sure that the U.S. Environmental Protection Agency was aware of the situation so that attention could be given to controlling the non-point-source pollution that threatened the safety of drinking water of the surrounding community. The nurse may have been able to facilitate testing of water from the wells of neighbors to assess the extent of the pollution and to institute preventive measures before others in the community were adversely affected by contamination of domestic well water. The nurse may have played a role in getting information to the community about: (1) the problem that had been identified, (2) the risks to the public's health, and (3) the appropriate actions citizens needed to take to protect themselves. Collaborating with colleagues in the field of environmental protection may have lead to the nurse's involvement in community initiatives to address the combined needs for farmers to have successful crops and for citizens to have safe drinking water. Nurses can also intervene with agencies and organizations to protect other infants at risk. Collaborative efforts may include meeting nurse researchers from the local school of nursing who would develop a research plan to assess the problem through the collection and analysis of data. On the basis of this research, the nurses might have developed plans for educating the community on disease prevention and health promotion related to the primary source of the problem: well water contamination with chemicals used to fertilize crops. The illness of one infant and the actions of one nurse may have reduced the risks for all infants and all members of one community.

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Nursing Health, & Environment: Strengthening the Relationship to Improve the Public's Health NURSING COMPETENCIES IN ENVIRONMENTAL HEALTH Nurses from a variety of practice settings can assist worried community residents and workers by bridging the gap between scientific information and public understanding of the environmental health risks. However, this will require nurses to view such roles as integral to nursing practice. The environmental health competencies for nurses in generalist practice presented in Box 3.4 were adapted by the committee from competencies set forth by the International Council of Nurses (Appendix A) and by Lipscomb, 1994a (Appendix C). CONCLUSION The practice of nursing has historically included a consideration of environmental factors that may affect the health of individuals, communities, and other populations. Attention to environmental factors is explicitly included in the scope of nursing practice as defined by the ANA (1994). Nevertheless, for the last half-century, the major focus of nursing Box 3.4 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.

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Nursing Health, & Environment: Strengthening the Relationship to Improve the Public's Health practice has been on treatment of diseases in acute care settings, rather than on health promotion and disease prevention in primary care and community-based settings. With changes in health care delivery systems and the emergence of environmentally related illnesses, all nurses (not just specialists) must refocus their attention and acquire new skills to address these changes. The nursing process, ubiquitous to all areas of nursing practice, can be used to address environmental health issues with minor adaptations that can be drawn from the CPHF's model of a nurse as investigator, educator, and advocate. Many factors influence changes in nursing practice, including professional associations, new and unfamiliar ethical dilemmas, credentialing requirements, funding for ''public-health"-related activities, and overall changes in health care delivery. Barriers to and incentives for changing nursing practice to routinely include consideration of environmental health problems have been described in this chapter, along with recommendations and strategies to address these factors. The committee believes that these strategies, if implemented, will be successful in changing the practice of nursing, no matter the setting, in order to improve the health of the public. Nurses are respected and trusted members of the community who often have firsthand knowledge of environmental hazards in the home, community, or workplace. Expansion of their roles as educators to include risk or hazard communication, and as advocates on behalf of communities and groups (class advocacy), in addition to individuals (case advocacy), will be fundamental for the success of interventions in environmentally related illness or injury. RECOMMENDATIONS Nurses in every area of practice encounter environmentally induced illnesses, either knowingly or unknowingly. However, nurses cannot begin to address these issues until they are aware of a potential link between environmental conditions and disease. Nurses are often the only health care providers who enter the home, workplace, or communities of the populations they serve, which allows them to assess directly the existence of environmental hazards. Because of this on-site aspect of nursing practice, nurses are well positioned to detect and intervene at both the individual and community levels. Nurses also comprise the largest number of health care professionals in the United States, with a clearly defined mission of caring, advocacy, and health promotion. Together, these factors suggest that the enhancement of environmental health activities in nursing practice would significantly affect environmentally related health conditions and, in turn, improve the public's health.

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Nursing Health, & Environment: Strengthening the Relationship to Improve the Public's Health Scope of Responsibility Recommendation 3.1: Environmental health should be reemphasized in the scope of responsibilities for nursing practice. Rationale: Nurses in every area of practice encounter environmentally induced illnesses, either knowingly or unknowingly. Nurses can address these situations if they are aware of the potential links between environmental conditions and disease. Strategies for Achieving Recommendation 3.1: Elicit an environmental health history during patient assessment (see Appendix G). Interventions should include referrals to health agencies as well as to occupational and/or environmental specialists; education about prevention techniques; and site visits to the home, workplace, or community. Licensure and certification examinations for all levels of nursing should include environmental health content. Professional nursing associations should be encouraged to address environmental health through the development of policy recommendations, continuing education programs, codes of ethical conduct, and written standards of care. Availability and Accessibility of Resources Recommendation 3.2: Resources to support environmental health content in nursing practice should be identified and made available. Rationale: Environmental health issues are increasingly complex, and practicing nurses cannot be expected to be expert in all aspects of environmental health. Nurses need access to comprehensive resources for technical assistance in assessment, planning, intervention, and evaluation in the area of environmental health. Such resources may include nurse experts; professionals from other disciplines; written materials; and local, state, and federal public health and environmental protection agencies. Institutional policies that support access to and use of these resources will help nurses realize their potential in addressing environmentally related illnesses. Strategies for Achieving Recommendation 3.2: Enhance distribution of Agency for Toxic Substance and Disease

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Nursing Health, & Environment: Strengthening the Relationship to Improve the Public's Health Registry (ATSDR) and Association of Occupational and Environmental Clinics (AOEC) teaching modules to nursing faculty, students, and nurses currently in practice. Advertisements and announcements can be sent to members of nursing associations and placed in selected nursing publications. Promote interdisciplinary approaches to environmental health issues in nursing practice, education, and research with funding support from private and public agencies and through recommendations from nursing professional associations, including American Association of Colleges of Nursing (AACN) and International Council of Nursing (ICN). Nursing faculty, students, and practitioners should be made aware of environmental health resources in local, state, and federal public health and environmental agencies, through avenues such as state nursing associations, for example. Institutional policies, including formal role definitions and staffing mix, must support nurses' access to resources and adequate opportunities for one-on-one contact between patients and nurses. Participation in Interdisciplinary Teams Recommendation 3.3: Nurses should participate as members and leaders in interdisciplinary teams that address environmental health problems. Rationale: The efficacious provision of environmental health services requires the expertise of a variety of professionals functioning as a well-coordinated team. Nurses need to know who these other professionals are, what they do, and how to work with them in an interdisciplinary team. Nurses must also be prepared to consult with other specialists in environmental health including, but not limited to, toxicologists, physicians, industrial hygienists, and epidemiologists. Strategies for Achieving Recommendation 3.3: Develop experience with interdisciplinary teams in basic nursing education by calling on experts from various fields to teach selected content and to participate in learning activities involving case studies or problem solving. Focus on the necessity of an interdisciplinary approach when teaching fundamental concepts of environmental health. Provide nurses with a basic understanding of the knowledge base and practice of various interdisciplinary team members, including toxicologists, industrial hygienists, risk communicators, and hydrogeologists.

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Nursing Health, & Environment: Strengthening the Relationship to Improve the Public's Health Such instruction may be done in basic RN education,2 in advanced-degree programs, and through continuing education. Facilitate interaction with other disciplines both within and external to the practice setting through clearly stated job expectations with the appropriate allocation of time and resources. Participate as interdisciplinary team members in community and public health assessments Educator Role: Risk Communication Recommendation 3.4: Communication should extend beyond counseling individual patients and families to facilitating the exchange of information on environmental hazards and community responses. Rationale: Nurses can build on existing interviewing and active-listening skills to provide an essential linkage among environmental scientists; medical and environmental epidemiologists; and individuals, neighborhoods, or community groups in communicating about risks and hazards. Strategies for Achieving Recommendation 3.4: Provide educational content and student experiences with communities concerned about environmental exposures or potential disease clusters. Involve nurses in planning for and as facilitators of meetings with community groups concerning environmental issues and public involvement with agency decision-making. Develop additional knowledge and expertise in communicating appropriately with identified audiences and in developing the group facilitation skills required for advocacy practice (see Appendix F). Advocacy Roles 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. 2   Including associate degree, diploma, baccalaureate education and those programs whose basic nursing education is obtained at the master's level.

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Nursing Health, & Environment: Strengthening the Relationship to Improve the Public's Health Rationale: Advocacy on behalf of communities and other groups (class advocacy) can be very different from advocacy on behalf of individual patients (case advocacy), and nurses must have some grounding in basic class advocacy skills. Strategies for Achieving Recommendation 3.5: Nursing faculty and other nursing leaders must demonstrate that advocacy activities are within the realm of professional practice through formal education of nurses and by serving as role models. Experts from other fields should be called upon to assist nurses in developing and building skills in advocacy practice (see Appendix F). Educational resources and experiences should include interactions with expert practitioners from other disciplines, for example, social work. Knowledge and skills basic to advocacy, such as group process, conflict resolution, and political and regulatory process, must be incorporated into nursing education and practice. Ethics Recommendation 3.6: Conduct research regarding the ethical implications of occupational and environmental health hazards and incorporate findings into curricula and practice. Rationale: Little research has addressed ethical issues related to occupational and environmental health hazards and how those issues are treated in nursing practice. Strategies for Achieving Recommendation 3.6: Identify common problems in occupational and environmental health practice that have implications for the ethical treatment of patients and communities (e.g., confidentiality of worker health information, exposure to occupational and health hazards, and informed consent). Include occupational and environmental health content related to ethical issues in nursing and public health curricula. Address the ethical implications of occupational and environmental health hazards and their consequences in both public and private policy documents. Include consideration of ethical principles related to occupational and environmental health in professional codes of ethical conduct.

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Nursing Health, & Environment: Strengthening the Relationship to Improve the Public's Health Florence Nightingale reading. Photo reproduction of an anonymous crayon drawing (1854). Property of Duke University Medical Center Library, History of Medicine Collections, Durham, NC.