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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