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i Nursing, Health, & the Environment Strengthening the Relationship to Improve the Public's Health Andrew M. Pope, Meta A. Snyder, and Lillian H. Mood, Editors Committee on Enhancing Environmental Health Content in Nursing Practice Division of Health Promotion and Disease Prevention INSTITUTE OF MEDICINE NATIONAL ACADEMY PRESS Washington, D.C. 1995
ii National Academy Press 2101 Constitution Avenue, N.W. Washington, D.C. 20418 NOTICE: The project that is the subject of this report was approved by the Governing Board of the National Research Council, whose members are drawn from the councils of the National Academy of Sciences, the National Academy of Engineering, and the Institute of Medicine. The members of the committee responsible for the report were chosen for their special competencies and with regard for appropriate balance. This report has been reviewed by a group other than the authors according to procedures approved by a Report Review Committee consisting of members of the National Academy of Sci- ences, the National Academy of Engineering, and the Institute of Medicine. The Institute of Medicine was chartered in 1970 by the National Academy of Sciences to enlist distinguished members of the appropriate professions in the examination of policy matters pertain- ing to the health of the public. In this, the Institute acts under both the Academy's 1863 congres- sional charter responsibility to be an adviser to the federal government and its own initiative in identifying issues of medical care, research, and education. Dr. Kenneth I. Shine is President of the Institute of Medicine. This project was supported by funds from the Agency for Toxic Substances and Disease Reg- istry, the National Institute for Occupational Safety and Health, National Institute of Nursing Research, National Institute of Environmental Health Sciences, Health Resources and Services Administration, and the Environmental Protection Agency (contract number U61/ATU398777-01). Library of Congress Cataloging-in-Publication Data Nursing, health, and the environment : strengthening the relationship to improve the public's health / Andrew M. Pope, Meta A. Snyder, and Lillian H. Mood, editors ; Committee on Enhancing Environmental Health Content in Nursing Practice, Division of Health Promotion and Disease Pre- vention, Institute of Medicine. p. cm Includes bibliographical references and index. ISBN 0-309-05298-X 1. Environmental health. 2. Nursing. 3. Industrial nursing. I. Pope, Andrew Mac Pherson, 1950- . II. Snyder, Meta A. III. Mood, Lillian H. IV. Institute of Medicine (U.S.). Com- mittee on Enhancing Environmental Health Content in Nursing Practice. (DNLM: 1. Environmental Healthânurses' instruction. 2. Environmental exposureâ nurses` instruction. 3. Occupational Healthânurses' instruction. 4. Nursing. WA 30 N974 1995] RA566.N87 1995 610.73âdc20 DNLM/DLC for Library of Congress 95-39601 CIP Copyright 1995 by the National Academy of Sciences. All rights reserved. Printed in the United States of America. The serpent has been a symbol of long life, healing, and knowledge among almost all cultures and religions since the beginning of recorded history. The image adopted as a logotype by the Insti- tute of Medicine is based on a relief carving from ancient Greece, now held by the Staatlichemuseen in Berlin. Cover Photograph: 1910. Courtesy of Visiting Nurse Service of New York.
iii COMMITTEE ON ENHANCING ENVIRONMENTAL HEALTH CONTENT IN NURSING PRACTICE LILLIAN H. MOOD (Chair), Director, Risk Communication, Environmental Quality Control, South Carolina Department of Health and Environmental Control, Columbia ELIZABETH T. ANDERSON, Professor, School of Nursing, University of Texas, Galveston HENRY A. ANDERSON, Chief Medical Officer for Occupational and Environmental Health, Wisconsin Division of Health, Madison NORMAN DePAUL BROWN, Associate Professor, College of Nursing, University of Arkansas, Little Rock GAIL F. BUCKLER, Clinical Instructor, Environmental and Occupational Health Sciences Institute, University of Medicine and Dentistry of New JerseyâRobert Wood Johnson Medical School, and Rutgers, the State University of New Jersey; and Assistant Professor of Clinical Nursing, School of Nursing, University of Medicine and Dentistry of New Jersey ANN H. CARY, Associate Dean, School of Nursing, Louisiana State University Medical Center, New Orleans SUE K. DONALDSON, Dean, School of Nursing, Johns Hopkins University GERALDENE FELTON, Dean, College of Nursing, University of Iowa ELAINE L. LARSON, Dean, School of Nursing, Georgetown University CAROLYN NEEDLEMAN, Professor, Graduate School of Social Work and Social Research, Bryn Mawr College DOROTHY S. ODA, Professor, School of Nursing, University of California, San Francisco RANDOLPH F.R. RASCH, Assistant Professor, School of Nursing, University of North Carolina, Chapel Hill KATHLEEN M. REST, Assistant Professor, University of Massachusetts Medical School, Worcester BONNIE ROGERS, Director, Occupational Health Nursing, University of North Carolina, Chapel Hill META A. SNYDER, National Center for Hazard Communication, University of Maryland, College Park Liaison to the Institute of Medicine's Board on Health Promotion and Disease Prevention Jean Goeppinger, Chair, Department of Community and Mental Health, School of Nursing, University of North Carolina, Chapel Hill
iv Study Staff Andrew M. Pope, Study Director Carrie E. Ingalls, Research Assistant Michael A. Stoto, Director, Division of Health Promotion and Disease Prevention Donna Thompson, Administrative Associate Mona Brinegar, Financial Assistant Laura Baird, Librarian
PREFACE v Preface In this time of local and global environmental concerns, peopleâas individuals and communitiesâlook increasingly to the health care system for information and advice on identifying and reducing health risks associated with environmental (including workplace) exposure to potential hazards, and for diagnosis and treatment of the diseases caused by such exposures. Nurses are often the first point of contact for patients and concerned individuals, and are in positions to provide considerable support. However, most nurses have little, if any, formal preparation in the field of environmental health. In response to a growing awareness of the need to enhance occupational and environmental health content in the practice of nursing, a workshop was conducted by the Institute of Medicine (IOM) in May 1993 to assess the need for an IOM study on the role of nurses in occupational and environmental health and to clarify the associated areas of education, training, and research that such a study would involve. It was an illuminating and successful workshop, chaired by Bonnie Rogers, that provided resounding affirmation of the need for the IOM to conduct a full-scale study of issues related to enhancing environmental health content in the practice of nursing. Following the workshop, and at the request of a consortium of federal agencies, the IOM established the Committee on Enhancing Environmental Health Content in Nursing Practice to carry out the study. Working from the premise that the environment, including the work environment, is a fundamentally important factor in determining the health of individuals
PREFACE vi and populations, the committee defined essential competencies and curriculum content in environmental health; recommended methods for developing nursing faculty expertise in environmental health; developed strategies for enhancing the dissemination and integration of environmental health content in nursing practice; and identified research issues that would benefit from study by a combination of environmental health and nursing investigators. I have been privileged to chair the study committee; it is comprised of an amazing group of experts in nursing and environmental practice, education, and research, encompassing a variety of disciplines and diverse perspectives. We particularly benefitted from a deliberate overlap in membership with the IOM Committee on Curriculum Development in Environmental Medicine, which had similar objectives yo ours, that is, enhancing environmental health in health care delivery, only with a focus on physicians and medical education. One of the hallmarks of the committee's work was the mutual respect present among the members. This group's work was an example of true interdisciplinary teamworkâthe valuing of differences, openness to others' ideas, a willingness to explore all options, an absence of jockeying for position or recognition, and a generous giving of time, effort, and plain hard work. The committee met several times during the course of a year, beginning in May 1994, and worked hard at both identifying and resolving issues, and at writing, rewriting, and revising segments of the report. We met as a whole and in small groups with individual and group assignments. Our discussions were held face to face and via conference calls, through FAX, and over the internet. We assembled an even wider circle of opinion and expertise than that represented by the committee through focus groups, surveys, guest presentations, commissioned papers, and literature and research reviews. Three themes emerged in the process of the study: 1. The environment is a primary determinant of health, and environmental health hazards affect all aspects of life and all areas of nursing practice. 2. Nurses are well positioned for addressing environmental health concerns of individuals and communities. Nurses are the largest group of health professionals; they have great variety in their settings and locations of practice; environmental health is a good fit with the values of the nursing profession regarding disease prevention and social justice; and nurses are trusted by the public. 3. There is a need to enhance the emphasis and awareness of environmental threats to the health of populations served by all areas of nursing practice. This will require changes in practice, education, and research.
PREFACE vii This study is not an exercise in defining a new nursing specialty. We recognize that experts will be needed to guide the changes described, and ways are suggested to facilitate the development of those experts. We also realize that some nurses will choose to make environmental issues the primary focus of their practice. Our emphasis, however, is on the role that every nurse can and should play in addressing environmental health issues. The competencies described for nurses are enhancements of content and focus, as well as some new dimensions of nursing practice. The competencies extend, but are continuous with, nurses' existing roles as investigators, educators, and advocates. The committee's report indicates the need for change for all practicing nurses. Change can seem overwhelming, but it can also be a source of new energy and new interest. Through careful investigation and thoughtful consideration, the committee has made recommendations and proposed strategies for accomplishing these goals. It is not our intent to be prescriptive, but rather to stimulate and challenge the thinking and action of all nurses. Finally, on behalf of the committee I want to acknowledge all of those who assisted us along the way. A list of these people is presented in Appendix H, but in particular I want to thank M. Virginia Ruth, Barbara Sattler, and Meta Snyder (who also served on the committee) for their assistance in both initiating the study and for providing thoughtful input throughout its tenure. In addition, the workshop and focus group participants deserve recognition for helping us clarify our objectives and the current needs in the field of nursing. The sponsors, of course, are appreciated not only for their initiative and financial support, but also for their substantive contributions and guidance. In particular, we thank the following sponsors: from ATSDR, Max Lum, Diane Narkunas, and Donna Orti; from NIEHS, Anne Sassaman; from NINR, Patricia Moritz; from NIOSH, Bernie Kuchinski and Jane Lipscomb; from EPA, Gershon Bergeisen; and from HRSA, Marla Salmon and Moira Shannon. Perhaps most importantly, I want to thank the IOM for taking the initiative to develop this activity, and for the staff's tireless efforts in guiding us through the shoals of committee work, and for making it an enjoyable, valuable experience. It was a pleasure to work with such competent professionals on a topic of such fundamental importance. I can only hope that our efforts will indeed enhance the environmental health content of nursing practice and thereby enlarge the indispensable contribution that nurses make to the health of the public. Florence Nightingale would be proud. Lilian H. Mood Chair
ACRONYMS ix Acronyms AACN American Association of Colleges of Nursing AAOHN American Association of Occupational Health Nurses ABOHN American Board for Occupational Health Nurses ACHNE Association of Community Health Nurse Educators ANA American Nurses Association ANCC American Nurses Credentialing Center AOEC Association of Occupational and Environmental Clinics APN advanced practice nurses ATSDR Agency for Toxic Substances and Disease Registry BLS Bureau of Labor Statistics CAI Computer-assisted instruction CD-ROM compact disk read-only memory CDC Centers for Disease Control and Prevention CFCs chlorofluorocarbons CPHF California Public Health Foundation DHHS Department of Health and Human Services DoD Department of Defense HRSA Health Resources and Services Administration ICN International Council of Nursing
ACRONYMS x IOM Institute of Medicine IRB institutional review board LPN licensed practical nurse MFS medical fee schedule NACNEP National Advisory Council for Nurse Education and Practice NANDA North American Nursing Diagnosis Association NBCSN National Boards for Certification of School Nurses NCEH National Center for Environmental Health NCLEX National Council Licensure Examination for Registered Nurses NCSBN National Council of State Boards of Nursing NIEHS National Institute of Environmental Health Sciences NIJ National Institute of Justice NINR National Institute of Nursing Research NIOSH National Institute for Occupational Safety and Health NLN National League for Nursing NP nurse practitioner OSHA Occupational Safety and Health Administration PPRC Physician Payment Review Commission RN registered nurse STTI Sigma Theta Tau International TRI Toxic Chemical Release Inventory
CONTENTS xi Contents EXECUTIVE SUMMARY 1 1 INTRODUCTION 13 Defining Environmental Health 14 Environmental Health as a Core Function of Nursing Practice 15 Moving to a Population-Based Perspective 17 The Nursing Workforce 18 Origin, Purpose, and Organization of the Report 20 2 OVERVIEW OF ENVIRONMENTAL HEALTH HAZARDS 23 Classifying Hazards 25 Air, Soil, and Water 25 The Workplace Environment 29 The Global Environment 30 Vulnerable Populations 31 Environmental Health Priorities 34 Conclusion 35 3 NURSING PRACTICE 39 Nursing Practice and Responsibilities in Environmental Health 40 Factors that Influence Nursing Practice 51 Case Study 57
CONTENTS xii Nursing Competencies in Environmental Health 62 Conclusion 62 Recommendations 63 4 NURSING EDUCATION AND PROFESSIONAL DEVELOP- 69 MENT Factors Affecting Nursing Curricula 70 Nursing Education Pathways 72 Model Program Development 78 Methods for Enhancing Dissemination of Environmental 86 Health Content in Nursing Education at All Levels Role of Federal, State, and Local Health Agencies 92 Methods for Evaluating Effectiveness of Curriculum 95 Recommendations 98 5 NURSING RESEARCH 103 Nursing Research Perspective 104 Multidisciplinary Research Base for Nursing Practice 105 Review of Nursing Research in Environmental Health 106 Meeting the Need for Nursing Research in Environmental 112 Health Recommendations 118 References 121 APPENDIXES A Position Statement from the International Council of Nurses: 131 The Nurse's Role in Safeguarding the Human Environment B Environmental Hazards for the Nurse as a Worker 134 C Environmental Health Curricula 142 D Environmental Health Resources: Agencies, Organizations, 148 Services, General References, and Tables of Environmental Health Hazards E Focus Group Summary and List of Participants 239 F Nursing Advocacy at the Policy Level: Strategies and 253 Resources G Taking an Exposure History 263 H Acknowledgments 271 I Committee and Staff Biographies 273 INDEX 279
xiii Nursing, Health, & the Environment
NURSING, HEALTH, & THE ENVIRONMENT xiv 'An Angel of Mercy." Florence Nightingale at a soldier's bedside at Scutari. Mezzotint engraving (1855). Property of Duke University Medical Center Library, History of Medicine Collections, Durham, NC.