SANITATION FOR PUBLIC HEALTH NURSES
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 NURSING COMPETENCIES IN ENVIRONMENTAL HEALTH 62 CONCLUSION 62 RECOMMENDATIONS 63 4 NURSING EDUCATION AND PROFESSIONAL DEVELOP MENT 69 FACTORS AFFECTING NURSING CURRICULA 70 NURSING EDUCATION PATHWAYS 72 MODEL PROGRAM DEVELOPMENT 78 METHODS FOR ENHANCING DISSEMINATION OF ENVIRONMENTAL HEALTH CONTENT IN NURSING EDUCATION AT ALL LEVELS 86 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 HEALTH 112 RECOMMENDATIONS 118 REFERENCES 121 EXECUTIVE SUMMARY EVERY DAY SANITARY KNOWLEDGE OR THE KNOWLEDGE OF NURSING OR IN OTHER WORDS OF HOW TO PUT THE CONSTITUTION IN SUCH A STATE AS THAT IT WILL HAVE NO DISEASE OR THAT IT CAN RECOVER FROM DISEASE TAKES A HIGHER PLACE FLORENCE NIGHTINGALE 1860 PREFACE ABSTRACT ENVIRONMENTAL HEALTH HAZARDS INCLUDING THOSE IN THE WORK ENVIRONMENT ARE UBIQUITOUS OFTEN INSIDIOUS AND GENERALLY POORLY UNDERSTOOD AS SUCH THEY ARE OF INCREASING INTEREST TO THE GENERAL PUBLIC AND OF FUNDAMENTAL IMPORTANCE TO HEALTH CARE PROVIDERS AMONG HEALTH CARE PROVIDERS REGISTERED NURSES OCCUPY A UNIQUE POSITION IN BOTH RURAL AND URBAN SETTINGS NURSES ARE OFTEN THE INITIAL AND SOMETIMES THE ONLY POINT OF CONTACT FOR PEOPLE SEEKING MEDICAL CARE THEY ARE ALSO THE LARGEST GROUP OF PROFESSIONAL HEALTH CARE PROVIDERS IN THE UNITED STATES AN ESTIMATED 2 2 MILLION IN OCCUPATIONAL HEALTH PRACTICE NURSES OUTNUMBER PHYSICIANS BY SIX TO ONE YET THE VAST MAJORITY OF NURSES HAVE HAD NO FORMAL TRAINING IN OCCUPATIONAL OR ENVIRONMENTAL HEALTH IF ENVIRONMENTAL HEALTH HAZARDS AND HEALTH EFFECTS ARE TO BE RECOGNIZED AND DEALT WITH EFFECTIVELY IT IS OF FUNDAMENTAL IMPORTANCE THAT ALL HEALTH CARE PROVIDERS HAVE A CLEAR UNDERSTANDING OF THE ASSOCIATION BETWEEN THE ENVIRONMENT AND HEALTH TOWARD THAT END THE COMMITTEE MAKES A SERIES OF RECOMMENDATIONS FOR THE INTEGRATION AND ENHANCEMENT OF ENVIRONMENTAL HEALTH IN NURSING EDUCATION PRACTICE AND RESEARCH INTRODUCTION THE ENVIRONMENT IS ONE OF THE PRIMARY DETERMINANTS OF INDIVIDUAL AND COMMUNITY HEALTH AND WHETHER IT IS JUSTIFIABLE OR NOT THERE IS 1 GROWING PUBLIC CONCERN AND APPREHENSION ABOUT THE POTENTIAL ADVERSE HEALTH EFFECTS ASSOCIATED WITH EXPOSURE TO SUBSTANCES IN THE HOME THE WORKPLACE AND IN THE OTHER COMMUNITY SETTINGS UNFORTUNATELY MOST HEALTH CARE PROVIDERS INCLUDING NURSES ARE INADEQUATELY PREPARED TO IDENTIFY OR RESPOND APPROPRIATELY TO SUCH HAZARDS OR CONDITIONS A COMPREHENSIVE APPROACH TO NURSING PRACTICE AS WELL AS OTHER HEALTH CARE PROFESSIONS REQUIRES THE AWARENESS RECOGNITION AND TREATMENT OF CRITICAL FACTORS THAT AFFECT INDIVIDUAL AND COMMUNITY HEALTH EVEN IF THESE FACTORS ARE NOT OBVIOUS AT FIRST TO PATIENTS OR PROVIDERS A CHILD WHO HAS A BEHAVIOR PROBLEM IN SCHOOL BECAUSE OF LEAD POISONING A YOUNG ADULT WHO HAS RESPIRATORY PROBLEMS DUE TO THE INHALATION OF SOLVENTS WHILE WORKING IN THE GARAGE AT HOME A WORKER WHO IS EXHIBITING NEUROLOGICAL SYMPTOMS RELATED TO HANDLING CHEMICALS ON THE JOB AND A RETIRED PERSON WHOSE RASH IS CAUSED BY A GARDEN PESTICIDE ARE ALL EXAMPLES OF PEOPLE WHO HAVE BEEN AFFECTED BY ENVIRONMENTAL HEALTH HAZARDS IN WAYS THAT COULD EASILY BE MISINTERPRETED IN THE ABSENCE OF INFORMATION ABOUT THE ORIGIN OF THE PROBLEM NURSES ARE WELL POSITIONED TO ADDRESS ENVIRONMENTAL HEALTH HAZARDS BOTH ON AN INDIVIDUAL AND COMMUNITY LEVEL FOR A NUMBER OF REASONS THEY ARE THE LARGEST GROUP OF HEALTH CARE PROVIDERS IN THE UNITED STATES 2 2 MILLION AND GENERALLY SPEAKING THEY HAVE MORE OPPORTUNITIES THAN OTHER HEALTH CARE PROVIDERS TO TALK IN DEPTH WITH PATIENTS IN ADDITION THEY ARE OFTEN THE ONLY HEALTH CARE PROVIDERS WHO VISIT PATIENTS IN THEIR HOMES WORKPLACES AND LOCAL COMMUNITIES THUS GAINING FIRSTHAND KNOWLEDGE OF THE POTENTIAL ENVIRONMENTAL HAZARDS PRESENT IN THESE SETTINGS THE CLOSE INTERACTION OF NURSES WITH PATIENTS AND THE ON SITE ASPECTS OF NURSING CARE PROVIDE TREMENDOUS OPPORTUNITIES FOR NURSES TO DETECT PREVIOUSLY UNRECOGNIZED HEALTH PROBLEMS INCLUDING THOSE RELATED TO ENVIRONMENTAL EXPOSURES AND TO INITIATE APPROPRIATE INTERVENTIONS FINALLY THERE IS A GOOD FIT BETWEEN ENVIRONMENTAL HEALTH CONCERNS THE HISTORICAL DEVELOPMENT OF THE NURSING PROFESSION AND CORE NURSING VALUES DEFINING ENVIRONMENTAL HEALTH THE COMMITTEE RECOGNIZES A NEED TO DISTINGUISH BETWEEN ISSUES OF ENVIRONMENTAL HEALTH AND ISSUES MORE SPECIFIC TO THE SCIENCE OF ECOLOGY THE PRIMARY FOCUS OF THIS REPORT IS ON THE ADVERSE HEALTH OUTCOMES THAT MAY BE ASSOCIATED WITH EXPOSURE TO ENVIRONMENTAL HAZARDS RATHER THAN EFFORTS TO CONSERVE NATURAL RESOURCES THIS FOCUS IS IN NO WAY INTENDED TO DIMINISH THE IMPORTANCE OF ECOLOGICAL ISSUES THE ENVIRONMENTAL HAZARDS OF CONCERN IN THIS REPORT FALL INTO FOUR WIDELY ACCEPTED CLASSES CHEMICAL PHYSICAL BIOLOGICAL AND PSYCHOSOCIAL SUCH HAZARDS MAY BE NATURALLY OCCURRING SUCH AS RADON OR ULTRAVIOLET SANITATION FOR PUBLIC HEALTH NURSES 2 LIGHT FROM THE SUN OR THEY MAY BE MANMADE OR CONSTRUCTED SUCH AS PARTICULATES AND GASES RELEASED INTO THE ENVIRONMENT FROM AUTOMOTIVE EXHAUST INDUSTRIAL SOURCES OR TOBACCO SMOKE AS THESE EXAMPLES DEMONSTRATE ENVIRONMENTAL HAZARDS MAY BE ENCOUNTERED IN THE HOME WORKPLACE AND COMMUNITY ENVIRONMENTS THUS ADVERSE HEALTH OUTCOMES RELATED TO ENVIRONMENTAL CONDITIONS INCLUDE WORKER AND CHILDHOOD LEAD POISONING CHILDHOOD AND OCCUPATIONALLY INDUCED ASTHMA AND REPETITIVE MOTION INJURY AMONG MANY OTHERS TAKEN IN THIS CONTEXT USE OF THE TERM ENVIRONMENTAL HEALTH THROUGHOUT THIS REPORT REFERS TO FREEDOM FROM ILLNESS OR INJURY RELATED TO EXPOSURE TO TOXIC AGENTS AND OTHER ENVIRONMENTAL CONDITIONS THAT ARE POTENTIALLY DETRIMENTAL TO HUMAN HEALTH ENVIRONMENTAL HEALTH HAZARDS SINCE 1950 MORE THAN 65 000 NEW CHEMICAL COMPOUNDS HAVE BEEN INTRODUCED INTO COMMON USE IN THE WESTERN WORLD THE MAJORITY OF WHICH 84 PERCENT HAVE NOT BEEN TESTED FOR HUMAN TOXICITY THE POST WORLD WAR II ERA BROUGHT MAJOR TECHNOLOGICAL ADVANCES THAT WERE ACCOMPANIED BY THE RELEASE OF AN UNPRECEDENTED NUMBER OF NEW SYNTHETIC CHEMICALS ONTO UNITED STATES MARKETS NEW CHEMICAL COMPOUNDS CONTINUE TO BE INTRODUCED INTO THE ENVIRONMENT EACH YEAR PRESENTLY 72 000 CHEMICALS ARE USED IN COMMERCE IN THE UNITED STATES AND MOST HAVE HAD LIMITED TESTING FOR THEIR EFFECTS ON HUMAN HEALTH FURTHERMORE THE U S ENVIRONMENTAL PROTECTION AGENCY EPA REPORTS THAT MORE THAN 40 MILLION PEOPLE LIVE WITHIN 4 MILES OF A SUPERFUND SITE 1 AND APPROXIMATELY 4 MILLION PEOPLE RESIDE WITHIN 1 MILE OF A SITE FURTHER INCREASING THEIR RISK OF EXPOSURE IN THE HOME OTHER ENVIRONMENTAL HAZARDS HAVE WELL DOCUMENTED ADVERSE HUMAN HEALTH EFFECTS THESE INCLUDE RADON ENVIRONMENTAL TOBACCO SMOKE PESTICIDES CARBON MONOXIDE AND AIRBORNE PARTICULATES FROM WOOD BURNING STOVES NITROGEN DIOXIDE FROM NATURAL GAS STOVES FORMALDEHYDE AND OTHER CHEMICALS THAT ARE RELEASED AS OFF GASES FROM NEW CARPETS BLOWN IN FOAM INSULATION AND THE SYNTHETIC MATERIALS THAT COVER THE INDOOR SURFACES OF MANY MOBILE HOMES ENVIRONMENTAL HAZARDS IN OCCUPATIONAL SETTINGS CAN BE SUBSTANTIAL AND WORKPLACE INJURIES AND FATALITIES ARE THE BEST DOCUMENTED ENVIRONMENTAL EFFECTS ON HEALTH MORE THAN 2 25 MILLION WORK RELATED ILLNESSES 1 SUPERFUND SITES ARE HAZARDOUS WASTE SITES DESIGNATED BY THE EPA TO BE A THREAT TO HUMAN HEALTH THESE MAY INCLUDE LEAKING UNDERGROUND STORAGE TANKS OR INACTIVE HAZARDOUS WASTE SITES SUCH AS MUNICIPAL DUMPS AND CONTAMINATED FACTORIES OR MINES AND MILLS CHIRAS 1994 P 462 SANITATION FOR PUBLIC HEALTH NURSES 3