Environmental Health

The environment has a symbiotic relationship to the health of individuals, families and communities. The environment must be healthy in order for achievement of optimal health (Stanhope and Lancaster, 2014). Nurses have a responsibility to understand the health environmental risks, including how and what, should be included in assessment, planning and implementing interventions to reduce or eliminate the environmental risk. In addition, nurses must be able to communicate the environmental health risks, provide needed education and advocate for public policies to mitigate the risk to health (Stanhope and Lancaster, 2014). This paper will explore the nurse’s role in environmental nursing through the review of environmental principles, explaining differences between an environmental exposure history and an environmental health exam and the four phases of a chemical exposure. Finally, author will discuss the differences between community-based and community-oriented nursing and explain the how population-based approaches are applicable to the hospital setting.

Environmental Principles According to Stanhope and Lancaster (2014), nurses must know how to assess for environmental health risks in order to help the individuals, families and communities they care for. In 1995, The National Academy of Science’s Institute of Medicine (IOM) published a report calling for all nurses to have a basic understanding of environmental health principles including these competencies in all aspects of nursing practice (U.S. Department of Health and Human Services, 2012). Stanhope and Lancaster (2014), aptly explain the four core competencies recommend by the IOM and integrate them with the American Nursing Association’s (ANA) Principles for Environmental Health.

1. Basic Knowledge and Concepts: Nurses must comprehend the scientific principles that form the foundation between the environment and humans. According to Stanhope and Lancaster, 2014) nurses must have a basic understanding regarding the relationship that exists between the two. By having a solid comprehension of the environmental health sciences, toxicology, epidemiology and multidisciplinary approach, the nurses can conduct the appropriate assessments leading to the development of interventions that will result in prevention and control of environmental health issues. An example of this competency is seen in nurses who are caring for patients who live in poverty. These patients may reside in environments that expose them to environmental hazards such as, overcrowded homes, living close proximity to hazardous waste, have access to poor quality of foods and environmental hazards such as lead paint. By understanding these risk exist and the potential outcome to the patient, the nurse can plan accordingly. 2. Assessment and Referral: Nurses must be competent in completing environmental health histories, be able to recognize potential hazards and unexpected illness, make appropriate referrals that will include plausible environmental origins. Examples of nursing assessments that might discover an environmental risk is when nurses care for older patients. The patient’s presenting symptoms may warrant further investigation for past exposure to toxic substances such as asbestos. To ensure that patient and or community needs are met, the nurse must be aware of available resources and have the ability to access them in order develop and implement nursing interventions. Stanhope and Lancaster (2014) provide a listing of basic resources that nurses may utilize such as, The National Lead Information Center, Local Poison Control Centers, The Office of Pesticides, The American Lung Association and Agency for Toxic Substance and Disease Registry, just to name a few. 3. Advocacy, Ethics and Risk Communication: Nurses must understand the role of advocacy for specific environmental health risks. Many individuals and communities do not have adequate access to information regarding environmental health risks. Nurses are ethically responsible to ensure the individuals and communities in which they practice are provided this information (Pope,A., Synder, M and Mood, L. 1995). Having knowledge regarding the availability to consult with other disciplines such as food safety specialists, sanitarians, radiation specialists and industrial hygienist will ensure issues are address thoroughly. In the example of lead poisoning, nurses can collaborate with house inspectors trained in lead paint detection, a sanitarians with expertise in lead exposure risks in the home, healthcare workers that can manage clinical issues associated with lead poisoning and laboratories that can provide analysis on blood and or paint samples for measurement of lead levels. The agencies needed for this type of situation may have local or state health department oversight. The nurse must ensure they have the knowledge needed to be able to access the correct agency and coordinate the needs of the patient (Stanhope and Lancaster, 2014). 4. Legislation and Regulation: Nurses are often one the first professions that an individual or a community may turn to for advice regarding an environmental health issue. It may be from a pregnant woman requesting information about birth defects, persons asking about the safety of drinking water, or questions from homeowners about radon levels. Nurses must obtain knowledge regarding laws and public policy that provide information on various topics of environment health risks. Stanhope and Lancaster (2014), provide examples of consumer confidence reports, otherwise known as right to know reports. For example the suppliers of a community’s’ water source is required to test for quality standards to ensure the safety of consumption. The results of such tests are reported to the community through community confidence reports. The federal Freedom of Information Act ensures that the public can have access to request public documents such as the water board reports. In the movie Erin Brockovich, the public water records were reviewed indicating contaminated drinking water. This movie was based on the real life events regarding the town of Hinkley, California. This community suffered serious health issues related to a toxic chemical exposure through ground water contamination.

Environmental Exposure verses Environmental Health Assessment An environmental exposure can occur in any setting where people spend time (Stanhope and Lancaster, 2014). Nurses should complete a thorough assessment to determine if exposure has occurred. The assessment should include all potential environments. Stanhope and Lancaster (2014), explain the use of the mnemonic I PREPARE to assist nurses in identifying potential environmental exposures. • I- Investigate- potential exposures direct questions about potential exposure. • P-Present work- provides answers to questions about the current workplace. • R- Residence- provides answers to questions about the place of residence. • E- Environmental concerns- provides answers to questions about concerns in the living environment. • P- Past Work- provides answers to questions about previous work environments. • A- Activities- provides answers to questions about current activities that would risk exposure. • R- Referrals and Resources- provide referral and resource information to review. • E- Educate- a checklist of points to cover during education.

There are several techniques used in assessing for environmental health risks within a community. These are risks and not confirmations of actual exposures. Stanhope and Lancaster (2014), describe the use of various assessments, completed by setting category. This may provide information regarding a risk of exposure that is unique to one setting or an exposure that could be overlapping to one or more areas. If a nurse is considering the risk of exposure to the toxic gas, ethylene oxide the assessment would only include the workplace setting. The use of ethylene oxide is seen in hospitals for sterilization of surgical equipment. In comparison, exposure to pesticides could be found in the home, workplace, school and community. Environmental health assessments can be broken down into four categories including air, water, land and food.

• Air- Air pollution is a common contributor to health issues (Stanhope and Lancaster, 2014). Air quality is regulated thorough the Clean Air Act which established criteria to measure acceptable levels of air quality. Air pollution is monitored by the Environmental Protection Agency who has the ability to mandate changes such as improvement in motor vehicle emission systems. There are two categories used to gather data regarding air pollution. 1. point source- the source of the pollution is fixed and identifiable. An example of a point source is a factory that emits byproducts of production through smoke stacks. 2. non-point source- this source is variable such as motor vehicle exhaust. • Water- Water is necessary to sustain all life forms thus measuring the quality of safe drinking water is a primary concern for public health officials (Stanhope and Lancaster, 2014). The Clean Water Act and The Safe Drinking Water Act outline specific expectations for ensuring the safety of water supplies. Water quality can also be pinpointed to point and non-point sources. • Land- How land is used has an impact on the health of communities (Stanhope and Lancaster, 2014). Various types of controls help to ensure the use of land is not detrimental to the health of a community. This controls include: 1. Zoning laws were established to regulate how land developed such as establishing what type of structure can be built and where. An example of the use of a zoning law is the prevention of a housing development from being built on top of a previous landfill. 2. Agricultural practices such a fertilization can impact food and water supplies as well as human actions such as building materials that include toxins. 3. Lead based paint is no longer acceptable due to the negative health impact on humans. If soil is contaminated, exposure to environmental risks may be made through hand to mouth activity. (Stanhope and Lancaster, 2014). 4. Research is being done on the configuration of communities and obesity. According to Stanhope and Lancaster (2014), communities that have walking or biking trails and available shopping that is accessible without a vehicle may have a direct correlation to healthier communities. • Food- Laws such as the Food Quality Protection Act and the Federal Insecticide, Fungicide and Rodenticide Act help in the monitoring and control of food related environmental risks. The primary concerns around food handling, preparation and storage are preventable risks through proper education. Salmonella and Esherichia colia are two of the more serious food related illnesses.

Risk Assessment in Chemical Exposures According to Stanhope and Lancaster (2014), risk assessment is defined as, “a process to determine the probability of a health threat associated with an exposure”. Risk assessments are subject to interpretation and therefore may result in differing recommendations. Recommendations may or may not carry the same weight to drive change due to the varying opinions regarding public and economic health concerns. Economic interest is a third factor that may also impact the health concerns of a chemical exposure. The Toxic Substances Control Act according to the Environmental Protection Agency (2014) will allow the organization “to regulate the production and distribution of commercial and industrial chemicals in order to ensure that chemicals made available for sale and use in the United States do not harm human health or the environment.”

There are four stages used in completing a chemical exposure assessment.

1. Is the chemical known to be associated with negative health effects (in animals or humans)? 2. Has the chemical been released into the environment by the air, water, soil or food? 3. How much of the chemical is thought to have entered the human body and by which route? 4. Final Phase considers all of the answers to the first three questions and then asks; a. Is the chemical toxic? b. What is the source and mount of exposure? c. What is the route and duration of the exposure for humans? This last question is often a source of scrutiny. Stanhope and Lancaster (2014), list five factors that must be present in order to show there was human harm: i. A source of harm that has chemical and/or physical properties ii. An environmental medium for transport-air, water or soil. iii. A receptor population within the exposure pathway for harm to human health. iv. A route of exposure for humans these are inhalation, ingestion and skin absorption. v. As adequate amount (dose) of the chemical to result in human harm.

Nursing Roles in Environmental Health Stanhope and Lancaster (2014), discuss the settings in which nurses practice environmental health principles. These include, the specialty practice of environmental health, an adjunct to other practice settings and the knowledgeable and engaged citizen. Assessment and referral are two steps in the nursing process that have a more defined meaning in environmental health. Assessments may vary from individuals to communities or environmental sites, and referrals will vary according to specific communities (Stanhope and Lancaster, 2014).

1. Community involvement and public participation- the nurse assists in the organizing, facilitating and often presenting information on the environmental issue. This form of education is no different from education provided in an acute care setting. The nurse must ensure the information is presented in a manner understandable by the community. 2. Individual and population risk assessment- using assessment skills to identify actual or potential exposures and health outcomes for patients in acute, chronic and well care settings. 3. Risk communication- Stanhope and Lancaster (2014), describe this as, providing the right information to the right people at the right time. 4. Epidemiological investigations- nurses must use scientifically sound yet sensitive methods to complete investigations where the public may have fear due to the environmental issue. 5. Policy development- influencing policy change or development. The nurse participates by proposing change and monitoring action from agencies, communities and organizations.

Community–based Nursing verses Community-oriented Nursing Community-based nursing is the practice of nursing outside of a facility or institution. Community-based services are administered to both individuals and families (Stanhope and Lancaster, 2014). Community-oriented nursing is focused on a community or a population of individuals, families or groups. Hospitals would be considered a type of population approach to environmental health. This concept is supported by, Harris, Pisa, Talioaga and Vezeau (2009), in the statement “hospitals directly affect the health of those within their walls”. This statement implies that hospitals thus have the ability to impact the environmental health of the population within.

Conclusion Florence Nightingale documented patient outcomes to support her theories regarding environmental control and improved health (Harris, Pisa, Talioaga and Vezuau, 2009). This concept is still a core foundation in nursing practice today. Nurses make up the largest number of professionals in healthcare and are considered one of the countries most trusted sources of information (Stanhope and Lancaster, 2014). Integrating concepts of nursing practice, research, education and advocacy, nurses have a significant responsibility in ensuring the needs of environmental health are being met in all practice settings. In the words of Florence Nightingale, “No amount of medical knowledge will lessen the accountability for nurses to do what nurses do; that is, manage the environment to promote positive life processes.” (Harris, Pisa, Talioaga and Vezuau, 2009)

References

American Nurses Association,(2007). ANA’s principles of environmental health for nursing practice with implementation strategies. Retrieved from: http://www.nursingworld.org/MainMenuCategories/WorkplaceSafety/Healthy-Nurse/ANAsPrinciplesofEnvironmentalHealthforNursingPractice.pd.
Harris,N., Pisa,L.,Talioaga, S., and Vezuau,T.,(2009). Hospitals going green. Holistic Nursing Practice. 23(2), 101-111.
Stanhope, M. & Lancaster, J. (2014). Foundations of nursing in the community: Community oriented practice (Fourth ed.). St. Louis: Elsevier.
Pope,A., Synder, M and Mood, L. (1995). Nursing, health and the environment. Washington, DC. National Academy Press.
U.S. Department for Health and Human Services, (2012). Nurses and environmental health: Success through action, illustrations from across the nation. Retrieved from: http://www.neefusa.org/pdf/NursingBooklet.pdf
U.S. Environmental Protection Agency, (2014). Toxic substances. Retrieved from: http://www2.epa.gov/regulatory-information-topic/toxic-substances.