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We are encouraged by the
nursing profession's efforts to work on environmental health activities
in its areas of practice. Many worthwhile activities have come from
the national nursing initiative- activities such as the Howard University
Environmental Health and Nursing curriculum, the nursing listserv,
the nursing satellite broadcast, and this special edition of the
Hazardous Substances
and Public Health newsletter. These efforts could not occur
without commitments from and partnerships with the skilled nursing workforce
in this nation.
[Table
of Contents]
History
Integrating the Curriculum
Outcomes to Date
Future Directions
References
The
Mississippi Delta Region (MDR) is a 219-county strip along the Mississippi
River in Arkansas, Illinois, Kentucky, Louisiana, Mississippi, Missouri,
and Tennessee. MDR stretches from southern Illinois to southeastern Louisiana.
This area is rich in agricultural production and is also becoming home
to corporate farming, petroleum processing, and other related industries.
The increase in development has led to concerns about not only the health
of people living in the region, but also the lack of environmental health
training for health-care professionals in the region.
To address these concerns,
The Howard
University College of Nursing,
in partnership with the Minority
Health Professions Foundation
and the Agency for Toxic Substances and Disease Registry,
developed Environmental Health and Nursing [EHN]: The Mississippi Delta
Project, a Modular Curriculum. The curriculum developed out of a 1994
agreement between The Howard University College of Nursing and the Minority
Health Professions Foundation for a nursing initiative to increase the
focus on environmental health. The goal of the curriculum is to provide
a comprehensive instructional guide for faculty and students in associate
and bachelor degree nursing programs for incorporating regional-specific
environmental health into existing curricula of schools of nursing (1).
The curriculum consists of six modules:
- environmental health
of the Mississippi Delta
- the role of culture,
poverty, race, and economic development on environmental health
- toxicology: major substances
affecting the data
- assessing individual,
family, and community responses to toxic substances
- environmental justice
- community perspectives:
community organization, empowerment, partnering, and education
For more information, see
the Howard University Division of Nursing Web site (http://www.cpnahs.howard.edu/Nursing/).
According to Dr. Dorothy
Powell (Associate
Professor and Associate Dean for Nursing, Howard University, Washington,
DC, and Project Director, Mississippi Delta Project), the modules are
now being used in three places in the Howard University undergraduate
nursing program.
- Last spring much of the
community health module content was put into a community health course.
This summer the thrust of the community health course was environmental
health. Students took exposure histories, surveyed the community,
looked at jurisdictional regulations (e.g., emissions standards),
interviewed persons in neighborhoods, and evaluated contamination
in fish obtained from the Anacostia River in Washington, DC. These
activities raised excitement about environmental health as part of
what nurses do.
- Environmental justice
was incorporated into an existing course. Justice issues are a large
part of health policy, and Dr. Powell believes that no other nursing
programs are integrating environmental justice into their curricula.
- A community-based Nursing
I course was developed. Students were instructed to look at the community
for potential hazards, to look at differences in communities, and
to ask questions about possible exposures as part of an overall picture
of the community.
An addendum module (the
Users' Guide to
Environmental Health and Nursing [2])
is now included as part of the curriculum. The guide addresses issues
of how to integrate portions of the curriculum without rebuilding nursing
school curricula or adding courses. This module shows participants how
to identify the pieces of the curriculum that are important to them,
then how to evaluate their responses. The evaluation assists participants
in determining whether the pieces they identified as important are already
in their curricula or related to something already in their curricula.
For example, the curriculum could already include pharmacology; toxicology
is an extension of pharmacology. The participants then rank their responses
and can see how information can move into their curricula without disrupting
the current balance. Some pieces of the EHN curriculum can substitute
for segments already included in participants' curricula. Initial workshops
on the EHN curriculum did not include this integration module,
although it has been incorporated into more recent workshops.
The curriculum is starting
to be used in public health: it has been used to develop training program
plans for public health nursing managers, and it will be used in upcoming
training in Alaska. In Arkansas, a statewide public health nursing meeting
is being planned for May 2001; the meeting will include a track on environmental
health. In addition, the curriculum's table of contents provided a guide
for building the agenda for a managers' meeting on environmental health.
A graduate-level nursing
program in Tennessee is using the curriculum content on environmental
assessment for health promotion for family nurse practitioner students.
This will help such students understand possible toxicants in areas
where they live and work.
The curriculum will also
be used to orient newcomers to the Georgia public health system. It
will be especially useful for issues in environmental health and factors
that facilitate the development of nurses' roles in environmental health.
Environmental health is
not addressed to the extent it ought to be in existing nursing curricula.
The relationship between environmental hazards and human health is complex.
We must better understand this relationship to be in a position to prevent
adverse health effects. For nurses in the 21st century, this is the
kind of awareness and problem-solving that is needed: physically being
there and working with communities (e.g., providing information on environmental
exposures, emissions standards, and environmental justice). All of these
elements are within the scope of nursing. In addition to changes in
nursing school curricula, information must be disseminated through a
variety of other media.
Copies of the module and
the guide are available on request from The Howard University College
of Pharmacy, Nursing, and Allied Health Sciences; Division of Nursing;
501 Bryant Street, NW; Washington, DC 20059.
1.
Howard University, Division of Nursing; Agency for Toxic Substances
and Disease Registry; and Minority Health Professions Foundation. 1999.
Environmental health and nursing: the Mississippi Delta Project, a modular
curriculum. Atlanta: US Department of Health and Human Services.
2. Howard
University, Division of Nursing; Agency for Toxic Substances and Disease
Registry; and Minority Health Professions Foundation. 2000. Users' guide
to environmental health and nursing. Washington (DC): Howard University,
Division of Nursing, College of Pharmacy, Nursing, and Allied Health
Sciences.
[Table
of Contents]
The
Road Ahead: Onward, Upward, and Negotiating the Bumps
Patricia Butterfield, PhD, RN, Associate Professor,
College of Nursing, Montana State University-Bozeman, and Robert Wood
Johnson Executive Nurse Fellow
Efforts
To Reduce Local Health Problems
Getting a Few
More Hours in Nursing Curricula
Looking Down the Road
Reference
The year 2000 finds environmental
health and nursing at a crossroads--moving from the margins of clinical
nursing into a recognized part of comprehensive health care. For those
of us who have worked on efforts to expand the nursing profession's
ability to address environmental health problems, it is a particularly
rewarding time. We are beginning to see the fruits of our labor, and
many of us are receiving requests to present at nursing conferences
or provide input for curriculum revisions. From my vantage point, here's
where we are and where we're heading.
Nurses are acting to prevent
and minimize health problems in children and adults exposed to environmental
hazards such as pesticide misapplications, groundwater contaminants,
and lead. We are also discerning environmental triggers of asthma. These
efforts have primarily occurred through regional networks of nurses
working in public health and school settings. Most projects to date
have been developed as extensions of existing community-based programs.
Instead of creating stand-alone environmental health programs, most
of the current efforts take an existing program that already has a strong
nursing presence--like Head
Start or the Women, Infants, and Children Supplemental Nutrition Program
(WIC)
--and expand patient services to include environmental health assessment
and screening. This approach works well because it capitalizes on nurses'
existing expertise, builds capacity in clinical settings, and keeps
nurses in familiar territory.
Progress has been made within
nursing education on curriculum design and integration. The
Institute of Medicine
competencies (1) have given a clear
road map for nursing education, and many nursing programs are developing
environmental health case studies for their undergraduate and graduate
students. Increased attention to environmental health has resulted from
faculty access to the Web sites of the Agency for Toxic
Substances and Disease Registry (ATSDR), the
U.S. Environmental Protection Agency,
and academic health sciences centers. Easy access to material safety
data sheets information and ATSDR's Case
Studies in Environmental Medicine has enabled students to incorporate
environmental health actions into nursing care plans and community assessment
projects. Finally, environmental health topics are now being addressed
in classes other than public health nursing, so that faculty members
who teach pediatric, chronic illness, and psychiatric nursing are beginning
to consider environmental health as it applies to their scope of clinical
practice.
Several obstacles must be
overcome if we are to move to the next level of integration. As always,
opportunities for the nursing profession are hidden within these obstacles;
they include the following:
- Document exposure history
data on all patients and revise chart forms to include environmental
exposure data. The Pew
Environmental Health Commission
recently released a report emphasizing the need for a national tracking
system so that health problems that may be due to environmental factors
can be systematically examined. One of the key recommendations in
the Pew report was
for increased documentation of exposures, and this is an area where
nurses can make a remarkable contribution to public health. More nurses
are charting environmental information on health history forms, but
it is time to emphasize the importance of having all nurses in all
clinical settings document basic exposures on all patients. ATSDR
sponsored the development of a mnemonic called "I PREPARE."
The mnemonic cues health providers to ask about and chart key environmental
exposures; it is a good idea for busy health providers, who need quick
reference materials. By revising clinical history forms to include
exposure history data, and by charting exposures, nurses can improve
the quality and quantity of environmental exposure data throughout
the nation.
- Create or modify patient
reimbursement codes to include environmental health problems. Health
care is quantified using current procedure terminology (CPT) or other
codes to bill for care. Nursing care is often an invisible piece of
outpatient and public health care because it is integrated into other
services, which are then billed as medical services. It is important
to revise or develop an appropriate set of codes for environmental
health services delivered by nursing personnel. Good program evaluation
requires solid data, and we need to have service codes that accurately
reflect nursing care for environmental health problems.
- Document evidence of
suspected disease clusters and provide training for nurses so that
the information they collect can be used by public health professionals
to address citizens' concerns about suspected disease clusters. Because
of our presence in schools, homes, clinics, and worksites, nurses
are aware of local health concerns and can assist in disease surveillance.
We can be more effective in preventing environmental health incidents
if we know how and where to report potential disease clusters. To
do this, nurses need to learn more about collecting meaningful and
unbiased data for use in cluster investigations.
- Enhance risk communication
skills within the nursing profession. Nurses are experts in translating
technical health information into clear and concise guidelines. This
expertise comes through our daily work in explaining medication regimes
and treatment procedures in a way that is clear and practical for
patients. We need to extend these communication skills further into
the realm of environmental risk communication. Several highly qualified
nurses are designated as risk communication experts within their own
states, but we need to strengthen nursing capacity in this area. During
and after environmental health incidents, effective risk communication
skills are needed to keep members of the public updated, informed,
and provided with scientifically accurate information addressing environmental
health concerns.
Nurses are taking leadership
roles in initiatives
addressing asthma, pediatric lead exposure, and exposure to organic
solvents. We are also working on the front line of programs designed
to reduce environmental risks for vulnerable groups such as children,
immunosuppressed adults, and the frail elderly. Regional networks of
nurses are working together and with other health
professionals to initiate primary prevention programs through local
and state health departments. ATSDR has assumed national leadership
in mobilizing and strengthening nursing's capacity in environmental
health and has worked to "connect the dots" among groups of
nurses across the country. It is a long and winding road, but we are
off to a good start. All new health initiatives encounter bumps along
the way, but I am confident that we can improve the nation's health
by focusing on the road ahead.
1.
Institute of Medicine. 1995. Nursing, health, and environment.
Washington (DC): National Academy of Sciences.
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October 24, 2003
Contact Name: Wilma López/ WLópez@cdc.gov
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