You will use the concept of primary prevention when instructing a patient to

In watching diseases, both in private homes and in public hospitals, the thing which strikes the experienced observer most forcibly is this, that the symptoms or the sufferings generally considered to be inevitable and incident to the disease are very often not symptoms of the disease at all, but of something quite different—of the want of fresh air, or of light, or of warmth, or of quiet, or of cleanliness, or of punctuality and care in the administration of diet, of each or of all of these.

—Florence Nightingale, 1860, p. 8

Environmental determinants of health and disease are pervasive and integral to the assessment, diagnosis, intervention, planning, and evaluation components of nursing practice. However, environmental factors that affect health are commonly overlooked in routine patient assessments. When environmental health concerns are missed, an opportunity for prevention is lost, and public health is less well served.

Although not every illness has an environmental etiology, nearly everyone will have a health problem related to an environmental hazard for which evaluation or advice is appropriate in terms of good nursing practice. It is important in nursing practice to identify not only the hazards that contribute to a current diagnosis (e.g., exposure to lead-contaminated dust resulting in elevated blood lead levels, and outdoor ozone or indoor allergens exacerbating childhood asthma), but also those that have not yet caused illness but are amenable to intervention (e.g., friable asbestos, radon, formaldehyde gases from building materials, and carbon monoxide and nitrogen oxides from poorly ventilated furnaces). By taking a proactive approach, nurses can initiate preventive actions to abate hazards before they manifest as disease. Thus, consideration of environmental health concepts as a core nursing function will vastly strengthen nursing's contribution to disease prevention.

Nursing Practice and Responsibilities in Environmental Health

The practice of nursing is guided by standards and definitions established by leaders of nursing in professional associations and to some extent by governmental agencies such as the Public Health Service's Bureau of Health Professions. Systematic frameworks for the practice of nursing also guide nurses in actual nursing performance. The most widely accepted framework for nursing practice currently in use is the nursing process of assessment, diagnosis, planning, intervention, and evaluation. A model to guide medical and nursing practice specific to environmental health concerns established by the California Public Health Foundation (CPHF, 1992) consists of three roles: investigator, educator, and advocate.

Awareness of the formal descriptions, definitions, and systems of nursing practice is useful for determining how environmental health concepts and related activities fit into nursing as it is currently practiced. A brief overview of the definitions and systems that guide nursing practice and their application to environmental health concerns is presented in the following section to demonstrate the "fit" between nursing practice and environmental health issues. The integration of environmental health concerns into nursing's scope of practice and the profession's philosophy of health and health care also illustrate nursing's historic and continued concern about environmental influences on human health.

Definition of Nursing Practice

The American Nurses Association (ANA) provides leadership in determining the goals, objectives, and professional practice of nursing. ANA defines nursing as " … a caring-based practice in which processes of diagnosis and treatment are applied to human experiences of health and illness" (ANA, 1994).

ANA describes three basic nursing activities that explicitly include issues related to the environment and health, a preventive approach to health, and concern for populations as well as individuals:

1.

Restorative practices modify the impact of illness and disease.

2.

Supportive practices are oriented toward modification of relationships or the environment to support health.

3.

Promotive practices mobilize healthy patterns of living, foster personal and familial development, and support self-defined goals of individuals, families, and communities.

Thus, major concepts and activities necessary to address environmental factors that can affect the health of individuals and populations are within the scope of practice and definition of nursing set forth by the ANA.

The Nursing Process

The nursing process, consisting of assessment, diagnosis, planning/outcomes, intervention, and evaluation, has been described as the core and essence of nursing, central to all nursing actions. It is a deliberate, logical, and rational problem solving process whereby the practice of nursing is performed systematically. The nursing process includes continuous input from patients, their families, or communities through all phases from assessment to evaluation. Diagnoses, planning, and interventions may be altered at any stage based upon new information from the patient or any other source. As far as possible, the patient should have an active and equal role in the nursing process, constricted only by physical or emotional limitations on their ability to participate.

It is worth noting that the nursing process was developed for the care of individuals, and has since expanded to include a role in the care of families and communities. Application of the nursing process to environmental health issues may require nurses to employ various phases of the process in new ways. For example, the intervention may be recommending a change in the source of drinking water that affects a whole neighborhood or community. The process is compatible with the framework of investigator, educator, and advocate, established by the California Public Health Foundation (1992) to address nursing roles and responsibilities particular to environmental health issues. The CPHF framework augments rather than duplicates the nursing process.

During the assessment phase of the nursing process, data are gathered to determine a patient's state of health and to identify factors that may affect well-being. This activity includes eliciting a health history to identify previous illnesses and injuries, allergies, family health patterns, and psychosocial factors affecting health. Environmental health components of history taking can be integrated into the routine assessment of patients by including questions about prior exposure to chemical, physical, or biological hazards and about temporal relationships between the onset of symptoms and activities performed before or during the occurrence of symptoms. During an assessment, the nurse should be alert to patterns of co-morbidity among patients, family members, and communities that are indicative of environmental etiologies. Nurses also conduct assessments during visits to patients in their homes and places of work, gaining first hand information about environmental factors that may adversely affect health.

Diagnosis occurs with the culmination of objective and subjective data collection. In this phase of the nursing process health problems are identified and described. Depending upon their practice setting, nurses may use the diagnostic terms established by the North American Nursing Diagnosis Association (NANDA) or medical diagnostic terminology, as is often the case with APNs who are nurse practitioners. Routine consideration of environmental factors that affect health is essential in the diagnostic phase of the nursing process; without knowledge of such factors, problems may be misdiagnosed and subsequent interventions will address environmental issues haphazardly, if at all.

Planning/outcomes is the phase of the nursing process in which optimal outcomes are identified. A range of interventions are identified to address the health problem, and plans for implementing those interventions are developed. The ability to establish interventions that address environmentally related illnesses depends on a nurse's ability to formulate diagnoses that include consideration of environmental factors. Without attention to environmental factors, intervention plans are likely to focus on secondary- and tertiary-level activities (care and cure) rather than primary prevention strategies.

Intervention is the component of the nursing process in which the nurse implements activities to promote health, and prevent or alleviate illness and injury. The nurse may act as educator in this part of the nursing process, informing patients, families, workers, and communities about hazards in the environment and how to protect themselves. Effective interventions require a knowledge of resources, including texts, databases, and professional experts, and an ability to access these resources.

Intervention also includes the role of advocate. Although nurses are familiar with the concept of advocacy on behalf of individual patients, often they have not been trained in techniques of advocacy for populations or in settings other than health care facilities. Nurses need to extend the concept of advocacy to include activities on behalf of communities and other groups and in settings such as the workplace or community meetings. This extension of nursing advocacy is often essential for addressing environmentally related health issues because they are frequently intertwined with social and political factors. Interventions focusing exclusively on the individual patient are rarely effective as primary prevention methods in matters of environmental health.

Evaluation, the final step in the nursing process, can be conducted on numerous levels and frequently results in additional interventions. The health outcomes of an individual are one method of determining the effectiveness of nursing interventions. Another measure of effective intervention in environmentally related illness is an evaluation of hazard abatement methods. Has the hazard been contained or removed from the environment of the individual? Are others living in the area protected from exposure? Evaluation should also include an assessment of the effectiveness of interventions directed toward other populations at similar risk, for example, other family members, co-workers, and community members. Were the existence of the hazard and protective measures communicated clearly and consistently to those at risk? Was effective treatment provided to others at risk who experienced symptoms? Are measures being taken to prevent similar incidents of exposure in the future? Are the patient, work population, and community satisfied with the interventions used to identify and abate hazardous conditions related to the environment? Are those affected by the hazard satisfied with the health care that was provided, including educational interventions and medical treatment? These questions and the answers to them provide nurses and other health care providers with important information for determining the effectiveness of interventions undertaken in a particular incident and in identifying more effective measures for dealing with similar problems in the future.

Application of the nursing process to environmental health concerns requires an expansion of the tools and processes used to assess patients, reason diagnostically, and develop treatments and interventions that consider environmental factors. Responsibilities for implementing clinical services relevant to environmental health will vary according to practice settings; however, the nursing process is a useful framework for applying environmental health concepts in all settings and roles.

Scope of Responsibilities

A nurse's role in addressing environmental health issues can be conceptualized in a variety of ways. The nursing process can be augmented or integrated with other models of practice, such as the CPHF model, which consists of three roles for the health professional: investigator, educator, and advocate (CPHF, 1992). The role of investigator supports the assessment and evaluation phases of the nursing process, while the roles of educator and advocate would be carried out as interventions. This framework incorporates a range of activities, including working with communities and on matters of public policy, that may be unfamiliar to nurses who structure their practice within the more traditional framework of the nursing process applied to individual patient care.

Role as Investigator

Nurses may act as investigators by

  • taking careful environmental health histories and looking for trends in exposure, illness, and injury;

  • being alert to environmental factors that influence health;

  • working with interdisciplinary teams and with agencies to determine if an environmental exposure is affecting the health of a community;

  • initiating or engaging in research to identify and control environmental exposures that adversely affect human health; and

  • working with public and private institutions to perform risk and hazard assessments.

In actual practice, this role may include home visits to look for peeling or chipping lead paint in the residences of young children or to identify the use of poorly vented wood stoves in the home of an asthmatic child. It may also involve entering a work site to assess conditions that affect worker health and safety, including ergonomic hazards, chemical exposures, or mechanical hazards such as poorly guarded conveyor belts. Moreover, the practice of nursing itself is uniquely hazardous. A discussion of the hazards to nurses (and other health care workers) is presented in Appendix B.

One example of a nurse as investigator is a situation that occurred in 1992 in Brownsville, Texas, a town on the Mexican border. A nurse working in the labor and delivery department of a local community hospital noticed what seemed to be an unusual number of neonates born with a relatively rare but devasting birth defect, anencephaly. The nurse subsequently reviewed all birth records for the previous year and found that the incidence of children born with this defect in her facility was significantly greater than the national rate: 30 cases per 10,000 births versus 10 cases per 10,000 births, respectively. Further investigations suggested contamination of groundwater and surface water sources with chemicals known to cause adverse health outcomes of this nature (Suro, 1992) (see Box 3.1).

You will use the concept of primary prevention when instructing a patient to

Box 3.1

Sentinel Health Events and Disease Clustering. Environmental health concerns often surface in a community when residents or others notice an unusual pattern of illness, for which an environmental cause is suspected. Perhaps residents notice ''too many" (more...)

Eliciting an environmental health history, another investigative activity, is one of the most important actions for enhancing the environmental health content in nursing practice, because information derived from the history is essential to all other nursing activities related to environmental health. Through the environmental history, a nurse may uncover exposures to hazardous substances that neither the patient nor the clinician had suspected as etiologic agents of existing symptoms or disease. Methods and tools for taking a complete environmental health history have been well described (Goldman and Peters, 1981; Tarcher, 1992). Sample forms for taking a comprehensive environmental health history are included in Appendix G. Three key questions to be included in all histories of adult patients are the following:

1.

What are your current and past longest-held jobs? (For children and teenagers, the question can be modified to: Where do you spend your day, and what do you do there?)

2.

Have you had any recent exposure to chemicals (including dusts, mists, and fumes) or radiation?

3.

Have you noticed any (temporal) relationship between your current symptoms and activities at work, home, or other environments?

The investigative role of nurses may extend to their being part of a community or interdisciplinary public health assessment team. The Assessment Protocol for Excellence in Public Health (NACHO, 1991) and ATSDR's Public Health Assessment process (Lybarger et at., 1993) involve identifying risk factors and exposures that affect the health of the community. Both processes also emphasize soliciting and incorporating community health concerns as part of the assessment. Nurses skilled in interviewing, active-listening, and group processes, as well as epidemiological methods, can be invaluable team members.

Role as Educator

Nurses have long served as patient educators; they teach patients how to get out of bed following surgery, how to change a dressing, the possible side effects of medication, and the importance of diet and exercise in maintaining health. This role can be expanded to include educating patients, families, workers, and communities about the possible adverse effects of exposure to environmental hazards and how to reduce or eliminate such exposures. This type of education is commonly referred to by public agencies and environmental health specialists as hazard or risk communication.() Nurses can further develop this role by providing information to create environmentally safe homes, schools, day-care settings, workplaces, and communities. As role models, nurses can conduct their practice and lives in an environmentally safe manner, that is, by limiting unnecessary exposure to chemicals or by carrying out routine duties in a manner that minimizes injury due to ergonomic hazards. Nurses can act as educators by speaking at community gatherings and becoming involved in community-level activities related to the environment and human health. They may also participate in risk or hazard communication for public health agencies.

The original focus of risk communication was on developing and delivering a message from an expert or agency to the public, in order to help the public better understand a situation and its implications for their health and well-being. This definition is widening to incorporate a two-way dialogue between regulators or managers and the public (Cutter, 1993). The interactive process of exchanging information on technical hazards and the human response, both physiological and emotional, calls for professionals who can listen, interpret, clarify, and reframe questions and information in emotionally charged and sometimes hostile situations. The basic patient education role of nurses with individuals and families will need expansion to include communication with entire communities and the general public if they are to fill an essential niche in environmental health. The ability to assess the target audience, develop a message that is meaningful and understandable, choose a method or media for conveying the message, and conduct community-level conflict resolution are skills beyond the current preparation of most nurses.

The basic skills of linking individual needs with information and other resources will need to be broadened to include community linkages with environmental experts who may be outside the usual network of nursing referrals. The need to expand nursing's role in environmental health is not obvious to many nurses, for several reasons. First, no role models (faculty, supervisors) have alerted them to the potential hazards of environmental exposures. As a result, nurses are not aware that certain substances are highly hazardous to human health or that certain environmental conditions are contributing significantly, although insidiously, to the morbidity and mortality of the populations they serve. Second, nurses suspect, or are questioned by their patients about, the safety of certain conditions, but they do not know where to find accurate information about environmental hazards and measures to control them. Nurses who have attended NIOSH sponsored educational programs in occupational health can assist other nurses in learning about environmental issues by acting as guest lecturers in schools of nursing and as preceptors in the field of occupational health. Further support of this nature will enhance the ability of nurse generalists to educate their patient populations about environmental health issues.

Role as Advocate

In theory, the human health aspects of environmental problems can be isolated and dealt within traditional medical systems. In practice, these issues usually unfold in a highly charged social and political context. Nurses and other health care providers often need to help individual patients locate and secure access to specialized services for health problems related to environmental hazards. They may also be called upon to contact individuals, agencies, and organizations outside the health care system, working on behalf of patients or communities to change hazardous conditions and prevent future health problems.

It is generally agreed that the interests of patients, workers, or community members are best served by empowering them to act as their own advocates. However, nurses' scientific knowledge and experience in speaking with scientists, physicians, and other authorities equip them to be effective advocates in some situations where individual citizens are likely to feel intimidated. This role is particularly important when advocacy involves communication with public health agencies and private industry, wherein inquiries by individual citizens sometimes meet with responses that fail to address their concerns.

Establishing the legitimacy of advocacy activities as elements of nursing practice will require concerted effort among educators and leaders in the nursing profession. Environmental health issues are highly intertwined with social and political policies; thus, in the area of environmental health, advocacy is needed at the policy level as well as on behalf of individual clients. Advocacy as one component of the nurse's role is essential if a stronger, more prevention-oriented model of nursing practice is to be established. A more in-depth discussion of the practice of advocacy by nurses is provided in Box 3.2 and Appendix F.

You will use the concept of primary prevention when instructing a patient to

BOX 3.2

Advocacy Practice. Interventions in environmental health problems often require nurses and other health care professionals to assume the roles of advocate, activist, and policy planner on behalf of a single patient or population of patients. Patient advocacy (more...)

Interdisciplinary Aspects of Environmental Health

Environmental hazards and their health effects rarely lend themselves to simple solutions applied from a single discipline. Effective interventions for environmentally related illness require collaborative efforts from many disciplines due to the complex nature of environmental health issues, the rapidly advancing science base in environmental health, and the need for primary prevention strategies that often must involve professionals from fields other than nursing. Such collaboration includes ongoing dialogue and fluidity of roles and responsibilities.

Nurses are accustomed to working with members of other disciplines toward a shared goal, although it is often in a multidisciplinary manner, with members of each discipline performing their activities independently and with clear role delineation. Various nursing associations and other health professions advocate a more collaborative approach to health problems that is highly interactive and more likely to be termed interdisciplinary. This issue is important to consider in order to most effectively address environmental health issues.

The ANA's draft Nursing Social Policy Statement notes that nursing has an "external boundary" that interacts with other professions in response to changing societal needs and the advance of scientific knowledge. The boundaries are fluid rather than firmly defined, with members of various professions cooperating in the exchange of knowledge, techniques, and ideas on how to deliver quality health care. Collaborative practice, with some overlap of function, enables members of various disciplines to interact with a shared overall mission (ANA, 1994).

The National League for Nursing (NLN) has described several aspects of the complex nature of health care: technological advances that increase access to information, the need to educate professionals to recognize patterns and engage in innovative problem solving rather than simply mastering didactic content, and an increasingly broad and integrated knowledge base that is not discipline specific (NLN, 1992). These issues are particularly relevant to environmental health, a field that requires (1) an ability to access information that is current and comprehensive, (2) the ability to recognize patterns of disease, and (3) engagement in interdisciplinary actions to gain expertise from disciplines such as physics, sociology, political science, history, and ecology as well as various health disciplines.

A great deal of emphasis has recently been placed on the idea of collaboration as a component of the interdisciplinary approach:

The ability to co-labor (collaborate) is clearly vital when the plethora of health professionals and their increasing specialization and role differentiation combine with the complexity of patient care demands to make interdependency among professionals essential (AACN, 1995).

Others have written in the same vein, stressing the urgent need for interdisciplinary training in the health professions (IOM, 1988) and collaborative practice between nurses and physicians (Fagin and Lynaugh, 1992). Unfortunately, despite the clear mandate for interdisciplinary practice, many barriers to such arrangements exist; these include restrictive licensure and practice laws and inadequate interdisciplinary education (AACN, 1995; Safriet, 1994).

Individuals practicing in public health and occupational health and their professional associations support interdisciplinary models of practice. Professions involved in addressing environmental health concerns include, but are not limited to, specialists in industrial hygiene, toxicology, safety, ergonomics, engineering, hydrogeology, medicine, and occupational health. Nurses must know the types of knowledge, functions, and practice that constitute these disciplines, and of equal importance, other health professionals must be aware of the knowledge base, functions, and practice of nurses.

Nursing offers a unique and invaluable perspective on environmentally related health issues. However, to incorporate environmental health concerns into their practice, nurses will need to function as members of interdisciplinary teams. To accomplish this, (1) training of health professionals must put greater emphasis on developing skills for interprofessional collaboration, negotiation, critical thinking, and mutual problem solving; (2) there must be opportunities for interdisciplinary interaction throughout professional education and clinical practice; and (3) existing barriers to interdisciplinary collaboration and practice must be removed.

What is the aim of primary prevention quizlet?

Primary prevention is concerned with preventing the onset of disease; it aims to reduce the incidence of disease. It involves interventions that are applied before there is any evidence of disease or injury. Examples include protection against the effects of a disease agent, as with vaccination.

Which one is the best example of primary prevention?

Primary Prevention: It commonly institutes activities that limit risk exposure or increase the immunity of individuals at risk to prevent a disease from progressing in a susceptible individual to subclinical disease. For example, immunizations are a form of primary prevention.

Which nursing activity is an example of primary prevention?

Immunizations are a familiar example of primary prevention.

Which behaviors are examples of primary prevention?

Primary prevention Examples include: legislation and enforcement to ban or control the use of hazardous products (e.g. asbestos) or to mandate safe and healthy practices (e.g. use of seatbelts and bike helmets) education about healthy and safe habits (e.g. eating well, exercising regularly, not smoking)