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A model to guide medical and nursing practice specific to environmental health concerns established by the California Public Health Foundation CPHF, 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. 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, 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:.

Supportive practices are oriented toward modification of relationships or the environment to support health. Promotive practices mobilize healthy patterns of living, foster personal and familial development, and support self-defined goals of individuals, families, and communities.

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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. 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.

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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.

ACOG Practice Bulletin No. Pregnancy and Heart Disease : Obstetrics & Gynecology

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 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.

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. 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?

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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.

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, 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. 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 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, births versus 10 cases per 10, births, respectively.

Further investigations suggested contamination of groundwater and surface water sources with chemicals known to cause adverse health outcomes of this nature Suro, see Box 3. 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, ; Tarcher, 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:.

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Box 3. 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" cases of childhood leukemia in a particular neighborhood near a waste dump. Perhaps local health professionals discover a common disease such as asthma or breast cancer occurring in a community at much higher rates than would normally be expected.

Perhaps several cases of a relatively rare disease are detected among individuals who work at the same plant or live on the same street.

Suspicion might be triggered by even a single case of illness that breaks the usual profile for that disease, such as a cardiac arrest in a 20 year-old when such an event would normally occur at an older age. This might occur following exposure to carbon monoxide, fluorocarbons, or hydrocarbons, for example. Such atypical patterns, whether in community populations or in individuals, are called sentinel health events see Rutstein et al.

When investigated, they may turn out to be coincidental, with no particular relationship to environmental factors, or there may have been misperceptions of the pattern in the first place Schulte, However, they can also signal larger health problems related to environmental hazards, such as pesticide poisoning, heatstroke, lead and other heavy metal poisonings, or respiratory diseases triggered by poor air quality DHHS, Detection of a sentinel health event should lead to investigation of the subpopulation of individuals who may be at risk for similar adverse health effects.

This population-based approach to the tracking of environmental health concerns has been formally recommended by the U. In , that agency recommended the establishment of 35 state plans to define and track sentinel environmental diseases DHHS, Such tracking systems lead to early detection of disease and primary prevention through the control of hazards before they cause illness in others.