Question

What are the approaches that the nursing profession could use to alert the public of the danger and the need to avoid exposure?

Answer 1

The occurrence and undesirable complications from health care–associated infections (HAIs) have been well recognized in the literature for the last several decades. The occurrence of HAIs continues to escalate at an alarming rate. HAIs originally referred to those infections associated with admission in an acute-care hospital (formerly called a nosocomial infection), but the term now applies to infections acquired in the continuum of settings where persons receive health care (e.g., long-term care, home care, ambulatory care). These unanticipated infections develop during the course of health care treatment and result in significant patient illnesses and deaths (morbidity and mortality); prolong the duration of hospital stays; and necessitate additional diagnostic and therapeutic interventions, which generate added costs to those already incurred by the patient’s underlying disease. HAIs are considered an undesirable outcome, and as some are preventable, they are considered an indicator of the quality of patient care, an adverse event, and a patient safety issue.

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.

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 Responsibilities
Clinical care staff and other health care workers are the frontline defense for applying daily infection control practices to prevent infections and transmission of organisms to other patients. Although training in preventing bloodborne pathogen exposures is required annually by the Occupational Safety and Health Administration, clinical nurses (registered nurses, licensed practical nurses, and certified nursing assistants) and other health care staff should receive additional infection control training and periodic evaluations of aseptic care as a planned patient safety activity. Nurses have the unique opportunity to directly reduce health care–associated infections through recognizing and applying evidence-based procedures to prevent HAIs among patients and protecting the health of the staff. Clinical care nurses directly prevent infections by performing, monitoring, and assuring compliance with aseptic work practices; providing knowledgeable collaborative oversight on environmental decontamination to prevent transmission of microorganisms from patient to patient; and serve as the primary resource to identify and refer ill visitors or staff.

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 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.

Prevention Strategies
Multiple factors influence the development of HAIs, including patient variables (e.g., acuity of illness and overall health status), patient care variables (e.g., antibiotic use, invasive medical device use), administrative variables (e.g., ratio of nurses to patients, level of nurse education, permanent or temporary/float nurse), and variable use of aseptic techniques by health care staff. Although HAIs are commonly attributed to patient variables and provider care, researchers have also demonstrated that other institutional influences may contribute to adverse outcomes. To encompass overall prevention efforts, a list of strategies are reviewed that apply to the clinical practice of an individual health care worker as well as institutional supportive measures. Adherence to these principles will demonstrate that you H.E.L.P. C.A.R.E. This acronym is used to introduce the following key concepts to reduce the incidence of health care–associated infections. It emphasizes the compassion and dedication of nurses where their efforts contribute to reduce morbidity and mortality from health care–associated infections.

Gaps in Current Knowledge
Barring unprecedented growth in the workforce or unforeseen new forces in health care that intervene to reduce burden of care in society, the numbers of nurses will not keep pace with the demand for services. In the coming decades, we face the prospect of fewer professionals and more unlicensed workers in the healthcare workforce. Decisions will have to be made about how hospitals will safely adapt to this situation. At this time, little evidence exists on what constitutes a safe and efficient labor force mix. Therefore, the general impact of nurse working conditions needs to be examined. First, longitudinal studies that track change in infection rates and other untoward incidents over time, under different working conditions, and with different staffing models are essential. Second, researchers need to study how the actual care received by patients varies under different staffing conditions at the bedside so that a better understanding of the impact of work environments at the point of care can be gained. Finally, since costs of care increase when patients have adverse outcomes and nurses’ working conditions affect outcomes, better working conditions could arguably save the healthcare system money. However, the cost-benefit ratio is not known and economic analyses, which include costs related to training, recruitment, and retention, need to be conducted.

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 and educator. 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.

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. 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.