The following is a compilation of responses from focus groups that were convened by individual members of the IOM Committee on Enhancing Environmental Health in Nursing Practice. Twelve (12) focus groups were held with nurses in California, Iowa, Massachusetts, New Jersey, North Carolina, South Carolina, Texas, Washington, DC, and Louisiana.

Participants included specialists in the fields of occupational health, nurse practitioner and public health nursing faculty, practicing public health nurses, practicing family nurse practitioners, nursing doctoral students, nurses representing the American Organization of Nurse Executives, and representatives from the American Association of Colleges of Nursing.

Responses to this question fell into eight major categories.

• Absence of EH in current scope of nursing practice, including primary care.

• Issue of "jurisdiction" was commonly mentioned. Nursing not linked with public sector in addressing EH issues.

• Reimbursement for EH services (how, by whom?)

• Recall early PHN practice, where health problems were related to poor sanitation

• Detection, assessment, evaluation, treatment of hazardous substances' toxic effects

• Accident prevention and elimination of hazards

• Pollutants from health care industry

• Practicing with the unit of analysis being the community rather than the individual

• Inner city violence and poverty at epidemic levels (**mentioned by almost all)

• Hostile, life threatening environments created by crime

• Psychological effects of overcrowding, high density living (condos)

• Cultural issues around food and water contamination

• Environmental racism (burden of environmental hazards greatest on poor and minorities)

• Violence—family, community and workplace

• Heightened public awareness about environmental hazards

• Teaching kids to recycle, but not health effects

• Media interest, expense

• Conflicts between business and well-being of community

• EH legislation without funding to enforce

• Control and dissemination of information

• Conflict in consumer values—want technology, but not risks

• Cost of intervention vs. prevention

• Rights of the individual—to live in environment of choice, NRA and gun control

• Refer and forget—lack of accountability and continuity in addressing these issues

• Cause and effect not often clear.

• Problems identifying causative agent(s) for illnesses that appear environmentally related.

• What is burden (or degree) of human illness/dysfunction that is associated with environmental conditions?

• Interaction of various conditions that result in illness

• Mechanism of environmental hazards in causing or contributing to disease

• Hazard control mechanisms inadequate

• Emphasis is more (too much?) on toxicology than society and community environs.

• Hospitals and indoor air pollution

• Housing, homelessness

• Contamination of community by local industry

• Urban problems—violence, stress, crowding

• Rural health—lack capacity for assessments and referrals (lack of money)

• Definition of environment needs to include concepts of economics and power

Air, water and waste management were primary concerns overall

• Water and air pollution (indoor and outdoor) most frequently cited issues

• Sanitation in general

• Contamination of soil and play areas

• Contamination of seafood and recreational waters

• Contamination of drinking and recreational water by irrigation, farm chemical, and urban runoff

• All types: chemical, biological, physical, mechanical, psycho-social

• Waste management and toxic waste (mentioned by more than half of groups)

• Fleas, mosquitoes, and pesticides

• Lead-based paint

• Sick buildings

• Farm safety

• Electromagnetic fields

• Noise (mentioned by more than half of the groups)

• Ozone depletion and UV-B exposure

• Natural disasters (tornadoes, fires, etc.)

• Workplace technology creating hazards to health

• Ergonomics

• Deforestation

• Foodborne disease

• Strip mining and contamination of wells

• Radiation exposures

• Disease vectors and pest management

• TB

• Gulf War syndrome

• Sick building syndrome

• Legionnaires disease; childhood asthma; increasing incidence of allergic reactions

• Carpal tunnel syndrome

• Accessing and disseminating info. regarding EH factors in health and illness

• Prevention oriented ed. on individual, worker, family and community basis

• Keeping track of local resources and distributing this info (as go between)

• Relaying standards and regulations to employers/employees

• Hygiene, immunization, risks, injury control, pica appetite

• Educate other team members/disciplines who are more narrowly focused

• Work with community, environmental groups, local government

• Legislative lobbying

• Reporting community hazards

• Ideally, all nurses should be advocates for safer environments

• Involved in implementing policy

• Via referrals from public sector

• Joint inspection of home, community, workplace

• ER, OH, and CH practice centers

• Involved in regulating teams

• Nurse is first to get complaint, then becomes involved in case management

• First line problem identification; taking O/E histories

• Identify link between illness and environmental condition

• Recording and designing interventions, evaluation of outcomes

• Implementing medical screening exams (e.g., childhood lead, worker exposures such as pesticides, solvents, pharmaceuticals). Individual and population based.

• Demonstrate links between cost effectiveness and reducing hazards at work

• Work as interdisciplinary team member (***many groups commented on this)

• Focus on prevention, advocacy and as knowledgeable resource

• Research in environmental science and technology

• Suggest avenues of recourse, make recommendations to improve work conditions

Although this is "routine practice" for some, it was mentioned so frequently and in such varied contexts, I made it a separate sub-section.

• Assessment of patients' environment, via history taking and onsite

• Identify exposures

• Field assessments as component of other ongoing intervention

• Extension of role into community and worker's family situation to identify problems related to community, home and workplace exposures

• Nurses are not involved if not OHN, PHN or CHN

• Hospitals are poorest model of workplace safety/control of hazards. Hazardous but not viewed as such. Many "unempowered nurses," especially in hospital setting.

• If EH issues raised at work (hospitals included), often get squelched by administration.

• Nurses familiar with holistic approach, have advantage of interacting on personal level.

• Generating data systems for environmental assessment and outcomes

• Designing "critical paths" which include environmental assessment

• Impact studies (consumer goods, land use)

• Increase visibility of issues via PSAs, working with community groups

• Work with professional associations

• Push for inclusion in interdisciplinary discussions

• More general education of public; publish in lay publications

• More thorough home assessments

• Become more involved with community, EH groups, corporate education

• More collaboration within nursing, share information with each other, e.g., PHN could work with ER nurse on issues like violence

• Move CH education to early part of nursing ed. so there is less separation between hospital and CH practice

• Educate, but also move political system. Law changes behavior more effectively than public education, e.g., bike helmet and seat belt laws.

• Revolutionize nursing ed. to focus more on social justice and critical thinking

• Serve as role models, and develop role expectations such that attention to EH is routine

• Big change in HC delivery system, perspectives of medicine and community

• Role of nurse would change, they would have some architectural input in HC system. Amplifier effect would occur: 1) make smarter consumer, voter, taxpayer and thus 2) shape behavior of industry and business.

• Nurses and clients will be better able to think at a system level to effect change

• Primary prevention would be enhanced

• Decrease health care costs over long term, with earlier detection of "real" problem or etiology of disease, and interventions that address causative factors as well as medical symptoms.

• More holistic approach

• Nurses would become resource brokers

• Increasing power of lay-groups, if nurses openly stand with them and educate them.

• Consumer would be more prevention oriented

• Nurses would become a political voice for disenfranchised, at-risk peoples

• Increase scientific knowledge base about environmental exposure and disease

• More funding for EH practice, education and research—as knowledge base builds

• Will be difficult to change practice and education:

  • Nurses don't know "what they don't know," thus cannot understand impacts of enhancing knowledge base about EH issues

  • Nursing curricula already full

  • No faculty expertise in this area, and curricula is driven (in part) by this

  • Practicing nurses already spread too thin, no time to add new routine duties

  • Will require "revolution" or "new paradigm" of nursing education and practice based on systems level approach and/or critical thinking

  • May require redrawing the picture of nursing ed., rather than just adding content

  • No reimbursement structure for these activities

  • Be careful about creating expectations of quick fixes and easy solutions to EH problems.

• Social and Economic Issues

  • Employers and employment may be threatened by nurses speaking out, drawing attention to issues

  • Turf battles rather than interdisciplinary collaboration may result.

  • Crusader image, can be portrayed negatively by peers, administrators, media

  • Backlash from political orientation: stereotyping and further division among nurses

• Revamp nursing education: either add on EH piece, integrate it into other components, or include part of total revision of nursing curricula

• Develop faculty expertise

• Create new specialty in EH at graduate level (?)

• "Market" or educate nursing faculty and administrators about magnitude of EH problems, and value of creating more knowledgeable nursing workforce in this area

• Provide EH education at all levels of nursing education, and CE for current workforce.

• CE must be ongoing as environmental health knowledge base expands

• Begin to introduce earth science terms in (or in preparation for) nursing curricula

• Two or three nursing schools need to take the lead, pilot revision of curricula

• Educate administrators, CEOs, corporate officials about role nurses can take in resolution of EH problems

• Demonstrate cost-benefit of interventions (e.g. primary prevention), to administrators, government officials, and legislators

• Develop reimbursement structure for nursing EH interventions, e.g., working with insurance industry, change in NANDA codes

• Amend ANA definition of nursing, NLN accrediting criteria

• Amend credentialing/licensure exams to include EH content

• Amend some specialty practice area definitions, e.g., CHN, PHN

• Build coalitions with other disciplines for education and practice of EH

• Create national info. systems with data elements that trigger indepth examination of environmental exposures (e.g., for asthma, lead poisoning, birth defects)

• Develop funding mechanism to support nursing expertise/faculty development in EH

• Shift health care funding priorities toward preventive, public health interventions

• Lack of time in routine practice situations

• Lack of faculty expertise to teach content

• Lack of administrative commitment to and knowledge about EH issues

• Absence of EH content in credentialing, licensure, and accrediting systems

• Lack of reimbursement structure

• Nurses may have difficulty in employing non-traditional interventions. Want to know, why learn about something (EH issues) if there are no clear solutions, or clearly defined and proven nursing interventions to resolve problems.

• Nursing job and role descriptions are often narrow, with discreet description of duties

• Lack of funding to build nursing faculty and existing workforce expertise

• Nurses are barriers; ''buying in" to EH as important to practice; need to see how knowledge will benefit them, help them do their job

• Consequences of speaking out (social and economic)

Alter basic nursing curricula

• Identify common threads and basics

• Examine models of practice that are successful

• Mandate competencies in accreditation of ed. programs

• Include environmental risk in nursing assessment

• Need some schools of nursing to test a new paradigm

• Create new specialists and expertise

• Make funding of health professionals a mandatory component of other federal funding related to EH

• Federal and foundation funding

• Work with national professional organizations to create initiatives in EH education

• Identify, characterize and control of EH hazards

• Initiate national data collection systems to 1) Further document scope of problem, 2) Identify populations at risk and develop and evaluate interventions, 3) Provide quantifiable justification for funding (nursing) research and education in EH

• Advocate EH for nurses on the job, before they even enter practice

• Develop multidisciplinary programs, projects to address EH.

• Empower nurses; impart knowledge and techniques for empowering community groups, workers, parents, etc.

• Educate govt. officials, consumers re. need for changes

• Take more business oriented approach to EH; define what customer wants

• Consciousness raising: family and peers, as well as public

(From most to least frequently cited)

• Deans, faculty and schools of nursing and public health

• Health care providers (nurses, MDs, related disciplines)

• Policy makers, legislators, public officials

• Industry, employers, CEOs

• Nursing administrators

• National nursing organizations, State Boards of Nursing, Accrediting Bodies

• Federal sector, private foundations, insurers

• Consumers, community activists, environmental groups (even extremists, because nurses mediate well, good brokers and coalition builders)

• Classroom; integrate in health assessment courses; literature—update textbooks to include EH; merge PH with nursing content

• Case Study

• Systems paradigm that focuses on decision making

• Specific Content on Environmental Risk

Internships, precepting, role models, interdisciplinary, community groups

Telecommunication, interactive video, visual aids, newsletters, media (with subliminal messages?), the arts

• Visiting workshops, professional conference topic, faculty education programs, lunch time seminars, CE, informal (fun) ways.

• Make efforts specialized to cultural concerns and relevance to client

• New view of world; view people in their context

(Number in parenthesis indicates number of times cited by focus groups)

• All basic nursing education—core component (8)

• CE and Post-graduate (4)

• Specialization at graduate level (3)

• Baccalaureate and Masters (AD has no room) (1)

• All specialties (1)

• At ADN level teach assessment only (1)

• CEOHN certification (1)

• Sophisticated systems thinking and pop. based assessment may not be possible at basic baccalaureate level; perhaps nursing ed paradigm changes need to be made

(Number in parenthesis indicates number of times specialty was mentioned)

• PHN and CHN (7)

• All nurses, all specialties (5)

• Occupational Health Nurses (5)

• Maternal and Child Health (4)

• Primary Care (3)

• Pediatrics

• Oncology (2)

• ER (2)

• Mental Health/Psych (2)

• School Nurses, Nurse Educators, Geriatrics, Home Health, Cruise Ship Nurses, Employee Health, Insurance Industry Nurses, Genetics (1)