Creative Education
2011. Vol.2, No.3, 321-326
Copyright © 2011 SciRes. DOI:10.4236/ce.2011.23045
Environment, Health, & Nursing Practice
Patt Elison-Bowers, Nancy Otterness, Mary Pritchard
Nursing Curriculum and the Environment, Boise State University, Boise, USA.
Received January 25th, 2011; revised March 11th, 2011; accepted March 30th, 2011.
The purpose of this s t u d y was to explore the connection nurses see between the environment and health concerns
of their patients. The study surveyed registered nurses (RNs) in a western state to determine whether they evalu-
ated themselves as knowledgeable about environmental health (EH) hazards and if they felt prepared by their
nursing curriculum to share this information with their patients. The study replicates a survey of Wisconsin
nurses concerning issues related to EH knowledge among RNs in Idaho. Data from 170 respondents to a mailed
survey indicated that although nurses agreed that they should be knowledgeable about EH hazards, few were
adequately prepared. Overall, many nurses felt unprepared from their nursing curricula to address EH issues in
the field. Corrective measures are discussed.
Keywords: Community Nursing, Environmental Health, Environmental Health Education, Environmental Health
Nursing Curriculum and the Environment
Environmental health (EH) hazards present formidable chal-
lenges to human health (Hunter & McCurry, 2010; Koplan &
Fleming, 2000; Meadows, 2009; Polk & Green, 2007; Salazar,
2000; Tarcher, 1992; US Department of Health & Human Ser-
vices, 2000). Recent studies have suggested that environmental
factors may be the single most important predictor of health
outcomes in the near future. They further suggest that the
degradation of our natural resources and other environmental
issues may represent the “ultimat e threat” to our health ( T ar c he r ,
1992; Van Dongen, 2002; CDC, 2005). In a 2002 survey of
nurses in Wisconsin, Van Dongen noted that nurses see a clear
connection between the environment and health concerns of
their patients. Nurses also reported that addressing these con-
cerns should be part of the role of nurses in the United States
But has anything changed in the 10 years since these study
results came out? Given the call for changes in nursing cur-
riculum coming from national agencies (e.g., National League
for Nursing, 2007), one would hope that nursing curriculum
had finally responded to these calls for change and included EH,
among other key issues, as a part of its course offerings. As
such, nurses should feel better prepared to address EH issues
today than they did 10 years ago. This study investigated just
this. Do nurses feel any better prepared to address EH issues
than they did in 2001 when Van Dongen sent out her survey?
We hypothesized that in the ten years since the Van Dongen
study, nurses would feel better prepared from nursing curricula
to address EH issues.
Though nurses are increasingly confronted with EH issues
(Philibin, Griffiths, Byrne, Horan, Brady, & Begley, 2010),
little EH knowledge has been incorporated into nursing educa-
tion with the result that nurses are not adequately prepared to
address EH concerns, despite their advantageous position as
frontline EH advocates (Ballard, 2008; Barnes, Fisher, Postma,
Harnish, Butterfield, & Hill, 2010; Chalupka, 1998; McCurdy
et al., 2004; Melamed & Jackson, 2003; Olmstead, 2009; Pope,
Snyder, & Mood, 1995; Watterson, Thomson, Malcolm, Shep-
herd, & McIntosh, 2005). It is important for nurses to educate
themselves about EH issues because when the public is con-
cerned about such issues, they frequently turn to the nursing
profession to learn how this will impact their health. Nursing
therefore plays a key role in educating the public about EH
issues. As early as the mid-1990s, the Agency for Toxic Sub-
stances and Disease Registry (ATSDR) began educating mem-
bers of the health care community on concerns about the health
effects of EH and exposure. The Institute of Medicine (IOM)
also worked to advance the EH agenda in nursing education
(Pope, Snyder, & Mood, 1995). Despite these efforts, EH has
received minimal attention in nursing curricula over the past
decade (Hewit, Candek, & Engel, 2006).
Perhaps even more alarming, nurses contend with exposures
to mixtures of chemicals and hazardous agents of which many
have never been tested for safety (Environmental Working
Group (EWG), 2007). The nurses that participated in the EWG
survey indicated they had been exposed to a va riety of h azar dous
substances such as sterilizing chemicals, residue from drug
preparation, radiation, housekeeping cleaners, etc. These nurses
also reported an increased rate of asthma, miscarriage, and
certain cancers and gave birth to children with birth defects
Building on the work done by the Centers for Disease Con-
trol and Prevention (CDC) to educate public health profession-
als, the Quad Council of Public Health Nursing Organizations
began drafting a set of public health nursing competencies. The
core competencies represented a set of skills, knowledge, and
attitudes necessary for the broad practice of public health (Quad
Council: Core Competencies for Public Health Professionals,
2003). The Quad Council believed that the competencies would
provide a guide for public health agencies that employ nurses
and the academic settings to facilitate education.
Based on an Institute of Medicine (IOM) report, Pope, Sny-
der and Mood recommended that nurses should develop basic
competencies that include: basic understanding of the relation-
ship between the environment and health; the ability to assess
for environmental hazards; advocate for the reduction of envi-
ronmental risks; and awareness of EH laws and regulations.
Van Dongen (2002) believed that in order to develop effective
EH programs, educators need to know what nurses believe
about EH and their nursing practice and what factors might
impinge on their ability to integrate EH into their practice. To
answer these questions, Van Dongen developed and imple-
mented a survey instrument to answer the following research
1) What do Registered Nurses (RNs) believe regarding the
relationship between EH and nursing practice?
2) How prepared and competent do RNs feel to address EH
issues in nursing practice?
3) What do RNs identify as barriers to addressing EH con-
cerns in nursing practice?
4) What do RNs identify as resources to facilitate addressing
EH in nursing practice?
5) What is the relationship between selected demographic
variables and responses of RNs on the survey instrument?
Analogous to previous research by Van Dongen (2002), this
study examines issues related to EH knowledge among regis-
tered nurses in a western state. As the state ranks as one of the
worst states in Facilities Releasing Toxic Release Inventory
(TRI) Chemicals to Land (Green Media Toolshed, 2005), the
state may have more than its fair share of EH issues in the
population. In addition, radioactive fallout from nuclear weap-
ons testing during the 1950s and 1960s harmed the health of
thousands of people (Snake River Alliance, 2010). Finally,
much of the state is at high risk for flooding or wildfire damage
(State of Idaho, 2007). Thus, it is crucial that the state’s nursing
population be aware of and be able to handle EH issues.
A mailing list of registered nurses (RNs) registered in the
state was obtained through the State Board of Nursing (SBON).
Based on a power analysis for analysis of variance (ANOVA)
with five groups, a medium effect size of 0.25, an alpha of 0.05,
and a power of 0.80, a minimum sample size of 195 was needed
(Cohen, 1988). However, a sample of 484 was selected in rec-
ognition of the low (often <40% to 50%) response rate associ-
ated with mailed surveys (Kerlinger, 1986). The participants (n
= 484) were selected from a list of 13,094 registered nurses that
were currently practicing in the state of Idaho through a strati-
fied random sampling based on zip codes (50% urban, 50%
Permission was granted from Van Dongen (2002) to replicate
her survey instrument in Idaho. The first part of this question-
naire asked for demographic information, including: current
employment status, educational level, size of their home town,
current workplace setting, education related to Environmental
Health, whether they had attended any EH programs, and
whether they or a close family member had been affected by
EH factors. The questionnaire was then broken into four parts.
Nurses were asked about their beliefs regarding EH issues and
heir nursing practice, their preparation and competency related
to Environmental Health, the barriers they faced to addressing
EH issues in their nursing practice, and the factors that facili-
tated their ability to address EH issues. Each item was rated on
a 5-point Likert scale. Endpoints for each scale varied based on
the question asked.
A cover letter explaining the purpose of the study and a
postage-prepaid return envelope were included with the survey
mailing. As no identifying information was asked on the survey,
participants were assured complete anonymity. One month after
the initial surveys we re mail ed, the comple te packet was re-sent
as a reminder to nurses who might not have already completed
the survey or lost it. Unfortunately, some of the mailing ad-
dresses provided by SBON were incorrect, which resulted in
170 useable surveys returned to researchers.
Data Analysis
Not all respondents answered all questions; thus data analy-
ses may not always be based on 170 surveys. Descriptive statis-
tics were used to analyze demographic and scale data. Four
items were negatively worded on the “Beliefs” subscale, and
were thus reverse-scored before analysis. All questions were
analyzed using SPSS 17.0.
Demographics of Participants
See Table 1 for key sample demographics. The number of
years practicing ranged from 1 to 50, with a mean of 20.75 (SD
= 12.83). The majority of respondents worked in rural or agri-
culture settings (42%), with 27% working in towns/suburbs of
fewer than 50,000 inhabitants, and 23% working in cities/su-
burbs with 50,000 to 100,000 residents. Thirty-six percent of
respondents had not attended any EH education beyond their
formal nursing program.
Quantitative Data Analysis Results
Total scores for all 39 Likert items ranged from 100 to 176
(the possible range was 39 - 95), with an average of 135.50 (SD
= 15.09). See Table 2 for summary analyses for each of the four
Beliefs ab out EH and Nursing Pract i ce
Respondents tended to agree that the environment affects
health and that nurses play a pivotal role in EH (overall item M
= 4.11, SD = .52). However, the results of the present study
were slightly lower (i.e., slightly less agreement) than those of
the original Van Dongen (2002) study (see Table 2).The item
with the highest mean on the “Beliefs” subscale was “Every
nurse should be aware of specific environmental hazards in
his/her community” (M = 4.39, SD = .63). This differed from
the Van Dongen study, in which the item with the highest mean
on the “Beliefs” subscale was “The environment is an impor-
tant determinant of health”. Similar to the Van Dongen study,
the item with the lowest mean was “Environmental health con-
Table 1.
Demographics of partici pants.
Employment 53% Full Time 21% Part Time 15% Retired 11% Not Employed in Nursing
Practice Setting 24% Community Hospital 20% Not Working in Nursing18% Regional Medical Center 38% Other
Education Level 9% Diploma 37% Associate Degree 31% Baccalaureate 22% Other
EH Illness 35% Family or Close Friend 57% No Illness 9% Uncertain
EH Education 18% Adequate 62% Minimal Coverage 11% No Coverage
Table 2.
Descriptive statistics for the Four Subscal es (Van Dongens (2002) original results from Wisconsin RNs are presented in italics below each subscale).
Subscale Subscale Range Total M (SD) Individual Item Mean Range Individual I tem M(SD)
(9 items) 22 - 45
19 - 45 36.87 (4.61)
38.08 (4.30) 2.44 - 5.00
3.94 - 4.55 4.11 (.52)
4.24 (.47)
(12 items) 12 - 57
12 - 57 34.08 (10.08)
32.10 (10.54) 1.00 - 4.75
2.38 - 3.08 2.84 (.84)
2.69 (.88)
(9 items) 12 - 45
9 - 45 29.45 (6.79)
28.81 (6.90) 1.33 - 5.00
3.02 - 3.45 3.27 (.75)
3.21 (.76)
(9 items) 18 - 45
9 - 45 35.10 (5.77)
35.67 (7.01) 2.00 - 5.00
3.58 - 4.25 3.90 (.64)
3.99 (.75)
Note: Items were rated on a 5-point Likert scale.
cerns should be addressed by other disciplines, not nursing” (M
= 3.75, SD = .95). Similar to the Van Dongen study, these re-
sults suggest that although RNs believe that every nurse should
be up-to-date on the specific environmental hazards in his/her
community, nurses realize that other disciplines must also get
Preparation and Competency Related to EH
The overall item mean on the “Preparation” subscale (M =
2.84, SD = 0.84) indicates that RNs were uncertain as to
whether they were prepared to address issues of environmental
health. This mean was slightly higher than the mean in the Van
Dongen (2002) study. Thus, although nurses in both studies
were uncertain about their preparation and competency to ad-
dress EH issues, the nurses in the present study felt slightly
more prepared or more competent than did the nurses in the
Van Dongen study (see Table 2). In fact, the highest mean on
the subscale (M = 3.18, SD = 1.03) was for the item “Under-
stand the relationship between major environmental hazards
and human health”, indicating that nurses were uncertain if they
even understood the relationship between environment and
health. This was true for the Van Dongen study as well. RNs
reported feeling least knowledgeable (M = 2.54, SD = 1.13)
about major environmental legislation, such as the Clean Air
and Clean Water Acts, similar to nurses in the Van Dongen
Barriers to Addressing EH Issues in Nursing Practice
Participants also seemed uncertain about what the greatest
barriers to addressing environmental health concerns in their
nursing practice actually were (M = 3.27, SD = .75). These
results were slightly higher than those of the Van Dongen
(2002) study. Thus, although nurses in both studies were un-
certain about the barriers to addressing EH issues in nursing
practice, the nurses in the present study were slightly more
certain about these barriers than were nurses in the Wisconsin
study (see Table 2). The two items with the highest means
(meaning they were perceived as great barriers tied at M = 3.45,
SD = 1.09) were “Little or no time to consider environmental
health concerns in my clinical practice” and “Few or no re-
source people with expertise related to environmental health”.
The latter item had the highest mean in the Van Dongen study.
The item with the lowest mean (least likely to be a barrier) was
“Addressing environmental health concerns is not seen as a part
of my nursing role” (M = 2.96, SD = 1.19). This differs from
the Van Dongen study, in which the item with the lowest mean
was “Personal lack of knowledge about how the environment
can affect human health and what to do about it”. However,
similar to the Van Dongen study, it should be noted that there
was merely a slight difference the means of the highest and
lowest rated items; regardless, nurses seem uncertain about
which items constitute barriers.
Participants were also asked to indicate the three most im-
portant barriers from the list of barriers queried on the “Barri-
ers” subscale. The following three statements were listed most
often: “Personal lack of knowledge about how the environment
can affect human health and what to do about it”, “Cli-
ents/families have little interest in understanding how the envi-
ronment can affect their health”, and “Few or no resource peo-
ple with expertise related to environmental health”. These re-
sults indicate that nurses feel unprepared to answer questions
about environmental health, that they do not feel they have the
resources required to learn, and that their clients do not seem
interested in this knowledge. While nurses in the Van Dongen
study rated “Personal lack of knowledge about how the envi-
ronment can affect human health and what to do about it”, as
one of the most important barriers, the last two barriers differed.
Nurses in the Van Dongen study felt that “Little or no time to
consider environmental concerns in my clinical practice”, and
“Lack of recognition by health professional regarding how the
environment can affect human health”, as the most important
Facilitators to Addressing EH
Scores on the facilitator items were relatively high (M = 3.90,
SD = .64), indicating that nurses had a good idea about what
they would need to help them address environmental health
issues in their nursing practices. These means were slightly
lower than those reported in the Van Dongen (2002) study,
indicating that nurses in the Van Dongen study were slightly
more sure about the factors that facilitated addressing EH issues
(see Table 2). Similar to the Van Dongen study, respondents
placed the greatest interest (M = 4.24, SD = .99) in free or in-
expensive continuing education programs on environmental
health via the Internet, and placed the least interest (M = 3.43,
SD = 1.32) in an expectation from the Joint Commission on
Accreditation of Healthcare Organizations (JCAHO) or any
other accreditation body that environmental health be addressed.
Thus, the availability of low-cost continuing education pro-
grams seemed more important to the RNs than did expectations
of accrediting bodies such as JCAHO.
Similar to the “Barriers” subscale, we asked respondents to
list the top three items that would facilitate their education
about environmental health issues. The top three items listed
were “Free or inexpensive education programs”, “A staff re-
source person”, and “Health education programs at my work-
place”. These were the same facilitators ranked as most impor-
tant by nurses in the Van Dongen (2002) study.
Additional Statistical Analysis and Results
As one might expect, RNs who had a family member and/or
close friend with an environmental illness scored significantly
higher (M = 38.53, SD = 4.68) than those who did not (M =
36.06, SD = 4.32) on the “Beliefs” subscale, t(148) = 3.28, p
< .001. Likewise, they scored higher (M = 37.49, SD = 7.63)
than those who did not (M = 32.08, SD = 11.23) on the “Prepa-
ration” subscale, t(134) = 3.00, p < .01.
Respondents who had a masters degree in a field other than
nursing had higher “Preparation” subscale scores (M = 44.40,
SD = 8.23) than those who had an associates degree (M = 32.33,
SD = 9.29) on the “Preparation” subscale, F(5, 147) = 2.32, p
< .05 (Note: due to missing values, respondents with doctoral
degrees were excluded from the previous analysis). As one
might expect, RNs who reported receiving adequate or excel-
lent coverage of environmental health issues in their nursing
curriculum scored significantly higher (M = 40.29, SD = 7.23)
than those who reported minimal coverage (M = 33.33, SD =
9.61) or than those who could not recall (M = 27.14, SD =
10.83) on the “Preparation” subscale, F(3, 149) = 6.60, p < .001.
However, no significant difference was found in “Beliefs” sub-
scale scores based on EH curriculum coverage. Excluding indi-
viduals who could not recall whether they had coverage of EH
issues in their nursing curriculum, there was a low but signifi-
cant difference (r = 0.22, p < .05) between “Preparation” sub-
scale scores and the extent of Environmental Health coverage
in one’s curriculum.
Stepwise regressions were conducted to predict each of the
four subscale scores based on education, EH coverage in nurs-
ing curriculum (excluding those who did not remember), years
in nursing, and community population size. Only EH coverage
in nursing curriculum significantly predicted “Preparation” sub-
scale scores, but accounted for only 4% of the variance, F(1,
134) = 6.68, p < .05. In addition, education accounted for 3% of
the variance in the “Barriers” subscale scores, F(1, 131) = 5.03,
p < .05. Finally, community size accounted for 2% of the vari-
ance in the “Facilitator” subscale scores, F(1, 141) = 4.18, p
< .05.
Results from Qualitative Data Analysis
Twenty-three (13.5%) RNs reported other barriers, including
the following: lack of time, businesses not providing employees
with proper safety equipment, lack of patient compliance, lack
of respect for nurses, uninformed nurses spreading false infor-
mation, lack of cultural sensitivity by health care workers, lack
of resources or reports linking increased incidences of certain
health problems in particular areas, lack of interest in environ-
mental health concerns, patients are unaware of the potential
environmental hazards in their area, cost of educating health
care professionals, cost of implementing changes, lack of nurs-
ing education, lack of assessment skills, and being unable to
convince physicians that patient’s conditions relate to environ-
mental health issues (even if the patient claims this).
In addition, 7 (4.1%) respondents listed other facilitators:
expectations from the state school board that environmental
health concerns be taught to children, reference materials avail-
able as handouts for personnel, quick simple explanations of
environmental health issues, encouragement from administra-
tion, having mandatory Continuing Education Units (CEUs) for
Idaho, nursing education programs, services from experts in the
workplace, public awareness of how health is affected by envi-
ronmental factors, and having a specific manual about envi-
ronmental health issues.
Finally, 20 (11.8%) participants made additional comments
at the end of the survey. The major themes included the fol-
lowing: concerns about poor air quality, unsafe food additives,
a lack of public environmental responsibility, legislative con-
stituencies not funding long-term threats or scientific evidence,
JCAHO’s excessive focus upon documentation, healthcare’s
focus upon crisis management and life extension rather than
prevention and evaluation, physicians not communicating with
one another about patient wellbeing and prescriptions, and
RN’s general lack of assertive ness when it c omes to EH issues.
The primary purpose of this study was to explore the connec-
tion nurses see between the environment and health concerns of
their patients. The study surveyed Idaho nurses to determine if
they evaluated themselves as knowledgeable about EH hazards
and if they felt prepared by their nursing curriculum to share
this information with their patients. The study replicates Van
Dongen’s (2002) study of Wisconsin nurses with a sample of
nurses from a western state. In the ten years between studies,
nursing curriculum seems not to have advanced in its coverage
of EH issues. Nurses reported similar barriers and facilitators,
they also reported feeling less prepared and had stronger beliefs
about the importance of EH. This is not surprising given the
environmental conditions in this western state. The results in-
dicated that although the RNs believed that nurses should know
about EH hazards, few were actually knowledgeable. Further-
more, subscale item means indicated that RNs felt unprepared
to answer questions about EH and were uncertain if they under-
stood the relationship between environment and health. Time
restraints and a lack of access to people with EH expertise were
the greatest perceived barriers. This finding suggested that
nursing curricula that included more EH classroom, field ex-
perience, and/or consultation time, as well as access to indi-
viduals with EH expertise, might improve RNs knowledge of
environmental health hazards (Tillett, 2006; Wu, Jacobs,
Mitchell, Miller, & Karol, 2007). It is interesting that the item
“Addressing EH concerns is not a part of my nursing role” had
the lowest subscale mean, indicating that most nurses felt it was
their responsibility to be informed about EH issues. Data re-
flected the RNs’ belief that the greatest facilitator of EH educa-
tion was an inexpensive online EH continuing education pro-
gram available in the workplace for current RNs, rather than
accreditations; thus, this type of training for current RNs should
be examined in future research (Shendell & Paris, 2007; Sirkin,
Cali, & Keough, 2007; Sweeney & De Peyster, 2005).
RNs who reported that their nursing curriculum covered EH
scored significantly higher on the “Preparation” subscale, indi-
cating increased EH preparation. In addition, only EH coverage
in nursing curriculum significantly predicted “Preparation” sub-
scale scores. However, no significant differences were found in
the “Beliefs” subscale scores, indicating that RNs felt that EH
awareness among nurses was imperative, regardless of their
level of formal EH instruction (Postma, 2006; Salazar, 2000).
This finding highlights the need for nursing curricula to better
prepare nurses to discuss EH issues.
A limitation of the study was that some of the mailing ad-
dresses provided by the State Board of Nursing were incorrect
which resulted in only 170 useable surveys returned to re-
searchers. In addition, we surveyed RNs, not students currently
enrolled in nursing programs. Thus, if any new changes have
been instituted in nursing curricula, our respondents may not
have been aware of them, having already graduated. Third,
although we clearly demonstrated the need for nursing curricula
changes in EH education, we did not implement any such cur-
ricular changes. Future studies should investigate innovative
ways to educate nursing students as well as registered RNs
about EH issues. For example, a recent study (Beale & Lane,
2010) found that educational games and videos were a good
way to educate practicing nurses about new issues in oncology.
Perhaps similar games and videos could be developed to edu-
cate nursing students and RNs about EH issues.
Although the response rate was low, making it unclear how
generalizable the results are to nurses in this western state, the
survey findings do suggest a problem. Overall, many nurses felt
unprepared from their nursing curricula to address EH issues in
the field. Thus, different types of EH curricula need to be de-
veloped and tested for efficacy. Based on an Institute of Medi-
cine (IOM) report, Pope, Snyder and Mood (1995) recom-
mended that nurses should develop basic competencies that
include: basic understanding of the relationship between the
environment and health; the ability to assess for environmental
hazards; advocate for the reduction of environmental risks; and
awareness of EH laws and regulations. With increased aware-
ness of EH hazards among healthcare professionals, current EH
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