Public Health Nursing Vol. 11 No. 3, pp.
155-162
0737-1209/94/$10.50
0 Blackwell Scientific Publications, Inc.
The Role of the
Community Health Nurse in
Environmental Health
Lynelle Neufer, R.N., M.P.H.
Abstract Chemical contamination in the environment is
affecting public health in increasing numbers of communities
across the country. Although historically and theoretically well
within the realm of nursing, methods for assessing and
diagnosing threats to community environmental health are not
being included in community health nurses’ training. A
community’s environmental health is assessed by retrieving
information from federal, state, and local sources. Developing
the diagnosis involves four steps: identifying a community
aggregate at highest risk of exposure, determining the potential
o r actual health response, citing related host and environmen-
tal factors, and correlating any existing epidemiologic data that
may substantiate the nursing diagnosis. To illustrate these
concepts, a systematic environmental health assessment was
conducted for Douglas, Arizona. The results indicated elevated
lead levels in residential soils and led to the community
diagnosis, potential for injury: children in Douglas are at risk of
developing adverse neurobehavioral health effects, and preg-
nant women in Douglas are at risk of developing adverse
reproductive health effects related to several environmental
and host factors, as evidenced by average blood lead levels in
children exceeding the Centers for Disease Control recom-
mended level of 10 pg/dl.
Lynelle Neufer is an environmental health scientist with the Commu-
nity Health Branch of the Division of Health Assessment and Consulta-
tion, Agency for Toxic Substances and Disease Registry, Public Health
Service, c! S . Department of Health and Human Services.
Address correspondence to Lynelle Neufer, ATSDRICHB, MIS E 32
1600 Clifton Road, Atlanta, G A 30333.
In 1948 an air inversion occurred in Donora, Pennsylva-
nia, a small but highly industrialized town in the
Monongahela River valley near Pittsburgh. In air inver-
sions, the surface air is cooler than the layer of air above
it and thus cannot rise (Blumenthall985). The result was
a toxic fog of industrialized emissions that settled over
the town for six days. Local public health practitioners
not only failed to warn residents of the fog’s potential
dangers, they even allowed townspeople to hold a
parade. As a result of the air inversion and toxic fog,
6000 of the town’s 12,000 people fell ill and 18 died
(Blumenthal, 1985; RouechC, 1984).
For years, residents of a small neighborhood in
Augusta, Georgia, noticed something was wrong with
the water in their private wells. They said that when one
filled a glass with water, the water separated into two
layers and often smelled like moth balls. Residents
questioned officials at a local wood-treatment plant
because the plant was a potential source of groundwater
contamination. Plant managers reportedly suggested that
the oily layer was harmless, and could even be used as a
skin softener. Local public health officials did not
address the complaints until 1987, when they discovered
that private well water contained elevated levels of
naphthalene and other creosotes, some of which are
known to be or are suspected of being carcinogens
(Agency for Toxic Substances and Disease Registry
[ATSDR], 1991a). The wells have since been capped,
and a federal agency is planning a community health
investigation in the area (ATSDR, 1991a).
In both cases, interventions from community health
nurses are conspicuously absent. A community health
nurse could have assessed and made a nursing diagnosis*
*Diagnosing a patient’s condition for the purpose of instituting
treatment or therapeutic measures is clearly the province and
156 Public Health Nursing Volume 11 Number 3 June 1994
for these community environmental health problems,
and intervened to mitigate the health risks of both
communities through primary, secondary, and tertiary
prevention. Granted, the field of environmental health
was still in its infancy in 1948; but today, although a lot
more is known about environmental health, exposure
assessment, and toxicology, it is the community assess-
ment and diagnostic skills of nurses that are required to
identify potential threats to communities.
In the nursing field, environmental health has tradition-
ally been limited to the immediate environment of the
individual (e.g., hospitalized patient) or the family home
(e.g., home safety) (Sherwood et al., 1988). However,
with 30,000 hazardous waste sites and over 1400 Su-
perfund sites having been identified in communities
across the country thus far (Orti, 1991), the term
requires broader definition. Addressing environmental
health today requires a systematic assessment of air, soil,
surface water, and groundwater quality, and the related
public health implications of toxic chemicals in the
environment. Community health nurses must adapt their
assessment and diagnostic skills and play a proactive role
in emerging community environmental health issues.
HISTORY OF NURSING IN ENVIRONMENTAL
HEALTH AND HEALTH EDUCATION
It is ironic that community health nurses have not been
leaders in the environmental health field, given that this
is where the profession has its roots. Florence Nightin-
gale was famous for her concern about sanitation in the
human environment. Her philosophy of health care was
consistent with the beliefs of her time, the miasma era of
modern health. The era was characterized by the belief
that disease is caused by dirt, noxious odors, and lack of
cleanliness (Logan & Dawkins, 1986). As a proponent of
the miasma theory of disease, Nightingale focused on
developing sanitary codes for military hospitals during
her commission in the Crimean War. She recognized that
environmental contamination of army hospitals resulted
in health hazards for ailing soldiers. Thanks to her
administrative efforts in sanitation, the mortality rate of
hospitalized soldiers dropped from 42.7% to 2.2% in six
months (Donahue, 1985). In her School of Nurses she
instructed nurses to make sure their patients always had
clean air to breathe and safe water to drink (Kozier &
Erb, 1983).
function of a physician. However, the professional nurse is always
authorized to make a nursing diagnosis, to evaluate factors (physical,
mental, sociological, economic) that may have an influence on the
patient’s recovery (Bernzweig, 1981).
LITERATURE REVIEW
In view of her philosophy of health, Nightingale would
be alarmed at the lack of training community health
nurses receive in environmental health. For instance, a
survey of 10 professional textbooks published since 1985
reveals lack of content in this area (Table 1). Although
nine of the books did identify the need for nurses to
assess environmental health in their communities, only
six suggested possible data sources. All six identified the
Environmental Protection Agency (EPA) as a resource,
and three suggested screening programs. Two textbooks
suggested state and local environmental and health
agencies; two others identified local community action
groups. Of the 10 textbooks, three did not include
sources for locating environmental health data for the
community; one completely bypassed the subject.
Nursing journals published since 1987 do not contain
any related articles, according to a search of Index
Medicus. Areas searched were community health nurs-
ing, pollution, and environmental health. In short,
although many community health nursing resources
identify the need to conduct environmental health
assessments at the community level, information on
comprehensive and systematic methods of doing so is
sparse.
Information is also limited in the community environ-
mental health nursing process (diagnoses, goals, interven-
tions, evaluation). For instance, most diagnoses in this
profession focus on family or home health. However,
Neufeld and Harrison (1990) and Anderson et al. (1986)
provided theoretical models and excellent guidance for
developing nursing diagnoses for the community as a
whole or community subsections. Sherwood et al. (1988)
suggested a possible diagnosis that would be appropriate
for most instances of hazardous environmental contami-
nation, but no information was found about developing
subsequent care plans, either in textbooks or nursing
journals.
THEORY
In the field of nursing, four central concepts-person,
health, environment, and nursing-form the foundations
for any theoretical model (Anderson et al., 1986). The
theme of Neuman’s system theory, commonly used in
patient care, is that of a holistic, total-person approach to
viewing a client. The community-as-client model adapts
Neuman’s theory to define the community as “all persons
who reside within a defined geopolitical boundary or
who share a common characteristic” (Anderson et al.,
1986, p. 220). This model is a key because exposure to
environmental contamination affects the entire commu-
nity, or a large population within the community, rather
than an individual or a family. Using this model allows
 Neufer: Environmental Health Nursing 157

TABLE 1. Textbooks as Sources of Environmental Health Information

Source
Sher- Clement-
Archer & wood Andersen & Higgs& Logan& Stone
Stewart, Spradley, Cookfair, Fleshman, et al., McFarlane, Wold, Gustafson, Dawkins, et al.,
Information 1987 1986 1991 1985 1988 1988 1990 1985 1986 1987
Screening programs X x X
Systematic assessment
of environmental
health
Necessity of environ- X X X X X X X X X
mental health
assessment
Environmental protec- X X X X X
tion agency
Agency for toxic
substances and
disease registry
Toxic release inventory
data base
State health department X X
State environmental X X
department
Community X X

the nurse to make communitywide assessments and Federal Level

diagnoses, and therefore address the public health
threats to a community exposed to widespread environ-
mental contamination.
ENVIRONMENTAL HEALTH ASSESSMENT
The literature review revealed minimal guidance in
systematic assessment of community environmental
health. Although sources of related information have
improved greatly over the last decade, community health
nurses remain unaware of all of them. The following is a
systematic method for assessment based on federal,
state, and local sources of information (Table 2).
On the federal level, the nurse may begin by ascertaining
whether any sites in the community are on the national
priorities list (NPL). The NPL was developed as part of
the Comprehensive Environmental Response, Compen-
sation, and Liability Act (CERCLA) of 1980, or Su-
perfund legislation, as it is more commonly known
(Schoenbaum & Rosenberg, 1991). Under that legisla-
tion, NPL sites have been screened by the EPA, scored
by a standardized hazard ranking system, and given
priority ranking based on that score.
Currently, EPA has identified over 1400 NPL or
Superfund sites in the United States. The sites have

TABLE 2. Sources of Environmental Health Data

Federal
E P A studies and ATSDR public health
assessments for NPL sites
ATSDR public health assessments,
consultations, studies
Toxic chemical release inventory
data base
State Local
State environmental agencies (priority lists, Community health concerns
environmental monitoring data,
other studies)
State health agencies (health advisories, Community action groups
disease registries, epidemiologic
studies or surveys)
Health screening programs
and surveys
Local health departments
158 Public Health Nursing Volume 11 Number 3 June 1994
environmental and health-oriented investigations associ-
ated with them. First, EPA will complete an in-depth
characterization of environmental contamination, includ-
ing information regarding populations exposed to hazar-
dous substances, the estimated degree of exposure, and
the associated risks or potential risks to health. Second,
ATSDR is mandated by CERCLA to conduct a public
health assessment within the first year that a site is
proposed for the NPL (CERCLA, 1980).
Public health assessments focus on human health data
and health outcomes based on known or estimated past,
present, and future exposure to environmental contami-
nation. Both EPA and ATSDR can provide valuable
information about community health risks, including
those to sensitive subpopulations who might be particu-
larly vulnerable.
In addition to assessing NPL sites, ATSDR responds
directly to communities through petitions from commu-
nity members or licensed physicians. Congress recognized
communities as important sources of information and has
therefore chosen to empower them by including the
following statement in CERCLA: “The Administrator of
ATSDR may perform health assessments for releases of
facilities where individual persons or licensed physicians
provide information that individuals have been exposed
to a hazardous substance, for which the probable source
of such exposure is a release” (CERCLA, 1980). The
severity and complexity of public health hazards of a site
may warrant a public health assessment, or a less involved
response, such as a health consultation, or a more
immediate response, such as a public health advisory.
Whatever the response, ATSDR may provide valuable
information on environmental contamination and recom-
mendations to protect public health.
Another federal source of information is the Toxic
Chemical Release Inventory (TRI) data base. The TRI
data are submitted to EPA by industrial facilities in
compliance with Section 313 of the Emergency Planning
and Community Right-to-Know Act of 1986. That data
base lists all reported releases of hazardous substances
within a city, Z1P Code, or county, and is open to the
public. By using the data base, a community health nurse
can determine harmful contaminants in the city or county
and perhaps identify areas of concern. Data are available
for any part of the United States (U.S. Environmental
Protection Agency, 1989).
In addition to CERCLA, the Resource Conservation
and Recovery Act (RCRA) mandates safe and secure
procedures for treating, transporting, storing, and dispos-
ing of hazardous substances. Industries are regulated
under the act depending on the amount of hazardous
substances present on site. The EPA enforces the
regulations and has information on RCRA sites at its
regional offices.
Finally, adhering to a number of environmental laws
requires continuing monitoring. Such laws include the
Clean Water Act, the Clean Air Act, and the Safe
Drinking Water Act. Information about these acts is also
available from EPA and state or local agencies.
Retrieving data from federal agencies is easily accom-
plished through telephone contact or written requests to
the appropriate regional office. The EPA has 10 regional
offices across the country that have TRI, NPL, and other
information. The ATSDR also has regional representa-
tives in each of the 10 EPA regions. Regional representa-
tives of both agencies are important sources of informa-
tion about various sites within communities.
State Level
States may also provide valuable environmental health
information. For example, they have separate priority
sites and listings (aside from NPL sites) that are handled
by state environmental agencies. Those sites do not
receive federal attention or funding, but may be a
priority within the state. State agencies often have
valuable information about environmental contamina-
tion in their communities, including environmental
monitoring data, health advisories, health studies, and
additional data bases. All information helps to identify
areas of concern.
Health agencies may have useful epidemiologic infor-
mation, including disease registries and statistics. Many
states have environmental epidemiologists who are
instrumental in identifying and analyzing environmental
contamination of potential health concern.
Local Level
Additional environmental and health information is
available at the local level. Local health department
sanitarians and other environmental professionals can
provide valuable data. Birth, death, and other records
filed at health departments are useful sources of informa-
tion. For example, they may show trends in health
outcomes, which may help assess environmental health.
Community members often are one of the most
important sources of environmental health information.
They are well educated about environmental issues,
thanks to the news media, and it is not uncommon for
them to be the first to identify problems. Since commu-
nity health nurses are an integral part of public health in
the communities, they may be the first to recognize
trends in concerns.
Recently, the number of community activist groups
concerned about the quality of the environment has
proliferated. Those groups are often well informed about
local environmental issues because they attend confer-
ences or meetings that deal with environmental quality
or specific toxic products, read relevant government
reports, meet with activists from local or national

environmental groups, consult experts on specific topics,
and follow press coverage of related issues (Logan &
Dawkins, 1986). Community health nurses should con-
sult with such groups to complete a thorough environ-
mental assessment.
Also, nurses involved with periodic screening pro-
grams or health surveys may notice trends in data
(Clement-Stone, Eigsti, & McGuire, 1987). They may be
the first to consider an environmental causation when
attempting to explain trends. Once an initial assessment
is completed, the nurses should continue to monitor
environmental data sources to keep informed of con-
cerns within the community.
ENVIRONMENTAL HEALTH NURSING DIAGNOSIS
A community-based nursing diagnosis identifies the
potentially unhealthful response for a community. Devel-
oping such a diagnosis poses special challenges. Existing
community-based nursing diagnoses specific to human
exposure and environmental contamination are limited.
Environmental contamination often puts segments of the
community at different levels of risk, requiring a
diagnosis aimed at a group or aggregate rather than the
typical family unit or individual (Neufeld & Harrison,
1990). A diagnosis of impaired home-maintenance man-
agement is possible for toxic environmental contamina-
tion affecting a family residence, but does not address
exposures at the community level.
Potential for injury is a more appropriate diagnosis in
such cases (Sherwood et al., 1988); however, it still does
not adequately evaluate problems posed by environmen-
tal health. In developing a more thorough nursing
diagnosis, it is important to identify the group at highest
risk, or the aggregate. An aggregate is described as a
“collection of individuals who are not part of an
interdependent group, but who share some health risk or
TABLE 3 . Summary of Steps in Formulating an Environmental Health Nursing Diagnosis
Part Function
1 Identify target group or community aggregate,
e.g., children or residents within 1 mile of site
contamination
2 Identify potential or actual unhealthful response,
o r potential for injury
3 Identify related host and environmental factors
4 Identify any existing data that may substantiate
the nursing diagnosis
Neufer: Environmental Health Nursing 159
health-seeking behavior” (Neufeld & Harrison, 1990, p.
252). For example, a community health nurse may
identify the highest-risk group or target group as those
who live within a mile of the contamination source and
those most susceptible to the adverse effects of a
contaminant.
Once an aggregate has been identified, the next step
is to “determine the potentially unhealthful response”
(Neufeld & Harrison, 1990, p. 252). In the case of
environmental contamination, a variety of health out-
comes may be possible, depending on the level of
exposure and the chemical nature of the toxin. In most
cases, exposures are not limited to one contaminant,
but rather a mixture, further complicating the predic-
tion of health outcomes. In fact, of the standard
diagnoses, potential for injury may be the most specific
possible.
The next step is to determine the factors related to the
health problem. These are divided into host (motivation,
knowledge, skills of the aggregate) and environmental
factors (characteristics of the physical, psychologic,
political, or cultural environment, e.g., income, environ-
mental hazards, social support) (Neufeld & Harrison,
1990).
A nursing diagnosis often includes a substantial final
statement prefaced by “as evidenced by.” This may
identify epidemiologic evidence that supports conclu-
sions about public health hazards of environmental
contamination. Conclusions made in environmental
epidemiology are frequently inconclusive or controver-
sial, and bimonitoring information is rarely available.
This final step is therefore optional. The prime objective
of a nursing diagnosis is to protect the health of
community members. If evidence linking health effects
with environmental contamination is unavailable, a
potential for injury diagnosis may still be appropriate
(Table 3).
Question to Answer
Who in the community is at highest risk?
Is there a significant potential for injury or has an ac-
tual injury occurred?
Host: What characteristics of the target group influ-
ence the potential for injury?
Environment: What characteristics of the environment
influence the potential for injury?
Do any epidemiologic o r other health outcome data
correlate potential for injury with environmental
con tamination?
160 Public Health Nursing Volume 11 Number 3 June 1994

CASE STUDY Assessment

After conducting a community environmental assess-
ment and making a diagnosis, the nurse can intervene
appropriately to protect and promote public health. The
case study illustrates how a nurse identified a public
health problem through community assessment and
diagnosis. The community is Douglas, Arizona, a small,
remote, rural town of about 13,000 on the southwestern
border of the United States (Census of Population and
Housing, 1990). The main industry in Douglas was a
large copper smelter that operated from 1908 until 1987,
when it was shut down.
Douglas employs two community health nurses, four
school health nurses, and a sanitarian. The Douglas
neighborhood of Pirtleville has about 1200 residents and
is about a mile from the former smelter site (U.S.
Geological Survey, 1978). In 1990 a member of Pirtleville
observed what seemed to be a high rate of miscarriages,
and asked the local health department whether environ-
mental contamination from the former smelter was the
cause (ATSDR, 1991b).
An environmental health assessment of Douglas was
conducted by a community health nurse, who contacted
federal, state, and local agencies. She found that lead soil
contamination was the issue of greatest concern in
Douglas and Pirtleville (Table 4).
A review of the literature was conducted on the health
hazards of lead contamination. Lead binds tightly to
soils, persists in the environment for long periods, and
may migrate indoors as dust (Centers for Disease
Control [CDC], 1991). Contaminated dust represents an
additional exposure hazard because it can be inhaled as
well as ingested (ATSDR, 1992). In 1991 the CDC
lowered its intervention level for blood lead (PbB) levels
in children to 10 pg/dl, because levels in excess of that
are associated with decreased intelligence and impaired
neurobehavioral development (CDC, 1991). Studies also
indicated an association between high levels of blood
lead and miscarriages, although excess miscarriages may
also correlate with high rates of sexually transmitted
diseases in Douglas, as reported by a local obstetrician

TABLE 4. Environmental Health Assessment, Douglas, Arizona

Federal
ATSDR investigations in response
to a petition for a public health as-
sessment of Douglas. Site review
and update revealed that lead soil
levels may be of public health con-
cern (ATSDR, 1991~).
TRI data search by city indicated no
toxic releases in Douglas since 1987
(TRI, 1989).
EPA indicated that no sites in Doug-
las are on or are being evaluated for
the NPL list.
State Local
The environmental epidemiology de- A child with a history of pica came
partment conducted a study of soil to the health department with com-
lead and PbB levels in children in plaints of bone pain in January
1985 and found: 1992. He had PbB level of 30 pgldl
a. Soil lead in Pirtleville averaged and was referred to University of
341 mg/kg Arizona hospitals (ATSDR, 1991~).
b. Soil lead level in Douglas aver-
aged 254 mg/kg (background soil
lead level in southern Arizona is 100
mg/kg)
c. Children’s PbB levels averaged
13.7 pgldl in Pirtleville (Arizona De-
partment of Health Services, 1986).
State health department also had Community members report con-
record of CDC study conducted in cerns of perceived high rates of mis-
1975. At the time, children’s PbB carriages (ATSDR, 1991~).
levels averaged 20.47 pgidl (Baker
et al., 1977).
The state air quality department’s The border ecology project, a local
residential air monitoring data indi- community action group, expressed
cated elevated levels of ambient concern about high soil lead levels
lead particulate, which periodically and their effect on Douglas children
exceeded the national ambient air (ATSDR, 1991~).
quality standard (Arizona Depart-
ment of Environmental Quality,
1967-1987).
 Neufer: Environmental Health Nursing 161

(ATSDR, 1992). Given recent CDC guidelines, ATSDR to preventing lead poisoning in children recommends a
and the Arizona Department of Health Services ex- PbB screening program for high-risk communities such
pressed renewed concern about the 1985 study and as Douglas. In addition, ATSDR (1991~)recommended
possible current hazards of lead contamination in Doug- educating local health professionals and community
las (ATSDR, 1991~). members in recognizing and mitigating adverse health
outcomes related to lead exposure. The ATSDR, the
Nursing Diagnosis Arizona Department of Health Services, and local health
The environmental health assessment indicated a need department staff are currently collaborating to imple-
for a care plan for Douglas. In formulating a diagnosis ment these recommendations.
for the aggregate, the children of Douglas and Pirtleville,
the community health nurse organized the information in CONCLUSION
the following manner. The most alarming finding in a community is not the
magnitude of environmental contamination, but the fact
Who in the Community Is at Highest Risk?
that human exposure to contamination has persisted
Pirtleville had the highest soil lead levels, putting those
unchecked for years or even decades. Although health
residents at highest risk. Children are known to ingest
professionals are becoming more aware of the public
great quantities of soil, are likely to practice pica, and are
health hazards of pollution, community health nurses
susceptible to adverse health effects from lead exposure. have not applied their skills in assessing and diagnosing
Pregnant women are at risk of adverse reproductive
related community health problems. The case study
health effects from lead exposure.
demonstrates the progressive role nurses may take.
Can a Signijicant Potential for Injury Be Identijied? Unfortunately, nurses are provided scant guidance from
The children in Pirtleville and Douglas are at risk of textbooks and nursing literature, a very disturbing fact
developing adverse neurobehavioral health effects, and when nurses are increasingly confronted with communi-
pregnant women are at risk of developing adverse ties outraged by environmental contamination.
reproductive health effects. The field is wide open for nursing research and
involvement, and could represent tremendous and excit-
What Are the Host and Environmental Factors Related to ing challenges in the future. Just as the proliferation for
the Diagnosis? AIDS and the increase in teenage pregnancies have
Host factors are frequent high exposure to lead- prompted nurses to adapt to the changing needs of
contaminated soils and dusts through normal play and modern communities, the profession must grasp the
hand-to-mouth activity in children (ATSDR, 1991b); high challenges necessary to promote environmental health.
susceptibility of children to lead absorption and adverse Incidents such as those described in Donora, Pennsylva-
health effects (CDC, 1991); fetal susceptibility to lead nia, Augusta, Georgia, and Douglas, Arizona, and
absorption and adverse pregnancy outcome (ATSDR, better-known events such as Love Canal and Times
1992); and lack of knowledge of specific methods to Beach, are the signals that the time has come to act.
mitigate lead exposure.
Environmental factors are elevated soil lead levels; ACKNOWLEDGMENTS
lack of blood lead screening programs; lack of knowl-
This paper was originally submitted as part of a final
edge of signs and symptoms of elevated PbB levels in the
project for the Emory University School of Public
community; and lack of knowledge of methods to
Health. We thank Drs. Howard Frumkin and Frederick
mitigate soil exposure among health professionals and
Gerr of the EnvironmentaYOccupational Health Divi-
community members.
sion for their support. Special thanks go to project
Do Data Substantiate the Nursing Diagnosis? advisors Marcia McDonnell, M.N., CANP, of the Nell
A 1975 CDC study found an average PbB level in Hodgson Woodruff School of Nursing, and Joseph L.
children to be 20.47 pg/dl (Baker et al., 1977). A 1985 Hughart, P.G., M.S., M.P.H., of ATSDR for volunteer-
state health department study found average PbB levels ing their time and energy to this project.
to be 13.7 pg/dl (Arizona Department of Health
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