Integration of environmental health content into nursing curricula has been advocated since the release of the 1995 Institute of Medicine report, Nursing, Health, and the Environment (Pope, Snyder, & Mood, 1995). This sentinel report defined environmental health as “freedom from illness or injury related to exposure to toxic agents and other environmental conditions that are potentially detrimental to human health” (p. 3). The report also identified four general environmental health competencies for nurses: (1) basic knowledge and concepts, (2) assessment and referral, (3) advocacy, ethics, and risk communication, and (4) legislation and regulation. The importance of environmental health knowledge for all nurses has been reasserted with the publication of the American Nurses Association ANA’s Principles of Environmental Health for Nursing Practice with Implementation Strategies (ANA, 2007) and the inclusion of environmental health as a standard for professional nursing practice (ANA, 2010).
Although environmental health content and student learning activities have been described in the literature (Gerber & McGuire, 1999; Hewitt, Candek, & Engel, 2006; N.M. Sweeney & de Peyster, 2005), Healthy Homes—a national interdisciplinary framework that uses a comprehensive approach to addressing home environmental health—has not been a focus area in nursing curricula. The only published account of including home environmental hazard assessments in nursing education to date is by N. Sweeney and de Peyster (2005), who described revisions to the undergraduate community health nursing course to include additional environmental health classroom content and field experiences. A component of the field experience was a home visit in which an environmental health risk appraisal was incorporated into a family analysis. Students used the faculty-developed Environmental Health Risk Appraisal tool to determine actual or potential risks in the home, at work or school, and in the community. The authors noted that because students are often uncomfortable looking around a client’s home and completing an environmental assessment, dialogue with students before and after the visits to discuss findings and address any concerns or situations that arose during the visit is critical.
Although no other published nursing literature addresses home environmental hazard education, Zickafoose, Greenberg, and Dearborn (2011) described a program that provides Healthy Homes content to physicians in pediatrics and family practice during their first year of residency. After receiving basic home environmental hazards information, a resident physician works with a home environmental specialist to conduct a home inspection for a patient identified in a clinic for which the resident physician will provide ongoing care. Family education and behavior interventions are addressed during the home visit and in subsequent clinic visits. Resident physicians’ evaluations of the program have been positive despite difficulties scheduling and completing home visits.
This article describes the development, multistep implementation process, and evaluation of a Healthy Homes modular component of the environmental health content in a quarter-long (10-week) community health nursing course at a midwestern college of nursing. The relevant student populations are traditional undergraduate baccalaureate nursing (BSN) students, second-degree graduate prelicensure students, and students in the online distance BSN completion program. The overall aim of this project was to address the need for innovative and timely Healthy Homes education for undergraduate and graduate nursing students. The knowledge and skills gained by the students can be applied in a variety of practice settings and on a personal level with families, friends, and neighbors. Content from all four environmental competency areas identified in the Institute of Medicine report (Pope et al., 1995) were represented in the project.
Healthy Homes Framework
The National Center for Healthy Housing’s (NCHH) framework for Healthy Homes, which guided this project, is based on the premise that a well-constructed, maintained, or rehabilitated home supports the health of its residents (NCHH, 2012). Healthy Homes is a holistic approach in which the home is viewed as a system. The seven core principles of Healthy Homes are Keep it: Dry, Clean, Pest-Free, Well Maintained, Contaminant-Free, Ventilated, and Safe. Keeping the home dry is important because moisture in the home can result in mold and mildew. Clean homes reduce the risk of allergens, dust mites, chemical contaminants, and harborage for pests. Examples of pests in the home are cockroaches, which are asthma triggers, and rodents, which are associated with histoplasmosis and hantavirus; integrated pest management principles are advocated to address pest infestations. Effective ventilation in the home decreases risks from hazards such as radon, moisture, environmental tobacco smoke, allergens, and carbon monoxide. Home safety efforts reduce the risk of injuries such as falls, poisonings, burns, and electric shock. Contaminants in the home can include lead, volatile organic compounds, and pesticides. Maintaining the home involves actions such as regularly changing furnace filters, repairing broken water spouts, sealing entry points for insects, and having routine inspections of heating and cooling systems.
Healthy Homes Education
Using the NCHH framework, the Healthy Homes education module was created in three phases. Phase 1 included nine Web-based, recorded lectures on the Healthy Homes principles and on home assessment and referral. In the next phase, students also participated in a Healthy Homes clinical laboratory simulation (home visit scenario and four mock rooms of an apartment). Phase 3 involved developing protocols for and piloting home visits by students who, under the supervision of a clinical instructor, conducted Healthy Homes assessments of clients living in two low-income subsidized housing sites (apartments and townhomes).
Components of the NCHH Pediatric Environmental Home Assessment (PEHA) free online training for nurses were incorporated throughout the Healthy Homes education (NCHH, 2011). The purposes of the PEHA training are to teach nurses how to obtain a pediatric environmental health history and make recommendations for interventions to mitigate home hazards. Included in the PEHA training are video scenarios, a structured environmental home assessment form, and a standardized Nursing Care Plan with nursing and family interventions. In the video scenario, a mother who is concerned about potential asthma triggers affecting her 6-year-old child with asthma accompanies a public health nurse who does a Healthy Homes assessment of the family’s home. The PEHA assessment form completed by the public health nurse is presented at the end of the recorded lecture along with a completed Nursing Care Plan that reflects the hazards identified in the assessment.
Web-Based Recorded Lectures
Didactic content in the nine recorded lectures addresses each of the seven Healthy Homes principles, how to implement a Healthy Homes program, working with people in their homes, how to do a Healthy Homes assessment, and a segment on putting all of the Healthy Homes elements together, including administrative considerations, establishing objectives for Healthy Homes visits, identifying partners and funding sources, and sustaining the program. Recorded lectures, which are made available on the course Web site to students, are between 9 minutes (Keep it Contaminant-Free) and 45 minutes (Assessment and Referral) in length. The lecture content was adapted from NCHH (2012) training modules and edited for length without materially affecting the essential principles conveyed.
The Healthy Homes Assessment and Referral recorded lecture is based on the NCHH PEHA assessment form (NCHH, 2011) and the standardized Nursing Care Plan that accompanies the PEHA assessment form. The PEHA assessment form addresses general characteristics of the home, indoor pollutants (e.g., mold, pests), home environment (e.g., moisture), the sleep environment in the home, home safety, and particular environmental risks associated with young children (e.g., unsafe medication storage). Selected video segments of the PEHA online education (NCHH, 2011) were included in the recorded lecture to illustrate how to complete a Healthy Homes assessment.
Healthy Homes Clinical Laboratory Simulation
The scenario for the Healthy Homes clinical laboratory simulation is a referral for a home visit with Healthy Homes assessment for a 6-year-old child recently discharged from a 3-day hospitalization for uncontrolled asthma. The family is composed of the child, mother, father (recently unemployed), 6-month-old brother, and the target client’s paternal grandfather, who is a disabled, homebound older adult recently hospitalized for diabetes and respiratory problems. The home is a 2-bedroom, subsidized housing apartment, including a kitchen, living room, children’s bedroom (these three rooms are part of the simulation), and parent’s bedroom (not included in the simulation). The simulated apartment also includes a bathroom with a shower. Clinical staff or a faculty member play the role of the parent; the target child is at school, the father is out seeking employment, the 6-month-old child is sleeping (manikin in a crib in the children’s bedroom), and the grandfather (manikin) is asleep on the living room couch.
Each of the simulated rooms is created in a technical learning center (TLC) classroom in the college and includes numerous hazards that students would have learned about through the Healthy Homes recorded lectures (See the Table for examples of environmental hazards per room). We adapted components of the TLC classroom to simulate a similar entity in the home. For example, an existing sink usually used for student hand washing during standard TLC activities was converted into a kitchen sink with dirty dishes. In addition, we hired an art student to create movable walls with painted scenes for three of the simulated rooms. A kitchen wall has a painted refrigerator and cabinets; two walls in the bedroom depict a dresser with a television, a closet with clothes, and evidence of mold at the ceiling border; and a living room wall is illustrated with a television and video cabinet.
Table: Examples of Environmental Hazards per Simulated Room by the Healthy Homes Principle
Students attend the Healthy Homes clinical simulation during their assigned clinical day with their clinical instructor. Before the simulated assessment visit begins, a faculty member facilitates a 20- to 30-minute overview of the simulation (purpose and objectives, the seven Healthy Homes principles, and the basics of a Healthy Homes home visit assessment) with the 8 to 10 students in the clinical group (The INASCL Board of Directors, 2011a). The instructor also explains the format of the simulated home visit assessment: students play the role of public health nurses from the local health department with whom the parent has set up an appointment for the home visit in response to the hospital referral. The Healthy Homes assessment includes both visual observations of the home and dialogue with the parent. Students are instructed to identify home health hazards that are easily observable, as well as those that are not immediately noticeable, such as cleaning products in unlocked cabinets, roaches under rugs, and leaking sinks. After the presimulation briefing, students are placed in subgroups of 2 to 3 for the simulated home visit. The subgroups are instructed to complete the home environmental hazard assessment as a team. Students knock at the door, introduce themselves and the purpose of the visit, and, after receiving permission from the parent to enter the home, begin the assessment. Students complete the PEHA assessment form as they conduct the visit. At the conclusion of the visit, they explain to the parent that they will return next week to review their assessment findings and thank the parent for allowing them to visit. Students then finalize the PEHA assessment form and complete the PEHA Nursing Care Plan.
A faculty member then facilitates a postsimulation debriefing session, during which students discuss their experiences and identify the hazards they observed in each room (The INASCL Board of Directors, 2011b). After the discussion, students complete the postsimulation evaluation form. They then accompany their instructor to examine some of the Healthy Homes resources set up for display in the TLC (e.g., smoke alarm, radon test kits, high-efficiency particulate air [HEPA] vacuum, educational materials, moisture meter).
Healthy Homes Visit
Accompanied by their instructor, students were paired to complete Healthy Homes assessment visits across the two housing sites. Before the visit, the students and the clinical instructor reviewed the purpose of the visit and the Healthy Homes home assessment visit protocol. A 2-gallon bucket, a quart of vinegar, a box of baking soda, a 32-ounce spray bottle, two cleaning cloths, and laminated instructions on green cleaning were provided to each home during the assessment visit. At the conclusion of the assessment, the students thanked the client resident for allowing them to visit their homes and reminded them that they would return the following week to share their findings. After leaving the home, students worked together to discuss their findings, complete the PEHA assessment form and the Nursing Care Plan, and plan the follow-up visit, which they reviewed with their clinical instructor. During the follow-up visit, the student teams return to the homes where they reviewed their findings with the client resident and provided basic Healthy Homes education for identified or potential environmental hazards, including how to use any additional supplies (e.g., roach traps, mattress and pillow encasings) brought specifically for the client’s use.
Initial implementation of the Healthy Homes content occurred over four consecutive academic quarters (Autumn 2010 and Winter, Spring, and Autumn 2011). The community health nursing course is offered for traditional BSN students in Autumn, Winter, and Spring; for second-degree graduate prelicensure students in the Autumn; and for BSN completion students in Winter. The Web-based recorded lectures first went live in Autumn 2010; the Healthy Homes simulation was first available in Spring 2011. Home visits were piloted with second-degree prelicensure students in the Autumn 2011 course. BSN completion students had the option to take the Healthy Homes recorded lectures in their online Winter 2011 course. Due to the nature of the online distance BSN completion program, these students were involved only in the Web-based recorded Healthy Homes lectures.
The evaluation of the Healthy Homes education module consisted of pretest–posttest assessments of knowledge gained from the recorded lectures; student surveys of satisfaction with the recorded lectures, the clinical simulation, and home visits; and review of completed Healthy Homes simulation PEHA assessment forms to determine students’ competency in identifying and recording key hazards in the simulated rooms. Evaluations were determined to be exempt from risk to human subjects by the university’s institutional review board.
Web-Based Recorded Lectures
Evaluation data for recorded lectures were collected in Autumn 2010 and Winter, Spring, and Autumn 2011. Prior to and after viewing all of the recorded lectures, students completed a 20-item, multiple choice online quiz. Results of paired t tests indicated that quiz scores (n = 332) increased significantly from an average of 14.25 (SD = 2.16) correct answers to 16.54 correct answers (SD = 2.3) (t122= 12.6, p < 0.001). Quiz scores increased significantly for all three student groups (traditional BSN, second-degree graduate prelicensure, BSN completion), with the second-degree graduate prelicensure student scores increasing significantly more than scores for the BSN completion students (2.57 points versus 2.4 points for traditional BSN, 1.5 points for BSN completion; F = 3.8; p = 0.024).
Students also were asked to respond to an anonymous 10-item online evaluation that used a 4-point scale (strongly agree, agree, disagree, strongly disagree) to evaluate the Web-based learning experience. More than 80% of the 297 students who completed the evaluation either agreed or strongly agreed with six items (“lectures were organized”; “learned about basic environmental health”; “learned about environmental health in the home”; “lectures helped me apply ecological multiple determinants of health approach to the home environment”; “will be able to apply healthy homes content to my nursing practice”; “modules and handouts were easy to access”). Fewer students agreed that recorded lecture handouts were useful (79%), narrators conveyed interest in the topic (72%), pacing of narration was acceptable (69%), and the modules would have been better presented through in-class lectures (43%).
Healthy Homes Clinical Laboratory Simulation
Evaluation data for clinical simulation were collected in Spring and Autumn 2011. After completing the simulations and debriefing, students were asked to complete an 8-item evaluation of the Healthy Homes simulation. More than 85% of the students (n = 128) agreed or strongly agreed that online modules were helpful in preparing for the simulation, the Healthy Homes assessment was helpful in recording assessment findings, having a faculty member play the parent during the simulation was effective, the simulated rooms were useful for practicing a Healthy Homes assessment, the presimulation overview was helpful, there was enough time to complete the assessment of each simulated room, and the postsimulation debriefing was helpful for clarifying questions.
Assessment competency was evaluated by reviewing the completed PEHA assessment forms to determine whether students identified and recorded key targeted health hazards in each simulated room. More than 95% of the students identified the poisons under the sink, the mold and mildew on the shower curtain, and a cord from a window blind hanging in the infant’s crib. Only approximately half of the student groups noted that oxygen was in use while a family member was smoking, and less than 20% addressed clutter on the floor and medications on a table within easy reach of the young children.
Healthy Homes Visits
Evaluation data for pilot Healthy Homes visits were collected in Autumn 2011. The post–Healthy Homes assessment visit evaluation revealed that all of the 24 students who conducted assessment visits in the clinical setting agreed that the Healthy Homes simulation helped prepare them for the assessment visit and that they felt at least somewhat effective in their ability to complete a Healthy Homes assessment. More than 75% reported the previsit review with the clinical instructor was helpful in conducting the Healthy Homes assessment, they had the supplies needed to complete the assessment, the assessment visit proceeded in an organized way, and the recorded Healthy Homes lectures helped prepare them for the home visit assessment. When asked to indicate three things they learned from the Healthy Homes assessment visits, nine students noted they learned how to communicate with clients in their own home. One student commented, “I learned how to ask questions that I thought might be uncomfortable at first.” Six students addressed the importance of being respectful and nonjudgmental. Six students wrote about the challenges faced by their clients; two comments made in this area were “Poverty is much worse than I imagined,” and “Their concerns are much more with survival than with health.” Several students commented that clients appreciated receiving the supplies given to them, that clients had pest infestations in visited homes, and that they (the students) learned to apply content they learned in the modules and simulations. One student summed up the experience with this comment: “I enjoy assessing homes for health conditions now that I have the knowledge about environmental hazards.”
To introduce nursing students to the essentials of evaluating health and safety hazards in the home, we recorded Web-based Healthy Homes lectures, created a Healthy Homes simulation to give students a standardized experience to evaluate the home setting for hazards, and piloted student-completed in-home environmental assessments that integrated learning across didactic and laboratory modalities. Despite the largely positive evaluations and evidence of increased knowledge of Healthy Homes, some components of the Web-based modules were better received than others. Smaller percentages of students agreed that the recorded lecture handouts were useful, narrators conveyed interest in the topic, and pacing of narration was acceptable. The Web-based modules are being reviewed for clarity, pacing, and length.
The clinical laboratory simulations were well received by students and will continue largely as developed, although challenges remain related to the lack of storage space at the college of nursing. Faculty posing as the parent in the simulations continue to take a formative approach in ensuring that students immediately address key health hazards, such as a lit cigarette with oxygen flowing in the same room, and role-playing to increase students comfort when addressing such hazardous yet potentially sensitive topics. The piloted in-home assessment visits provided students with real-world experience evaluating health and safety hazards, and students were satisfied with the experience. We will have more students conduct these visits and more rigorously link outcomes of those visits to the didactic and laboratory experiences before we can more widely disseminate these methods.
Although our multistep approach to Healthy Homes education was implemented successfully, any educational institution adopting our approach will incur costs of developing simulation materials and purchasing supplies to provide to residents for in-home visits. We are exploring the possibility of developing virtual reality and gaming environment simulations that would reduce simulation costs.
Healthy Homes education for nursing students can have long-term implications for patient education regardless of the eventual practice setting in which nurses are employed. For example, a nurse should recognize that a child with asthma discharged to a home containing multiple environmental asthma triggers, such as pet dander, spray pesticides, or tobacco smoke, is at risk for readmission (Welsh, Hasan, & Li, 2011). Nurses have been identified as one of the health disciplines needing to be proficient in Healthy Homes principles (Morley, Mickalike, & Mack, 2011) and to have basic levels of competency in four specific areas of environmental health (Pope et al., 1995). Our educational initiative provides didactic content regarding these principles and competency areas, as well as simulated and real-world Healthy Homes assessment experiences. Given the increasing emphasis on community-based health care and the growing understanding of the importance of environmental factors to health outcomes, proficiency in Healthy Homes principles for nurses is critical.
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Examples of Environmental Hazards per Simulated Room by the Healthy Homes Principle
|Healthy Homes Principle||Environmental Hazard per Simulated Room|
|Keep it dry||Kitchen and bathroom: water under sink|
|Bedroom: evidence of leaking roof|
|Bathroom: evidence of mold and mildew in shower|
|Keep it clean||Living room, bedroom, and bathroom: clutter (boxes, clothes, toys, towels) on floor|
|Kitchen: stove and table with food encrusted pots, pans, and dishes|
|Keep it pest-free||Living room: evidence of bed bug bites on Grandpa, pest traps on floor, dirty dishes sitting out|
|Kitchen: food and crumbs on counter and stove, evidence of pests and rodents in cupboards|
|Bedroom: evidence of roach infestation and bed bugs|
|Keep it well maintained||Kitchen: simulated window with evidence of water leakage outside|
|Keep it contaminant-free||All rooms: candles, air fresheners|
|Keep it ventilated||Living room: window that cannot be opened|
|Kitchen: dryer vented into kitchen|
|Bathroom: no window or working ventilation fan|
|Keep it safe||Living room: clutter by Grandpa’s feet and by his walker, toys with small parts scattered on floor, smoke alarm without battery, open pill bottles, oxygen canister with Grandpa holding simulated lit cigarette|
|Kitchen: pots and pans with handles hanging over side of stove, pesticides and cleaning fluids within easy reach of children, lint in dryer vent|
|Bedroom: blind cord hanging in crib, unsafe crib|
|Bathroom: pesticides and cleaning fluids under sink|