ANSWER
The American Nurses Association (ANA) takes the lead in determining nursing goals, objectives, and professional practice. The American Nurses Association defines nursing as “… a caring-based practice in which processes of diagnosis and treatment are applied to human experiences of health and illness” (ANA, 1994).

The American Nurses Association (ANA) defines three basic nursing activities that explicitly include environmental and health issues, a preventive approach to health, and concern for populations as well as individuals:

1. Restorative practices reduce the negative effects of illness and disease.

2. Supportive practices aim to improve health by altering relationships or the environment.

3. Promotive practices mobilize healthy patterns of living, foster personal and familial development, and support individuals’, families’, and communities’ self-defined goals.

Thus, major concepts and activities required to address environmental factors that can affect the health of individuals and populations are included in the ANA’s scope of practice and definition of nursing.
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Nursing Procedures
The nursing process’s assessment, diagnosis, planning/outcomes, intervention, and evaluation phases have been described as the core and essence of nursing, central to all nursing actions. It is a deliberate, logical, and rational problem-solving process in which nursing is practiced systematically. Throughout all phases of the nursing process, from assessment to evaluation, patients, their families, or communities provide continuous input. Diagnoses, plans, and interventions can all be changed at any time based on new information from the patient or another source. As much as possible, the patient should play an active and equal role in the nursing process, limited only by physical or emotional limitations.

It is worth noting that the nursing process was originally designed to care for individuals but has since evolved to include a role in the care of families and communities. Applying the nursing process to environmental health issues may necessitate nurses using different phases of the process in novel ways. For example, the intervention could suggest changing the source of drinking water for an entire neighborhood or community. The process is consistent with the framework established by the California Public Health Foundation (1992) to address nursing roles and responsibilities specific to environmental health issues. The CPHF framework supplements, not duplicates, the nursing process.

Data are gathered during the assessment phase of the nursing process to determine a patient’s state of health and to identify factors that may affect well-being. This activity includes eliciting a health history to identify previous illnesses and injuries, allergies, family health patterns, and psychosocial factors affecting health. Environmental health components of history taking can be incorporated into routine patient assessments by including questions about prior exposure to chemical, physical, or biological hazards, as well as questions about temporal relationships between the onset of symptoms and activities performed before or during the occurrence of symptoms. During an assessment, the nurse should look for patterns of co-morbidity among patients, family members, and communities that could be caused by environmental factors. Nurses also conduct assessments during visits to patients’ homes and workplaces, gathering firsthand information about environmental factors that may harm health.

The culmination of objective and subjective data collection results in diagnosis. Health problems are identified and described during this stage of the nursing process. Depending on their practice setting, nurses may use the North American Nursing Diagnosis Association (NANDA) diagnostic terms or medical diagnostic terminology, as is often the case with APNs who are nurse practitioners. Without routine consideration of environmental factors that affect health, problems may be misdiagnosed, and subsequent interventions will address environmental issues haphazardly, if at all.

The phase of the nursing process in which optimal outcomes are identified is known as planning/outcomes. Various interventions are identified to address the health issue, and plans for implementing those interventions are developed. The ability of a nurse to formulate diagnoses that include environmental factors is required to establish interventions that address environmentally related illnesses. Intervention plans that do not consider environmental factors are more likely to focus on secondary and tertiary-level activities (care and cure) rather than primary prevention strategies.

The component of the nursing process in which the nurse implements activities to promote health and prevent or alleviate illness and injury is known as an intervention. In this stage of the nursing process, the nurse may act as an educator, informing patients, families, workers, and communities about environmental hazards and how to protect themselves. Effective interventions necessitate a working knowledge of resources, such as texts, databases, and professional experts, and the ability to access these resources.

The role of an advocate is also included in the intervention. Although nurses are familiar with advocating on behalf of individual patients, they need to be more trained in advocacy techniques for populations or settings other than healthcare facilities. Nurses must broaden their definition of advocacy to include activities on behalf of communities and other groups and activities in settings such as the workplace or community meetings. Because environmental health issues are frequently intertwined with social and political factors, this extension of nursing advocacy is frequently required. Interventions solely focused on the individual patient are rarely effective as primary prevention methods in environmental health.

The final step in the nursing process, evaluation, can be performed on various levels and frequently results in additional interventions. Individual health outcomes are one method of determining the effectiveness of nursing interventions. An evaluation of hazard abatement methods is another measure of effective intervention in environmentally related illness. Is the hazard contained or removed from the individual’s environment? Are those who live nearby safe from exposure? Evaluation should also include an assessment of the efficacy of interventions aimed at other populations at similar risk, such as other family members, coworkers, and community members. Was the existence of the hazard and protective measures communicated to those at risk clearly and consistently? Was effective treatment given to others who were at risk and experienced symptoms? Are precautions being taken to avoid future incidents of exposure? Are the patient, work population, and community satisfied with the interventions used to identify and eliminate hazardous environmental conditions? Are those who have been impacted by the hazard pleased with the health care that has been provided, including educational interventions and medical treatment? These questions and their answers provide important information to nurses and other healthcare providers for determining the effectiveness of interventions implemented in a specific incident and identifying more effective measures for dealing with similar problems in the future.

Applying the nursing process to environmental health concerns necessitates broadening the tools and processes used to assess patients, reason diagnostically, and develop treatments and interventions that take environmental factors into account. Responsibilities for implementing environmental health clinical services will differ depending on practice settings; however, the nursing process is a useful framework for applying environmental health concepts in all settings and roles.

Responsibilities and Authority
A nurse’s role in environmental health issues can be viewed in various ways. The nursing process can be supplemented or integrated with other models of practice, such as the CPHF model, which assigns the health professional three roles: investigator, educator, and advocate (CPHF, 1992). The role of the investigator contributes to the assessment and evaluation phases of the nursing process, whereas the roles of educator and advocate are carried out as interventions. This framework includes various activities, such as working with communities and on public policy issues, that may be unfamiliar to nurses who structure their practice around the more traditional nursing process applied to individual patient care.

Nurses can take on the role of investigators by

Taking careful environmental health histories and looking for trends in exposure, illness, and injury; being alert to environmental factors that influence health; working with interdisciplinary teams and agencies to determine if an environmental exposure is affecting a community’s health; initiating or participating in research to identify and control environmental exposures that adversely affect human health; and collaborating with public and private institutions to p
In practice, this role may entail making home visits to look for peeling or chipping lead paint in the homes of young children or identifying the use of poorly vented wood stoves in the home of an asthmatic child. It may also entail entering a workplace to assess conditions that jeopardize worker health and safety, such as ergonomic hazards, chemical exposures, or mechanical hazards like poorly guarded conveyor belts. Furthermore, the practice of nursing is inherently dangerous. Appendix B discusses the risks to nurses (and other healthcare workers).

A situation involving a nurse as an investigator occurred in 1992 in Brownsville, Texas, a border town with Mexico. A nurse in a local community hospital’s labor and delivery department noticed an unusual number of neonates born with anencephaly, a relatively rare but devastating congenital disability. Following a review of all birth records for the previous year, the nurse discovered that the incidence of children born with this defect in her facility was significantly higher than the national rate: 30 cases per 10,000 births versus 10 cases per 10,000 births. Further investigation revealed that groundwater and surface water sources contaminated with chemicals are known to cause such negative health outcomes (Suro, 1992). (see Box 3.1).

Box 3.1 Sentinel Health Events and Disease Clustering. When residents or others notice an unusual pattern of illness, an environmental cause is suspected, and environmental health concerns often arise in a community. Residents may notice “too many” (more…)

Another investigative activity is eliciting an environmental health history, one of the most important actions for improving environmental health content in nursing practice. Information from history is essential to all other nursing activities related to environmental health. A nurse may discover hazardous substance exposures through the environmental history that neither the patient nor the clinician suspected as etiologic agents of existing symptoms or disease. Methods and tools for conducting a thorough environmental health history have been thoroughly described (Goldman & Peters, 1981; Tarcher, 1992). Appendix G contains sample forms for taking a comprehensive environmental health history. The following three key questions should be included in all adult patient histories:

1. What are your current and previous longest-held positions? (For children and teenagers, modify the question to: Where do you spend your day, and what do you do there?)

2. Have you been exposed to chemicals (including dust, mists, and fumes) or radiation recently?

3. Have you noticed any (temporal) link between your current symptoms and activities at work, home, or other settings?

Nurses’ investigative roles may include being a part of a community or interdisciplinary public health assessment team. The Assessment Protocol for Excellence in Public Health (NACHO, 1991) and the ATSDR’s Public Health Assessment process (Lybarger et al., 1993) involve identifying risk factors and exposures that impact community health. Both processes also emphasize the importance of soliciting and incorporating community health concerns into the assessment. Nurses proficient in interviewing, active listening, group processes, and epidemiological methods can be valuable team members.

Teacher’s Role
Nurses have long been patient educators, teaching patients how to get out of bed after surgery, how to change a dressing, the potential side effects of medication, and the value of diet and exercise in maintaining health. This role can be expanded to include educating patients, families, workers, and communities about the potential negative effects of environmental hazards and how to reduce or eliminate such exposures. Government agencies and environmental health specialists use hazard or risk communication to describe this type of education. (1) Nurses can expand on this role by providing information on creating environmentally safe homes, schools, day-care centers, workplaces, and communities. As role models, nurses can practice and live in an environmentally safe manner, for example, by limiting unnecessary chemical exposure or performing routine duties to minimize injury due to ergonomic hazards. Nurses can serve as educators by speaking at community gatherings and participating in community-level environmental and human health activities. They may also assist public health agencies with risk or hazard communication.

The original focus of risk communication was on developing and communicating a message to the public from an expert or agency to help the public better understand a situation and its implications for their health and well-being. This definition is expanded to include a two-way dialogue between regulators, managers, and the general public (Cutter, 1993). The interactive process of exchanging information on technical hazards and humans’ physiological and emotional responses necessitates the use of professionals who can listen, interpret, clarify, and reframe questions and information in emotionally charged and sometimes hostile situations. Suppose nurses are to fill an important niche in environmental health. In that case, they must expand their basic patient education role with individuals and families to include communication with entire communities and the general public. The ability to assess the target audience, develop a meaningful and understandable message, select a method or media for conveying the message, and conduct community-level conflict resolution are skills that most nurses need to gain.

The fundamental skills of connecting individual needs with information and other resources will need to be expanded to include community connections with environmental experts who may be outside of the usual network of nursing referrals. For various reasons, many nurses need to be made aware of the need to expand nursing’s role in environmental health. First, role models (faculty or supervisors) have yet to warn them about the dangers of environmental exposure. As a result, nurses are unaware that certain substances are extremely hazardous to human health or that certain environmental conditions are significant, albeit insidiously, contributing to the morbidity and mortality of the populations they serve. Second, nurses suspect or are questioned about the safety of certain conditions by their patients. However, they need help finding accurate information about environmental hazards and control measures. Nurses who have completed NIOSH-sponsored occupational health education programs can help other nurses learn about environmental issues by serving as guest lecturers in nursing schools and as preceptors in occupational health. More such assistance will improve nurse generalists’ ability to educate their patient populations about environmental health issues.

The Advocate’s Role
In theory, human health aspects of environmental problems can be isolated and addressed within traditional medical systems. These issues usually arise in a highly charged social and political environment. Nurses and other health care providers are frequently called upon to assist individual patients in locating and securing access to specialized services for health issues related to environmental hazards. They may also be asked to contact individuals, agencies, and organizations outside the health care system to change hazardous conditions and prevent future health problems on behalf of patients or communities.

It is generally agreed that empowering patients, workers, or community members to act as their advocates serves their best interests. On the other hand, nurses’ scientific knowledge and experience speaking with scientists, physicians, and other authorities equip them to be effective advocates in situations where individual citizens are likely to feel intimidated. This role is especially important when advocating with public health agencies and private industry, where inquiries from individual citizens are sometimes met with responses that need to address their concerns.

Establishing the legitimacy of advocacy activities as elements of nursing practice will necessitate a collaborative effort by educators and nursing leaders. Environmental health issues are inextricably linked to social and political policies; therefore, in the field of environmental health, advocacy is required both at the policy level and on behalf of individual clients. If a stronger, more prevention-oriented model of nursing practice is to be established, advocacy as one component of the nurse’s role is essential. Box 3.2 and Appendix F contain a more in-depth discussion of the practice of advocacy by nurses.

BOX ICON BOX 3.2 Advocacy Training. Interventions in environmental health problems frequently necessitate nurses and other health care professionals acting as advocates, activists, and policy planners on behalf of a single patient or group of patients. Patient representation (more…)

Environmental Health Aspects Across Disciplines
Environmental hazards and their health consequences are rarely amenable to simple solutions derived from a single discipline. Because of the complexity of environmental health issues, the rapidly advancing science base in environmental health, and the need for primary prevention strategies that frequently involve professionals from fields other than nursing, effective interventions for environmentally related illness necessitate collaborative efforts from many disciplines. This collaboration includes ongoing dialogue and the fluidity of roles and responsibilities.

Nurses are used to collaborating with members of other disciplines to achieve a common goal. However, this is frequently done multidisciplinary, with members of each discipline performing their activities independently and with clear role delineation. Various nursing organizations and other health professions advocate for a more collaborative approach to health problems that are highly interactive and more likely to be interdisciplinary. This is an important consideration in order to address environmental health issues effectively.

According to the ANA’s draft Nursing Social Policy Statement, nursing has an “external boundary” that interacts with other professions in response to changing societal needs and scientific knowledge advancement. Members of various professions collaborate in exchanging knowledge, techniques, and ideas on providing quality health care, so the boundaries are fluid rather than firmly defined. Collaborative practice, with some function overlap, allows members of various disciplines to interact with a common overall mission (ANA, 1994).

The National League for Nursing (NLN) has described several aspects of the complex nature of health care, including the need to educate professionals to recognize patterns and engage in innovative problem-solving rather than simply mastering didactic content and an increasingly broad and integrated knowledge base that is not discipline specific (NLN, 1992). These issues are especially relevant to environmental health, a field that necessitates
the ability to access current and comprehensive information,
the ability to recognize disease patterns, and
Participation in interdisciplinary actions to gain expertise from disciplines such as physics, sociology, political science, history, ecology, and various health disciplines.

Collaboration has recently received much attention as a component of the interdisciplinary approach:

When the plethora of health professionals and their increasing specialization and role differentiation combine with the complexity of patient care demands, interdependence among professionals is essential (AACN, 1995).

Others have written similarly, emphasizing the critical need for interdisciplinary health professions training (IOM, 1988) and collaborative practice between nurses and physicians. Despite the clear mandate for interdisciplinary practice, there are numerous barriers to such arrangements, including restrictive licensure and practice laws and insufficient interdisciplinary education.

Individuals working in public health and occupational health, as well as their professional associations, support interdisciplinary practice models. Specialists in industrial hygiene, toxicology, safety, ergonomics, engineering, hydrogeology, medicine, and occupational health are among those involved in addressing environmental health concerns. Nurses must understand the various types of knowledge, functions, and practices that comprise these disciplines, and other health professionals must be aware of the knowledge base, functions, and practices of nurses.

Nursing provides a distinct and invaluable perspective on environmental health issues. On the other hand, nurses will need to work as members of interdisciplinary teams to incorporate environmental health concerns into their practice. To achieve this:
Health professional education must emphasize developing skills for interprofessional collaboration, negotiation, critical thinking, and mutual problem-solving.
Opportunities for interdisciplinary interaction must be provided throughout professional education and clinical practice.
Existing barriers to interdisciplinary collaboration and practice must be removed.

Visit: Nursing Practice Influencing Factors Professional Associations
Professional associations play an important role in influencing nursing practice to ensure that it meets society’s healthcare needs. They identify and address practice issues while leading the nursing community regarding improved, expanded, and advanced practice and education. Professional associations also educate the public about the scientific discipline of nursing and lobby external bodies (e.g., governmental agencies and private foundations) to support nursing education and research.

Many professional associations are also involved in other activities, such as
developing standards of care to define the scope of practice and professional accountability, frameworks for measuring patient outcomes, and parameters for practice evaluation;
developing codes of ethics to guide ethical decision-making and the delivery of ethically centered care; and
Supporting education and research activities (e.g., journals, continuing education programs, and certification).

Professional societies can help identify mechanisms for increasing the integration of environmental health concepts into practice and provide relevant educational opportunities. Several national and international organizations, including the ANA, the International Council of Nurses (ICN), the American Association of Occupational Health Nurses, and the International Commission on Occupational Health (ICOH), play important roles in environmental and occupational health practice, education, and research and can serve as models for other organizations. The American Public Health Association is an interdisciplinary professional society that provides a forum for developing consensus on emerging public health needs and disseminating innovative solutions to these needs, including environmental health issues. Professional associations can significantly impact the integration of environmental health concepts into general and specialty nursing practice, and they must be considered when developing strategies for changing nursing practice to include environmental health issues.

Ethical Issues
Environmental and occupational health concerns are fraught with ethical quandaries. Nurses may find themselves in situations where they want to advocate for clients or communities at risk of adverse environmental exposures, but they are afraid of the consequences. For example, an occupational health nurse may jeopardize her job by advocating for a costly workplace change that would make workers safer. Nurses may face ethical quandaries due to various political and community forces. Clients whose health is jeopardized may deny or conceal the hazard because they fear losing their jobs or seeing their property values fall if the hazard becomes public knowledge. For example, migrant workers and farmers may be unwilling to jeopardize their income for health and safety reasons; similarly, community leaders may regard residential and commercial development as more important than the resulting noise, air, and water pollution.

Concerns about the confidentiality of health information obtained from employees are common, especially when managers threaten occupational health nurses with job termination if they do not relinquish specific health and medical information about a worker. Although employers have the right to know whether their employees are physically and mentally capable of performing their duties, employees have the right to keep specific information about their health or medical diagnoses private. Nurses frequently experience conflicting loyalties as a result of this situation. In such cases, nurses must follow professional codes of ethics, both general and specific to their field of practice.

Everyone has the right to know about actual or potential health risks to make informed decisions about protecting their own health and the health of their families and future offspring. For example, if a toxic spill occurs in a community or workers are exposed to chemical toxicants, the health professional owes it to all parties to inform them of the potential consequences of the exposure. Sometimes, community leaders and company executives adopt a paternalistic stance, believing they know best about information disclosure. Because of a lack of access to health care and the potential harm from continued exposure, this attitude may put certain populations at greater risk. Those living closest to a spill, those spending the most time near toxic substances during the cleanup, and especially vulnerable populations such as children and pregnant women living near a chemical spill may be at greater risk for adverse health effects than others in the community. They should have full access to information about substances to which they may have been potentially exposed. Nurses must be aware of potential hazards and may be required to act autonomously in providing the necessary information to community members based on professional and ethical responsibilities, whether explicit or implicit.

Ethical quandaries may also arise during environmental health nursing research, such as whether control groups should be identified and denied intervention for a study. Other environmental health intervention research concerns how to maintain confidentiality and obtain meaningful informed consent.

Resources for resolving ethical conflicts related to environmental health issues must be included in educational preparation for nurses at all levels of practice.

Credentialing Licensing
Individual nursing licensure is obtained by meeting the eligibility requirements and passing the National Council Licensure Examination for Registered Nurses. Registered nurse (RN) licensure authorizes a nurse to practice within the scope of practice established by the state. Although test items may reflect nursing knowledge secondary to an understanding of underlying environmental factors, the NCLEX does not directly measure the environmental health science content of the nursing curriculum. Because nursing schools use NCLEX pass rate data as an educational outcome indicator, the impact of NCLEX items and content on curricular decisions for nursing education cannot be overstated.

Certification
Certification, as opposed to licensure, is a voluntary process in which an RN seeks an additional credential in a specific practice area. Recognition as an advanced practice nurse may require both certification and licensure in the future.

The American Nurses Credentialing Center (ANCC), the American Board for Occupational Health Nurses, Inc. (ABOHN), and the National Board for Certification of School Nurses, Inc. (NBCSN) were polled and asked to describe the nature of environmental health nursing certification. Three questions were asked: (1) Is a certification examination in environmental health sponsored by the organization? (2) Identify by test content outlines and keywords those certification examinations with environmental health concepts among the test items. (3) What data does the organization have on the need for or interest in a certification examination in environmental health?

Bowers (1994), in responding to the ANCC, stated that environmental health nursing does not have a specific certification examination. Among the 24 certification areas where examinations exist, a test content review found that one or more concepts of environmental health nursing could be inferred in 21 of the examinations. These were typified by “lead poisoning, safety, poisoning and air pollution.”

Further analysis revealed that 19 of 24 certification areas included the word environment in the outline. Test content outlines two examinations, including environmental science: community health nurse and clinical specialist in community health nursing practice. The pediatric nurse practitioner examination content outline dedicated a section to environmental issues, and the general nursing practice test content outline noted the influence of “environmental and occupational factors” in consideration of health promotion, disease prevention, and control.

A keyword search of environmental health and its derivatives (e.g., air pollution, sanitation, and safety) located the presence of at least one keyword in 15 of 24 banks of items for specific examinations. Bowers reports that ANCC still needs to gather data to substantiate or refute the need for a certification program in environmental health nursing and has no current plan to offer such an examination (Bowers, 1994).

The ABOHN certification exam has integrated environmental health concepts into the certifying examination. Six content domains make up the examination blueprint, one of which is labeled “health and environment relationships.” This area focuses on environmental exposure in the workplace and the nursing process’s application to workers’ health status. ABOHN still needs to compile data to substantiate the need for developing a certification examination in environmental health separate from an examination in occupational health.

The NBCSN includes questions about the environment and human health on its certifying exam. These questions are found under the topic areas of health promotion/disease prevention, health problems, nursing management, and emergency care.

Currently, certification in environmental health nursing does not exist for the generalist or those in advanced practice. However, several certifying organizations report that environmental health concepts are somewhat present. Based on this certifying organization survey, current credentialing systems do not include the specificity and breadth of environmental health content necessary to ensure its inclusion in basic generalist practice.

Changes in Health Care Delivery
Healthcare delivery is undergoing rapid change, with a pervasive trend toward institutional consolidation and emphasis on cost-cutting.

The ANA (1994) has expressed concern about several events that are occurring with ever-increasing frequency:

Adoption of new models of care delivery without sufficient testing, including changes in workforce patterns that may cause a decline in patient safety and quality of care; downsizing, layoffs, and other cost containment measures, with substitution of less highly skilled personnel for RNs; and lack of education and redeployment strategies to ensure a supply of appropriately prepared RNs for the demands of the future.
Along with these trends, health services research has documented a statistically significant relationship between the level and mix of nursing staff in hospitals and patient outcomes (Prescott, 1993). Specifically, as the number of nurses and the percentage of RNs on staff increases, risk-adjusted hospital mortality rates decline, as does the length of inpatient stay.

The ANA is concerned about the possibility of declining patient safety and adverse health outcomes, as well as the increasing stress (physical and psychological) on nurses that is likely to increase work-related injuries as a consequence of downsizing and lowered skill requirements of the patient care workforce. As noted by Redman (1994), current changes in workforce patterns at healthcare facilities are resulting in the fragmentation of nursing care, with fewer opportunities for one-to-one contact of nurses with patients. The replacement of RNs with unlicensed assistant personnel (UAPs) further distances RNs from direct contact with patients. According to the ANA, almost half of the state nursing associations deem the new mix or proportions of RNs and UAPs unsafe. To paraphrase Redman, it may be possible to get knowledge of environmental concepts from the nurse. However, because of declining direct patient contact by RNs, it cannot be assumed that such environmental health concepts will be integrated into nursing practice (Redman, 1994).

Under such circumstances, the call for adding environmental health content to nursing practice may ring very hollow to some. However, the committee is not recommending something new but rather a return to earlier, broader views of the nursing profession, including environmental concerns. Enhancing environmental health content in nursing practice will involve elaborating existing skills and perspectives, such as including environmental factors in history taking and seeking methods of primary prevention to eliminate illness and injury.

Funding for Public Health
Recent efforts toward health care reform on both federal and state levels focus on improving access to care for the sick through adequate insurance coverage. Tied closely to these efforts is the concern for controlling healthcare costs. Nursing leadership has firmly supported such reforms. Not incidental to proposals by nursing leaders is the call for increasing the supply and inclusion of advanced practice nurses (e.g., nurse practitioners, clinical specialists, and certified nurse midwives) in community-based primary care systems. Compelling data have been compiled that demonstrate the potential to increase the accessibility of care and decrease costs without losing the quality of care (Boex et al., 1993).

Struggling for attention in the current healthcare reform debates, which focus largely on care for the sick, is the message from those in public health settings that it requires more than seeing a doctor for people to stay healthy. The public health community (e.g., state and federal governmental agencies; professional associations; and the Office of the Assistant Secretary for Health, U.S. Department of Health and Human Services [DHHS]) has been a persistent voice for a broader perspective of healthcare that encompasses preventive strategies as well as traditional care and cure models.

Public Health in America (PHS, 1994) describes the core functions of public health as follows:

Prevents epidemics and the spread of disease, protects against environmental hazards, prevents injuries, promotes and encourages healthy behaviors, responds to disasters and assists communities in recovery, and assures the quality and accessibility of health services.
To fulfill these core functions, public health advocates, including environmental health professionals, appeal for funding distinct from sick care services reimbursement. Strategies include a set aside in the health care budget or a separate, reliable appropriation to carry out governmental responsibility to protect the health of populations.

Nurses, dispersed throughout the health care system, have the potential to demonstrate that competent health care can be accessible, affordable, and acceptable to the public. The heritage of nursing services is designed to strengthen the populations they serve, the principles of social justice, and nursing’s broad definition of health care assets for nurses willing to take up new and expanded practice roles that include environmental health. Nurses’ ability to see the interconnectedness of environmental influences with opportunities for preventing health problems and controlling overall system costs can be invaluable.
QUESTION

You are testing that the mean speed of your cable Internet connection is more than three Megabits per
second. State the null and alternative hypotheses. What is the Ho and H1
Q2
A sociologist claims the probability that a person picked at random in Times Square in New York City is
visiting the area is 0.83. You want to test to see if the claim is correct. State the null and alternative
hypotheses. What is the Ho and H1
Q3
A hospital is trying to cut down on emergency room wait times. It is interested in the amount of time
patients must wait before being called back to be examined. An investigation committee randomly
surveyed 70 patients. The sample mean was 1.5 hours with a sample standard deviation of 0.5 hours.
Identify the following:
a. x = ____
b. sx = ____
c. n = ____
d. n – 1 = ____
Q4
A hospital is trying to cut down on emergency room wait times. It is interested in the amount of time
patients must wait before being called back to be examined. An investigation committee randomly
surveyed 70 patients. The sample mean was 1.5 hours with a sample standard deviation of 0.5 hours.
Construct a 95% confidence interval for the population mean time spent waiting.
Ans: CI: (1.3808 and 1.6192) Show your workings
Q5
One hundred eight Americans were surveyed to determine the number of hours they spend watching
television each month. It was revealed that they watched an average of 151 hours each month with a
standard deviation of 32 hours. Assume that the underlying population distribution is normal.
Find the 99% confidence interval for the population mean hours spent watching television per month.
Ans; CI: (142.92 and 159.08) Show your workings
Q6
The systolic blood pressure (given in millimeters) of males has an approximately normal distribution with
mean μ = 125 and standard deviation σ = 14. Systolic blood pressure for males follows a normal
distribution. Calculate the z-scores for the male systolic blood pressures 100 and 150 millimeters.
Ans: Z = -1.8 and 1.8
Q7
A baker is deciding how many batches of muffins to make to sell in his bakery. He wants to make enough to
sell everyone and no less. Through observation, the baker has established a probability distribution.
x P(x)
1 0.15
2 0.35
3 0.40
4 0.10
What is the probability the baker will sell more than one batch? P (x > 1)
Ans: 0.85 (Show your workings)
Q8
A candy bar manufacturer is interested in trying to estimate how sales are influenced by the price of their
product. To do this, the company randomly chooses 6 small cities and offers the candy bar at different prices.
Using candy bar sales as the dependent variable, the company will conduct a simple linear regression on the
data below:
City Price ($) Sales
River City 1.30 100
Hudson 1.60 90
Ellsworth 1.80 90
Prescott 2.00 40
Rock Elm 2.40 38
Stillwater 2.90 32
what is the coefficient of correlation for these data? Ans= -0.8854 (Show detailed workings)
Q9
Suppose that history shows that 60% of college students prefer Brand C cola. A sample of 5 students is to be
selected.
(a) Find the mean of this binomial distribution (Ans=3) (Show your solution)
(b) Find the variance of the binomial distribution (Ans=1.2) (Show your solution)
Q10
A manufacturer of power tools claims that the mean amount of time required to assemble their top-of-the-line
table saw is 80 minutes with a standard deviation of 40 minutes. Suppose a random sample of 64 purchasers of
this table saw is taken. The probability that the sample mean will be greater than 88 minutes is ________.
Answer: 0.0548 (Show your solution)