The NEHA Board of Directors (BOD), having reviewed the “Strengthening Partnerships between Environmental Public Health Professionals and Public Health Nurses” draft advanced by CDC, submits the following commentary and position on this matter. This does not represent a formal policy position on behalf of the board. It rather is a commentary on points raised in the paper cited above. It further represents a consensus of the board on the larger view within the environmental health community concerning the proposed enhanced cooperation between environmental health professionals and public health nurses.
NEHA members are acutely aware of the new challenges facing environmental/public health programs as we enter a new century. The expectations for these programs from policy-makers and the general public they serve have never been higher. The needs being imposed on these programs in a post September 11th world are fundamentally changing the very definition of what it means to be an environmental/public health professional. This paradigm shift is occurring at a time when other realities are producing tighter budgets, increased workloads and fewer qualified personnel that are entering or remaining in the profession. In short, there are fewer resources, less capacity and greater demands on the public/environmental health infrastructure in our country.
Given these challenges, and mindful of the responsibility within the profession to be
both proactive and positive in proposing solutions, the NEHA-BOD is supportive of the concept of enhanced cooperation between EH professionals and public health nurses. We, in fact, would note several areas where successful collaborations are already occurring. For example, in foodborne disease outbreak investigations, IAQ investigations such as asthma trigger investigations in schools, problems arising in occupational health and safety, and finally in community health promotion activities, there are currently successful collaborations occurring between PH nurses and EH professionals. A commitment between both sets of professionals is necessary. It would serve to identify other areas where combining the experience and expertise of the two groups would have beneficial results. It no doubt could produce enhanced cooperation and improved efficiency in public health services delivery.
Given both the high priority NEHA places on the subject and its current urgency, we would like to make special mention of the topic area of Terrorism Response and Emergency Preparedness. The NEHA BOD believes that in any number of ways, we should explore linkages that would provide a more coordinated and integrated local environmental public health response in the event of a terrorism or emergency incident. Most notably, this would be related to the need for effective disease surveillance and epidemiological investigation and response. A more coordinated team approach to response and remediation efforts between EH and PHN professionals would greatly enhance the local public health capacity to react to these situations.
Moreover, we would note and support what we believe to be a general consensus around one of the underlying assumptions of the CDC draft paper. That being the view that, for the good of the public health system, we need to “rethink” structure, relationship, service delivery and quality, and to explore where the two professions could support and complement one another. NEHA is uniquely well-qualified and positioned to represent environmental health professionals in discussions with public health nurses around these issues, and we would welcome the opportunity to do so.
At the outset of this process, however, the NEHA board would also note some areas of concern that would also have to be addressed as a fundamental part of the strengthening partnerships discussion. The specific policy areas where we need further clarification and resolution are as follows:
Compartmentalization/Turf: The board would note, with some concern, that all too often in local health departments traditional clinically-based public health programs are given priority over environmental health programs. This produces a dynamic that impairs what should otherwise be a more cooperative approach between the two groups. The extent to which the position paper fails to address this concern needs to be explored in developing a mutually acceptable policy. More specifically, our view is that the position paper pre-supposes a need for a more active role in EH by PH nurses, while there was no commensurate role for EH in any clinically-based programs within local health departments. It was an additional concern that perhaps the position paper envisioned a separate “niche” for PH nurses in EH. While we believe that in developing and fostering a climate of improved cooperation between the two groups additional areas of commonality would become apparent, we would also stress the need to retain the individual character of each program’s contribution to the public health system.
Differences in education, training and focus: The board feels compelled to note differences between the two groups in this area. While integrating (to some degree) the two workforces is a worthy goal, nevertheless, attempting this integration that by definition involves two workforces with different education, training, focus and responsibilities in the public health system will present challenges. PH Nurses often play a key role in both management and delivery of services in a clinical setting. It is very much an orientation toward personal health care. Even the preventative aspects of traditional PH nursing programs are personal health care based. By its very nature, environmental health is the reverse of the PH nurses’ orientation and focus. EH is more macro in its philosophy and approach. These differences are apparent and well noted. Given that, the board believes that any successful attempt at enhancing the partnership between the two groups must include resolving their respective roles and responsibilities within this framework presented by a new partnership model. A frank discussion of these differences and their effect on a model of enhanced cooperation between the two groups is a predicate to effective cooperation.
At the core of our concern is a generally held belief that clearly there would be no “spill over” from EH to the more traditional public health programs. There was, however, a potential for spill over from PH programs into EH. The concern was that PH nurses, while maintaining their control over these programs, would then move into an area that would involve them in traditional areas of EH. This is far more than just a turf issue. It goes to a basic concern about the quality of environmental health services. PH nurses simply do not have the education or training to adequately address EH problems or to actively manage EH programs. NEHA board members felt that EH embodied a specialized set of knowledge and skills that needed to be respected and protected. It is unclear the degree to which what was presented as an improved partnership would become a diminution of EH or would evolve into a system that would marginalize the EH professionals that are best prepared to address environmental health concerns. It should also be noted that every example of collaboration noted earlier involved a team approach model that still maintained the separation of the individual disciplines. Simply put, the board is willing to explore enhanced cooperation based upon a team approach, but one that respects the differences in education, training and focus between the two groups.
Differences in status, funding, salary and visibility: The board also wished to note the disparity between PH Nurses and EH professionals with regard to salary, visibility, political support and management responsibilities. There is a thirty-year history over which a trend has evolved in which PH nurses in local health departments have gained an upper hand in these areas. The board’s concern is that a side effect of this partnership model (admittedly an unintended one) would be to reinforce this disparity. Put bluntly, having PH nurses involved with EH programs and doing EH work could undermine the visibility and support that EH programs are attempting to build within local communities and within the management of local health departments.
Defining the dimensions of the problem: In developing a consensus position for this policy statement there was the widely held view that we need to better quantify the dimensions of the problem. More directly, there are assumptions and premises upon which the paper is founded, without quantifying the scope of the problem. Is there a need (for any of the reasons stated in the paper) for PH nurses to become involved in EH? Additionally, given some of the workforce supply challenges that everyone acknowledges are there, does the solution rest with increased collaboration between EH professionals and PH nurses? The NEHA board believes that these questions need to be explored more fully before committing to a proposed remedy.