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POPULATIONS AT RISK ACROSS THE LIFE SPAN:POPULATION STUDIES Student Nurses’ Risk Perceptions of Home Environmental Hazards Barbara J. Polivka, Ph.D., R.N. 1 and Celia Wills, Ph.D., R.N. 2 1 University of Louisville School of Nursing, Louisville, KY; and 2 The Ohio State University College of Nursing, Columbus, OH Correspondence to: Dr. Barbara Polivka, University of Louisville School of Nursing, 555 S. Floyd St., Louisville, KY 40202. E-mail: [email protected] ABSTRACT Objective: This study described nursing students perceptions of home health risks. Design and Sample: Nursing students (N = 254) at two large urban universities completed a cross-sectional survey during the 20112013 academic years. Measures: From a list of 22 com- mon home health hazards, students identified what they perceived as the three: (a) most dangerous hazards, (b) most common hazards in their state, (c) hazards most likely to be present in their cur- rent home, and (d) hazards they would most afraid to find in their home. Students also rated per- ceived dangerousness of the hazards, how healthy they perceived their home to be, and the perceived effect of their home on their own health. Results: Tobacco smoke, asbestos, and cleaning products were the most commonly identified home hazards. Individual characteristics, hazard experi- ences in personal homes, and university geographic location (state) were associated with perceptions of home hazards. Students who identified hazards in their own homes were more likely to identify them as hazards in general and for their own state. Conclusions: These results fill a foundational knowledge gap by describing the risk perceptions of near-future health care providers about home environmental hazards. Key words: environmental health, home health hazards, nursing students, risk perception. Background The perception of risk is inherently subjective and often shaped by one’s personal experiences. With regard to environmental hazards, risk perceptions are central to the accuracy of risk assessments. The perceived probability that an environmental expo- sure will have an adverse effect, concern over the severity of the effect, and the context of the expo- sure all impact risk assessment judgments. Assess- ment of risk is also influenced by factors such as familiarity with the source of the risk, ability to control the risk, awareness of danger, and reliability and clarity of information sources (Miller & Solo- mon, 2003; Renn, 2004; Slovic, 1987). Nurses’ knowledge and personal perceptions regarding environmental hazards influence their ability to educate, interpret information, advocate, and advice (Mujuru & Niezen, 2004). A large body of research over multiple decades supports the central role that clinician (and more generally, human) risk perceptions play in a wide range of interpreting and acting upon probabilistic risk information in health-related judgment and deci- sion making (for illustrative reviews, see Brewer et al., 2007; Sox, Blatt, Higgins, & Marton, 1988; Trevena et al., 2012). Home environmental risks, which are often significantly detrimental to the health of inhabitants, can include lead, dust mites, mold/moisture, carbon monoxide, radon, pesti- cides, tobacco smoke, uncovered electrical outlets, overheating in the winter, and volatile organic com- pounds (VOCs). VOCs are chemicals in products such as air fresheners, cosmetics, and cleaning products that volatize and become gaseous at room temperature (Davis, 2007; Hynes et al., 2003). Over half of childhood deaths from unintentional injuries occurred in the home and were caused by fires, submersion/suffocation, poisonings, and falls 298 Public Health Nursing Vol. 31 No. 4, pp. 298–308 0737-1209/© 2014 Wiley Periodicals, Inc. doi: 10.1111/phn.12098

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Page 1: Student Nurses' Risk Perceptions of Home Environmental Hazards

POPULATIONS AT RISK ACROSS THE LIFE SPAN: POPULATION STUDIES

Student Nurses’ Risk Perceptions ofHome Environmental HazardsBarbara J. Polivka, Ph.D., R.N.1 and Celia Wills, Ph.D., R.N.21University of Louisville School of Nursing, Louisville, KY; and 2The Ohio State University College of Nursing, Columbus, OH

Correspondence to:

Dr. Barbara Polivka, University of Louisville School of Nursing, 555 S. Floyd St., Louisville, KY 40202. E-mail: [email protected]

ABSTRACT Objective: This study described nursing students perceptions of home healthrisks. Design and Sample: Nursing students (N = 254) at two large urban universities completeda cross-sectional survey during the 2011–2013 academic years. Measures: From a list of 22 com-mon home health hazards, students identified what they perceived as the three: (a) most dangeroushazards, (b) most common hazards in their state, (c) hazards most likely to be present in their cur-rent home, and (d) hazards they would most afraid to find in their home. Students also rated per-ceived dangerousness of the hazards, how healthy they perceived their home to be, and theperceived effect of their home on their own health. Results: Tobacco smoke, asbestos, and cleaningproducts were the most commonly identified home hazards. Individual characteristics, hazard experi-ences in personal homes, and university geographic location (state) were associated with perceptionsof home hazards. Students who identified hazards in their own homes were more likely to identifythem as hazards in general and for their own state. Conclusions: These results fill a foundationalknowledge gap by describing the risk perceptions of near-future health care providers about homeenvironmental hazards.

Key words: environmental health, home health hazards, nursing students, risk perception.

BackgroundThe perception of risk is inherently subjective andoften shaped by one’s personal experiences. Withregard to environmental hazards, risk perceptionsare central to the accuracy of risk assessments. Theperceived probability that an environmental expo-sure will have an adverse effect, concern over theseverity of the effect, and the context of the expo-sure all impact risk assessment judgments. Assess-ment of risk is also influenced by factors such asfamiliarity with the source of the risk, ability tocontrol the risk, awareness of danger, and reliabilityand clarity of information sources (Miller & Solo-mon, 2003; Renn, 2004; Slovic, 1987).

Nurses’ knowledge and personal perceptionsregarding environmental hazards influence theirability to educate, interpret information, advocate,and advice (Mujuru & Niezen, 2004). A large bodyof research over multiple decades supports the

central role that clinician (and more generally,human) risk perceptions play in a wide range ofinterpreting and acting upon probabilistic riskinformation in health-related judgment and deci-sion making (for illustrative reviews, see Breweret al., 2007; Sox, Blatt, Higgins, & Marton, 1988;Trevena et al., 2012). Home environmental risks,which are often significantly detrimental to thehealth of inhabitants, can include lead, dust mites,mold/moisture, carbon monoxide, radon, pesti-cides, tobacco smoke, uncovered electrical outlets,overheating in the winter, and volatile organic com-pounds (VOCs). VOCs are chemicals in productssuch as air fresheners, cosmetics, and cleaningproducts that volatize and become gaseous at roomtemperature (Davis, 2007; Hynes et al., 2003).Over half of childhood deaths from unintentionalinjuries occurred in the home and were caused byfires, submersion/suffocation, poisonings, and falls

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0737-1209/© 2014 Wiley Periodicals, Inc.doi: 10.1111/phn.12098

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(Nagaraja et al., 2005). Exposures to house dustmites, cockroach allergens, molds, fragrances, form-aldehyde, and environmental tobacco smoke areassociated with asthma in children (Institute ofMedicine, 2000). Krieger and Higgins (2002) intheir seminal paper “Housing and Health: Timeagain for Public Health Action” noted substandardhousing is associated with infectious and chronicdiseases from exposures to hazards such as unsafedrinking water, pests, crowding, cold, mold/mois-ture, environmental tobacco smoke, lead basedpaint, and radon. A healthy homes approach wasencouraged for improving home environmentalquality. A healthy home is one that is dry, clean,pest-free, well ventilated, safe, contaminant-free,and well-maintained (National Center for HealthyHousing, 2011, 2013). Assessment of a homes’indoor air quality, asthma and allergen triggers,carbon monoxide, lead, water quality, chemicals,pesticides, and other poisons is advocated by theHealthy Homes Partnership (2012). The U.S. Envi-ronmental Protection Agency (2005) recommendsassessment of children’s exposures to environmen-tal hazards based on life-stage groupings (i.e., Birthto <1 month, 1 to <3 months, etc.) in which physio-logical and behavioral differences by age, as well asroute of exposure are considered. For example,hand to mouth activity in which lead can beingested is most prevalent during ages 1–3 years.

Incorporating healthy homes education in pre-licensure community health nursing contentimproves nursing students’ knowledge of homeenvironmental hazards (Polivka, Chaudry, & Craw-ford, 2012). Student nurses are near-future nurses,so understanding how students perceive environ-mental hazards is important as a basis forimproved educational interventions. However, dataon nursing students’ perceptions of risk regardinghome environmental health hazards is lacking.Therefore, the purpose of this study was to describepre-licensure nursing students’ perceptions of homeenvironmental hazards.

Nurses have repeatedly confirmed that environ-mental health is an essential component of nursingpractice (American Nurses Association, 2007, 2010;American Public Health Association Public HealthNursing Section, 2005; Institute for Medicine,1995), yet research has demonstrated the lack ofenvironmental health knowledge by nurses (VanDongen, 2002). Nurses report that pesticide expo-

sure content is generally not in their nursing educa-tion and they do not ask patients about pesticideexposures (Balbus, Harvey, & McCurdy, 2006;Karr, Murphy, Glew, Keifer, & Fenske, 2006). Pub-lic health nurses identified the lack of environmen-tal health training as a barrier to the delivery ofhome environmental health interventions while rec-ognition of the importance of environmental riskreduction was a facilitator (Tinker, Postma, & But-terfield, 2011). These studies document the signifi-cant lack of knowledge nurses have aboutenvironmental health hazards, including homehealth hazards. However, no research has exploredthe risk perceptions of nursing students with regardto health hazards in the home.

This study was guided by Griffin’s Model ofRisk Information Seeking and Processing (Figure 1)(Griffin, Dunwoody, & Neuwith, 1999). The modelposits seven types of factors as influences on thetime and effort on deliberative information process-ing, a cognitive appraisal process used to assess therisks of home health hazards. The seven factorsinclude individual characteristics, perceived hazardcharacteristics, affective responses to risk, felt socialpressure to possess relevant information, informa-tion sufficiency, personal capacity for learning, andbeliefs about information usefulness.

This study focused on the left side of the modelin which individual characteristics such as demo-graphics and relevant hazard experiences arehypothesized to directly impact perceived hazardcharacteristics. Perceived hazard characteristics, inturn, influence affective responses such as worry,anger or uncertainty, which in turn can impact thequality of deliberative information processing anddecision making. For example, based on relevanthazard experience, a nurse may accurately perceivea hazard such as toxic mold in the bathroom to becommon and potentially severe, which in turn mayinfluence the nurse to do a more careful homeassessment process due to concern (affectiveresponse) about the potential risk. Conversely, anurse who lacks information or experience abouthome health hazards due to lack of environmentalhealth training may either under- or overestimateactual risks, leading to suboptimal management ofhome health hazards. Beyond ability to provideappropriate teaching of patients and families, theGriffin et al. (1999) model also highlights theimportance of health care providers recognizing

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how their own perceptions of reality can signifi-cantly influence the provision of appropriate,culturally relevant care and patient/family centeredcare. The importance of culture in how peopledevelop their subjective risk perceptions and theimpact of behavior has been highlighted as a prior-ity for future research (Taylor-Gooby & Zinn,2006). Further description of individual character-istics and understanding their association with per-ceived hazard characteristics is important as adescriptive foundation leading to subsequent stud-ies to test the impact of training interventions toimprove the accuracy of risk perceptions.

Research questionsThree main research questions were addressed inthis study:

1. What are the risk perceptions of nursing studentsconcerning home environmental hazards in anyhome and in their state?

2. What are the risk perceptions of nursing stu-dents concerning: (a) environmental hazards intheir home, (b) the overall health of their home,and (c) the impact of their home on theirhealth?

3. Do risk perceptions differ based on the univer-sity the student attended, history of allergies orasthma, or self-reported home hazards?

Methods

Design and sampleThis cross-sectional descriptive survey includedbaccalaureate senior nursing students and pre-licensure graduate entry (second degree) studentsat two large urban universities in different states.All students had completed their curricular envi-ronmental health content. Data were collected dur-ing the 2011–2013 academic years. The study wasdetermined to be exempt from Institutional ReviewBoard review by the IRBs of both universities.

MeasuresThe 27-item instrument used in this study is anadaption of a tool used (with permission) byThompson (2011) in a pilot study assessing homehazard perceptions of residents of Georgia. The toolwas based on the U.S. Department of Housing andUrban Development (HUD) categorization of homehazards and is consistent with the Healthy HomeRating System (Thompson, 2011; U.S. Departmentof Housing and Urban Development, Office ofHealthy Homes and Lead Hazard Control, 2012). Todetermine perceived hazard characteristics per Grif-fin’s Model of Risk Information Seeking and Pro-cessing, participants were asked to identify whatthey perceived as the three most dangerous homehealth hazards in any home from a list of 22 haz-ards (listed in Table 2). Using the same list of 22hazards, participants were then asked their percep-tions of the three hazards most common in the state

Figure 1. Model of Risk Information Seeking and Processing, by Griffin et al. (1999)

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in which their university was located (Ohio/Ken-tucky), which three hazards they perceived weremost likely to be found in their current home, andwhich three they would be most afraid to find intheir home. Participants were also asked howhealthy they perceived their home to be (veryhealthy, healthy, unhealthy, very unhealthy, notsure) and the effect they perceived their home tohave on their own health (increasing length of life,not making me sick, might be making me a littlesick, making me sick, no effect on my health). Datawere also collected on demographic and personalhome characteristics. Content validity for this studywas achieved when two experts in home health haz-ards reviewed and approved the tool as presented.

The original survey by Thompson (2011) askedparticipants to indicate one hazard most likely tobe found in their home and the one hazard youwould be most afraid to find in your home. Forconsistency across all items, we asked participantsto rank the top three hazards in these areas. Forgreater relevance to the college-age population, weadding candles/air fresheners to the list of 21 haz-ards and adjusted the demographic items. Forexample, we did not ask educational attainmentbecause participants were currently college stu-dents; we did ask about a history of asthma andallergies given the susceptibility to environmentaltriggers for those with these respiratory conditions(Institute of Medicine, 2000).

ProceduresData collection occurred either before or after ascheduled class time. One of the co-authors intro-duced the study to the class using a script and a writ-ten explanation of the study was provided to eachpotential participant. All senior nursing students andpre-licensure graduate entry students at each univer-sity were invited to participate in the study. Surveypackets were distributed after the script was read tothose interested in participating. The survey tookapproximately 10–15 min to complete. Participantscompleting the instrument packet were eligible for adrawing for a flash drive by including their contactinformation on a separate incentive sheet. Studentsplaced the completed survey form and incentivesheet in separate envelopes. There were 317 potentialsurvey respondents; 254 students responded for an80.1% response rate. Comparisons between respon-dents and non-respondents was not possible as

responses were anonymous. Missing data, whichrandomly ranged from 0 to 5 (≤2%) cases per vari-able, was addressed using listwise deletion.

Analytic strategyData were entered into an SPSS Version 21.0 (IBMCorp, Armonk, NY, USA) database and analyzedusing descriptive statistics to summarize the surveyresponses for the first two research questions. Chi-square tests were used to determine significant dif-ferences between respondent subgroups. Alpha wasset a priori at .05.

Results

Respondents were primarily between the ages of21–25 years (M = 24.5, SD = 5.8), female, white,single, employed part-time, enrolled in a traditionalbaccalaureate program, rented their home, and hadlived in their home for up to 2 years (Table 1).Almost half lived in a home built before 1978. Overhalf owned a pet, and of those, most owned a dog.Less than 5% smoked cigarettes. While only 13.5%of the respondents were asthmatic, over a third hadbeen diagnosed with allergies. About two-thirds ofthe respondents were from University A.

Risk perceptions of student nursesconcerning home environmental hazardsStudents were asked to identify their perceptions ofthe three most dangerous health hazards in anyhome. The five most common responses weretobacco smoke, asbestos, cleaning products, mold/moisture, radon gas, and unclean drinking water(Table 2). When asked to identify their perceptionsof the three most common home health hazards intheir state, tobacco smoke, cleaning products, andmold/moisture were also ranked in the top five mostcommon environmental home health risks. How-ever, asbestos, radon, and unclean drinking waterwere not. Instead respondents noted dust/pollen/dander in indoor air and insects as the third and fifthmost common home health hazards in their state.

Risk perceptions of student nursesconcerning environmental hazards in theirhomeRespondents were asked to indicate their percep-tions of the three environmental health hazardsthat would most likely be found in their current

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home. The top five environmental hazards in theirhome noted by participants were cleaning products,dust/pollen/dander in indoor air, candles/air fresh-eners, mold/moisture, and poor ventilation(Table 2). When asked which three hazards they

would be most afraid to find in their home, the pri-mary hazards identified were insects, radon,rodents, cleaning products, and mold/moisture.The majority of students (80%) characterized theinside of their home as “very healthy” or “healthy”while 15.6% indicated their home was “unhealthy/very unhealthy.” When asked what effect the insideof their home was having on their health over one-third (37%) noted it was making them ill.

Differences in risk perception based onstudents’ university, history of allergies orasthma, and self-reported home hazardsComparison of findings by the student’s universityrevealed a number of differences between studentsfrom the two universities. Students from UniversityA identified unclean drinking water in any homesignificantly more often, while those from Univer-sity B noted candles/air fresheners as a hazard(Table 3). With regard to hazards in their state,University A students noted insects and radon werecommon health hazards significantly more oftenwhile University B students noted lead and tobaccosmoke significantly more often. When asked abouthazards in their own home, University A studentsidentified mold/moisture and poor ventilation asconcerns significantly more often. University B stu-dents identified fire hazards, leaks from heatingunits, and clutter significantly more often. Univer-sity A students were afraid to find insects andradon gas in their home significantly more often;finding mold/moisture was a significant fear forUniversity B students.

Students without a history of asthma/allergiesidentified asbestos significantly more often as ahealth hazard in any home (Table 3). Radiationfrom devices in their own home was a concern forthose with an asthma/allergy diagnosis as was find-ing radon in their home. Respondents who identi-fied candles/air fresheners, cleaning products,dust/pollen/dander, and mold/moisture as hazardsin their own home also identified these hazards sig-nificantly more often in any home and/or in homesin their state (Ohio or Kentucky).

Discussion

Study findings show that pre-licensure nursing stu-dents had some generally accurate awareness of keyenvironmental hazards in their own homes and

TABLE 1. Demographic Characteristics of Participants(N = 254)

Characteristic N (%)

Age21–25 years 201 (79.4)26–56 years 52 (20.6)

GenderMale 25 (9.8)Female 227 (90.1)

RaceWhite 217 (86.1)African American 18 (7.1)Asian 12 (4.7)Other 5 (2.0)

Hispanic – Yes 7 (2.8)Relationship statusSingle 161 (64.1)Married 46 (18.3)Part of a couple 39 (15.5)Divorced 5 (2.0)

EmployedYes – Part time 187 (74.6)Yes – Full time 14 (5.6)No 50 (19.8)

Type of nursing programBSN 214 (84.6)Grad entry 39 (15.4)

Pets in Home – Yes 139 (54.9)Type of petDog 86 (62.3)Cat 28 (20.3)Other 12 (8.7)Multiple pets 12 (4.7)

Living arrangementsRent 148 (58.7)Own 53 (21.0)Live with relative 43 (16.9)Live in dorm 8 (3.1)

Home built before 1978 – Yes 113 (47.3)Length of time in home<1 year 98 (38.9)1–2 years 57 (22.6)2–3 years 20 (7.9)3+ years 77 (30.3)

Do you smoke – Yes 12 (4.8)Have you been diagnosed with asthma – Yes 34 (13.5)Have you been diagnosed with allergies – Yes 95 (37.8)SiteUniversity A 163 (64.2)University B 91 (35.8)

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communities. For example, students were able toaccurately identify highly dangerous hazards such astobacco smoke, asbestos, radon, mold/moisture, andcleaning products. Tobacco smoke, mold/dampness,and cleaning products were documented by homehealth nurses as hazardous conditions encounteredin patient’s homes and as asthma triggers by schoolnurses (Gershon et al., 2008; Shendell, Alexander,& Huang, 2010). Interestingly, both the students inour study and the low-income adults in Georgiafrom the original study identified the same chiefhazards as dangerous in any home. Mold andtobacco smoke were identified as a major hazard inthe state by both the Georgian respondents and thenursing students. However, while nursing studentsindicated insects and dust/pollen/dander wereother key hazards in their state, Georgian partici-pants identified lead and fire hazards. Asbestos wasdenoted as a key hazard in any home both by ourparticipants and by the Georgian participants.Although the health effects of asbestos exposure are

well-known (lung cancer, mesothelioma, asbesto-sis), asbestos exposure is not generally considered aprimary home health hazard unless an older homeis under renovation (U.S. Environmental ProtectionAgency, 2013). Participants may have perceivedasbestos as an environmental home hazard due tomedia coverage related to asbestos in schools andother buildings and the overview of the etiology ofasbestos related illnesses in nursing education.

Support for the model of risk informationseeking and processingKey premises of the Griffin et al. (1999) Model ofRisk Information Seeking and Processing were sup-ported by the results of this study. For example, asposited by the model, some individual characteris-tics, experiences with hazards in students’ ownhomes, and university geographic location (state)were associated with perceptions of home hazards.Students who identified hazards in their homeswere more likely to identify them as hazards in

TABLE 2. Nursing Student’s Perceptions of Home Environmental Health Hazards Risks (N = 254)

Health hazard

Health hazards mostdangerous inany home

Health hazards mostcommon in

homes in their state

Health hazards mostlikely found in

own home

Health hazards mostafraid to find in

own homeN (%) N (%) N (%) N (%)

Tobacco smoke 72 (28.9) (#1) 116 (46.4) (#1) 9 (3.6) 10 (4.0)Asbestos 71 (28.5) (#2) 14 (5.6) 1 (0.4) 101 (40.6) (#4)Cleaning products 66 (26.0) (#3) 66 (26.4) (#4) 124 (49.6) (#1) 1 (0.4)Mold/moisture 64 (25.8) (#4) 112 (44.8) (#2) 96 (38.4) (#4) 72 (28.8) (#5)Radon gas 60 (24.1) (#5) 31 (12.4) 8 (3.2) 109 (43.6) (#2)Unclean drinking water 60 (24.1) (#5) 11 (4.4) 3 (1.2) 63 (25.2)Fire hazards 59 (23.7) 31 (12.4) 21 (8.4) 14 (5.6)Lead on surfaces 50 (20.1) 36 (14.4) 14 (5.6) 46 (18.4)Leaks, fires from heating unit 36 (14.5) 18 (7.2) 16(6.4) 43 (17.2)Poor ventilation 33 (13.3) 24 (9.6) 45 (18.0) (#5) 13 (5.2)Chemicals in medicines 25 (10.0) 22 (8.8) 22 (8.8) 2 (0.8)Poor housing construction 27 (10.8) 23 (9.2) 19 (7.6) 17 (6.8)Insects 23 (9.2) 45 (18.0) (#5) 18 (7.2) 112 (44.8) (#1)Candles/air fresheners 18 (7.1) 36 (14.4) 116 (46.4) (#3) 2 (0.8)Dust, pollen, dander 17 (6.8) 76 (30.4) (#3) 123 (49.2) (#2) 9 (3.6)Pest or weed control products 13 (5.2) 10 (4.0) 11 (4.4) 6 (2.4)Objects/clutter in livingspaces

10 (4.0) 31 (12.4) 35 (14.0) 1 (0.4)

Extreme cold 10 (4.0) 17 (6.8) 5 (2.0) 3 (1.2)Rodents 8 (3.2) 13 (5.2) 12 (4.8) 106 (42.4) (#3)Extreme heat 7 (2.8) 6 (2.4) 5 (2.0) 0Leaks, fires from airconditioning unit

6 (2.4) 2 (0.8) 3 (1.2) 8 (3.2)

Radiation from devices 3 (1.2) 9 (3.6) 27 (10.8) 6 (2.4)

The bold values highlight top five hazards in each category.

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general and for their state. Ohio students weremore likely to correctly identify radon, and Ken-tucky students were more likely to correctly identifysmoking as most common state-level environmentalconcerns. Students with allergies/asthma weremore likely to identify radiation and radon as risks,perhaps due to heightened awareness of the pulmo-nary impact of hazards.

Inaccuracy of subjective risk perceptionsHowever, students were not fully accurate in identi-fying some major hazards for their own state, suchas radon and unclean drinking water, which rankedbelow several other hazards. Also of concern is thelack of recognition of widely used hazardous sub-stances such as pesticides and herbicides. The EPAestimates that 84% of US households use pesticides(National Strategies for Health Care Providers,2003), yet only 5% of our respondents identifiedpest or weed control products as hazards. Almost

half of the respondents denoted they resided in ahome built before 1978, yet only 6% indicated leadwas a primary hazard in their home. Perhaps thisrelates to lead poisoning perceived as a hazard pri-marily for young children or a lack of awareness ofthe long-term impacts of lead exposure across thelife span (Krieger & Higgins, 2002). Additionally,lead was identified as a hazard by significantlymore of the students from University B althoughthe rate of positive blood lead tests in children isgreater in state A (CDC, 2013). It is possible thatstudents at University B had greater exposure tostate level lead screening rates in their nursing edu-cation.

Although a large majority (80%) of studentsrated their own homes as being “healthy,” a sub-stantial proportion of students (37%) also ratedtheir own homes as causing illness. This discrepantfinding could occur if students engaged in afavorable comparison of the environmental health

TABLE 3. Significant Differences of Nursing Student’s Perceptions of Home Environmental Health Hazards Risks byParticipant Subgroups (p ≤ .05)

Hazard most dangerous in

UniversityHistory of Allergies/

Asthma Hazard in own home

A B Yes No Yes NoN (%) N (%) N (%) N (%) N (%) N (%)

Any homeCandles/air fresheners 5 (3.1) 12 (14.9) 28 (24.1) 8 (6.0)Unclean drinking water 47 (29.0) 12 (14.9)Asbestos 34 (23.1) 37 (36.3)Cleaning products 40 (32.5) 26 (20.6)Dust/pollen/dander 14 (11.4) 3 (2.4)

Homes in my stateInsects 18 (23.5) 7 (8.0)Lead on surfaces 18 (11.1) 18 (20.5)Radon 25 (15.4) 6 (6.8)Tobacco smoke 63 (38.9) 53 (60.2)Cleaning products 41 (33.1) 25 (19.8)Dust/pollen/dander 47 (38.2) 29 (22.8)Mold/moisture 52 (54.2) 60 (39.0)

Own housingFire hazards 9 (5.6) 12 (13.6)Leaks/fires from heating units 5 (3.1) 11 (12.5)Mold/moisture 71 (43.8) 25 (28.4)Objects/clutter in living spaces 17 (10.5) 18 (20.5)Poor ventilation 41 (25.3) 4 (4.5)Radiation from devices 23 (15.5) 3 (3.9)

As most afraid to findInsects 82 (50.6) 30 (34.1)Mold/moisture 38 (23.5) 34 (38.6)Radon gas 79 (48.8) 30 (34.1) 72 (48.6) 37 (36.3)

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conditions of their own homes with the homes ofothers, yet still perceived their own homes as hav-ing some unfavorable health conditions. These find-ings highlight the importance of the relative frameof reference for reporting perceptions of hazards, aswell as a need for a finer-grained understanding ofwhat constitutes a “top” hazard. As described byGriffin et al. (1999), hazard characteristics aremulti-faceted, and can be perceived in terms ofpotential severity, frequency, duration, shorter ver-sus longer term impact dimensions. Risk percep-tions are also known to be sensitive to framing andother effects of how risk information is presented.Thus, checklist ratings of top hazards are likely togenerate varying estimates depending upon the spe-cific dimensions of risks that are considered inmaking judgments of risk.

Our findings underscore the importance of envi-ronmental health education for near-future andcurrent health care providers. Risk perceptions aresensitive to change in response to educational inter-ventions. For example, Mujuru and Niezen (2004)found significant increases in participants’ knowl-edge of environmental hazards, principles of riskcommunication, taking an environmental history,and local and national resources after a 1-day envi-ronmental workshop for nurses. Olson, Stedman-Smith, and Fredrickson (2005) found online educa-tion to be an effective delivery option for environ-mental health education for nurses. Health careworkers, including nurses, enrolled in a 1-day train-the-trainer program to reduce environmental expo-sures in migrant workers self-reported increasedknowledge of environmental health and its’ impacton children’s behavior and health as well as confi-dence in talking about environmental health withclients (Welker-Hood, Palmigiano, Cervantes-Con-nell, Stoimenoff, & Kubotera, 2010). Ohio nurseswere funded by the Alliance of Nurses for HealthyEnvironments (ANHE) to collaborate with the OhioPublic Health Association to form “Nurses Environ-mental Advocacy Team of Ohio” or NEATO. Several1-day workshops and webinars for nurses have beensuccessfully delivered. ANHE (EnviRN, 2013) is anetwork of nurses interested in environmentalhealth with a goal of integrating environmentalhealth education into nursing education and prac-tice. Resources to support that goal are located onthe ANHE website. Two mnemonics have beendeveloped by nurse researchers to assist practitio-

ners in conducting an environmental exposurehistory. “I PREPARE” (Investigate potential expo-sures; Present Work; Residence; EnvironmentalConcerns, Past Work, Activities, Referrals andResources, Educate) incorporates items related toage of residence, home heating, remodeling, chemi-cal use, and drinking water source (Paranzino, But-terfield, Nastoff, & Ranger, 2005). “I TALK”(Investigate and Invite Discussion, Teach, AssessActions, Lead interdisciplinary groups, Know aboutenvironmental risks near your workplace/home)was developed after Ercolano, Hendrickson, Dixon,and Dixon (2008) found that 49% of their partici-pants indicated they never talk to their doctor ornurse about reducing the effects of pollution onhealth. “I TALK” was designed to complement “IPREPARE” by inviting patients to inquire abouttheir health risks from environmental exposures.

While not abundant, exemplars of environmen-tal health education initiatives for nursing studentshave been published (Gerber & McGuire, 1999; He-witt, Candek, & Engel, 2006; McCurdy et al., 2004;Polivka et al., 2012; Sweeney & de Peyster, 2005a,b; Woeber, 2013). The American Association of Col-leges of Nursing recently endorsed recommenda-tions that environmental sustainability be includedin baccalaureate and graduate education (Butter-field, 2011). Environmental sustainability refers to“practices that are viable indefinitely and not dis-proportionately harmful to the environment” (p. 5).These recommendations along with the inclusion ofenvironmental health as a component of the 2010ANA Scope and Standards for Nursing (AmericanNurses Association, 2010) legitimize the importanceof environmental health as a competency fornurses.

The ability to generalize the study results is lim-ited by the use of a moderate size sample of 254senior and graduate entry nursing students enrolledin large nursing schools located in urban settings intwo states. In this study, nursing students wereconceptualized as near-future health care providers.The results might differ if other types of health careprofessionals in other settings were surveyed.Future studies should include a diverse group ofhealth professionals as well as additional socio/demographic information (e.g., infant/child inhome; political philosophy). While the list of homehazards was extensive, other hazards such as car-bon monoxide might also have been included in the

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list and not subsumed under the “poor ventilation”hazard. Our study relied on participants self-reportof perceived home environmental risks and did notcompare students’ perceived environmental risksand their assessment of hazards in a simulated oractual home.

The results of this study provide an essentialfoundation of descriptive knowledge about environ-mental risk perceptions in a sample of near-futurehealth care providers. Few studies have examinedthe actual process of how home health care profes-sionals assess risks and make decisions about man-aging hazards in the home health careenvironment. It is important to understand individ-ual differences in risk perceptions and decisionmaking based on individual characteristics andexperience level with hazards in relation to per-ceived hazard characteristics (Griffin et al., 1999).This descriptive knowledge can highlight modifiabletargets for future training interventions to improveknowledge and skills of health care providers inassessment and management of environmental haz-ards in home health care settings. For example,highly realistic virtual simulations can be designedand tested in which trainees interact with realisti-cally designed hazards. In improving knowledge ofhow to assess home hazards a trainee could go intothe virtual kitchen and be cued to appraise key haz-ards and receive feedback about the accuracy oftheir assessment. The trainee could also beprompted to select management options to mitigatethe hazard and receive real-time feedback about thequality of their ability to process the informationpresented in determining management decision.Training and appropriate risk-perception calibra-tion of perceived hazard characteristics using a vir-tual simulation is an emerging method for studentmastery of learning that warrants future evaluation.

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