Nursing · Community and public health
The cause of a great deal of the disease a nurse sees is outside the room, and becomes visible only when somebody asks
In the exams: NMCN Professional Examination: Community health and communicable disease (Core paper, reflecting the national disease burden)
A very large share of the global burden of disease is attributable to modifiable environmental factors — air, water, sanitation, chemicals, heat and the built environment — and air pollution alone causes millions of deaths a year. A child with recurrent wheeze living in damp housing beside a main road, and an adult with lung disease who spent thirty years in a foundry, both have causes that no prescription addresses. Nurses are unusually well placed to see this: they see where people live, what they do all day, who else in the family is affected, and patterns across a community, which is exactly the information environmental disease is diagnosed from and exactly what clinical systems fail to record. And all of it falls hardest on the poorest, everywhere, which makes this subject inseparable from inequality.
A very large share of the global burden of disease is attributable to modifiable environmental factors — air, water, sanitation, chemicals, heat and the built environment. That is a larger contribution than almost any clinical intervention can match.
Air pollution, indoor and outdoor together, causes millions of deaths annually through heart disease, stroke, lung disease, lung cancer and pneumonia in children. It is among the largest single environmental health risks in the world.
A child with recurrent wheeze living in damp housing beside a main road, and an adult with lung disease who spent thirty years in a foundry, have causes no prescription addresses. Recognising that changes what the nurse does.
Nurses see where people live, what they do all day, who else in the family is affected, and patterns across a community. That is exactly the information environmental disease is diagnosed from and clinical systems rarely capture.
Polluted air, contaminated water, hazardous work, unsafe housing, extreme heat and toxic waste are concentrated among poor communities everywhere. Environmental health is inseparable from inequality, and pretending otherwise misdescribes it.
Harm depends on how much, for how long, and at what stage of life, which is why a brief high exposure and a long low one produce different diseases, and why exposure in pregnancy and childhood matters most.
Many environmental diseases appear decades after exposure — asbestos disease, occupational cancer, effects of childhood lead — so the person no longer connects the illness with the cause. Asking about the distant past is necessary.
Children breathe more air and eat more food relative to their size, absorb some substances more readily, play on the floor and put things in their mouths, and have developing organs. Identical exposure harms them more.
Smoking plus asbestos, or heat plus dehydration plus a diuretic, produce more harm together than either alone. Assessing one exposure in isolation underestimates risk substantially.
Establishing that a specific exposure caused a specific person's illness is frequently impossible, and that uncertainty has historically been used to delay action. Acting on reasonable evidence is the standard rather than certainty.
Fine particles, nitrogen oxides, ozone, sulphur dioxide and carbon monoxide, from traffic, industry, power generation, burning of waste and agriculture. The fine particles are the most consequential for health.
Fine particles penetrate deep into the lungs and enter the bloodstream, causing heart attack, stroke, heart failure, worsened asthma and lung disease, lung cancer, low birth weight and reduced lung growth in children.
Health effects are measurable at concentrations well below most legal limits, so cleaner is better at every level rather than there being a threshold below which air is safe. Guideline values have been revised downwards repeatedly.
Children, older people, pregnant women, and people with existing heart and lung disease — and people living beside busy roads, industry and waste sites, who are disproportionately poor.
Avoiding the busiest roads at the busiest times, walking on the inside of the pavement, keeping windows shut on high pollution days, not idling engines outside schools, and checking local air quality information. Modest, and better than nothing.
Burning wood, charcoal, coal, dung and crop waste indoors for cooking and heating exposes billions of people to dense smoke, and causes an enormous number of deaths, mostly of women and young children.
Pneumonia in children, chronic lung disease, lung cancer, heart disease, stroke, low birth weight and eye disease. It is also a major cause of burns and scalds in small children near open fires.
Improved stoves, chimneys, better ventilation and above all cleaner fuels reduce exposure substantially, and the barrier is almost always cost and availability rather than willingness. Advice must be affordable to be advice.
Damp and mouldy housing causes and worsens asthma and respiratory infection, and cold homes cause excess winter deaths from heart disease and stroke. Both are housing problems presenting as medical ones.
Second-hand tobacco smoke indoors, naturally occurring radioactive gas in some areas, and fumes from cleaning products, paints and solvents. Each is measurable and each has a specific remedy.
Unsafe water, inadequate sanitation and poor hygiene cause diarrhoeal disease that kills very large numbers of children annually, plus cholera, typhoid, hepatitis and parasitic infection. It is one of the oldest and most solvable problems in health.
Separating human waste from water and hands prevents disease more effectively than treating the resulting illnesses, and a large share of the world's population still lacks a safe toilet. The intervention is infrastructure.
Handwashing with soap at key moments substantially reduces diarrhoea and respiratory infection, and it requires soap and water to be physically present where hands need washing. Instruction without provision achieves little.
Arsenic and fluoride occurring naturally in groundwater, and lead from pipes, cause disease in millions of people who have no way of knowing their water is harmful. Testing is what reveals it.
Where water is scarce, less is used for hygiene, people drink from unsafe sources, and women and girls spend hours collecting it instead of attending school. Scarcity produces disease indirectly and severely.
Hundreds of millions of people are made ill by contaminated food each year and a substantial number die, mostly children. Most of it is preventable at the point of handling, storage and cooking.
Clean hands and surfaces, separating raw and cooked food, cooking thoroughly, keeping food at safe temperatures, and using safe water and raw materials. Simple, evidence-based and worth teaching plainly.
Refrigeration failure is a common cause of foodborne illness, and where power is unreliable the practical advice is about buying, cooking and eating rather than storing. Advice assuming a working fridge is useless to many.
Pesticide residues, heavy metals accumulating in fish and rice, and toxins from mould on stored grain and nuts, which cause liver cancer and stunting. These are invisible and require regulation rather than consumer care.
Malnutrition from not having enough food, and obesity and diabetes from cheap energy-dense food being the only affordable option, together dwarf food poisoning. Both are environmental in the sense that matters.
Heat causes death from heat stroke and, far more commonly, from heart attack, stroke, kidney injury and worsening of existing disease. Heat-related deaths are substantially under-recorded because the certificate names the heart.
Older people living alone, people with heart, lung, kidney and mental illness, people on certain medicines, infants, outdoor workers, and people in top-floor flats without ventilation. The deaths are predictable and largely preventable.
Checking on isolated people, cool rooms, shade, fluids, reducing activity in peak heat, wet cloths and fans, reviewing medicines, and knowing the signs of heat stroke. Simple actions applied to identified people.
Confusion, collapse, a very high temperature and hot skin is rapidly fatal, and cooling begins immediately rather than after investigation. Distinguishing it from heat exhaustion determines urgency.
Cold homes cause excess winter deaths from heart disease, stroke and respiratory infection, particularly in older people who cannot afford heating. It presents as cardiac disease and is caused by fuel poverty.
Climate change increases deaths from heat, extreme weather, poor air quality, infectious disease, water insecurity and crop failure, and it worsens every existing inequality. Health bodies describe it as the largest health threat facing humanity.
More heatwaves, more intense storms and floods, drought and crop failure, changing distribution of insects carrying disease, longer pollen seasons, wildfire smoke, and displacement of populations. Each is already measurable.
A child born today will experience these effects across their whole life, and exposure in childhood has lifelong consequences. The time frame is not distant.
Water scarcity, crop failure and uninhabitable heat drive migration and conflict, and displaced people have interrupted healthcare, no records and greatly raised risk of infection and mental illness. Nurses meet the consequence.
Heat plans, checking on vulnerable people, reviewing medicines in hot weather, resilient services, and preparing for changed patterns of disease. This is practical rather than political work.
Immediate drowning and injury are followed by a much larger burden of infection from contaminated water, injury during clean-up, carbon monoxide poisoning from generators, interrupted treatment for chronic disease, and mental illness.
People displaced by disaster lose medicines, dialysis, insulin, oxygen and records, and deaths from those interruptions exceed the direct toll. Identifying those people in advance is the preventive measure.
Flooded homes develop mould that causes respiratory illness for months to years, and people frequently return before drying is complete because they have nowhere else. The health effects long outlast the event.
Smoke from fires affects populations hundreds of kilometres away, causing the same harms as other fine particle pollution but at very high concentrations. Advice about staying indoors and filtering air is practical.
Traumatic stress, depression, anxiety and substance use rise substantially after disasters and persist for years, and they are consistently under-resourced compared with the physical response.
Malaria, dengue, and other infections carried by mosquitoes, ticks and flies cause an enormous burden of illness and death, overwhelmingly in tropical and poorer regions and overwhelmingly in children.
Warming temperatures, changed rainfall and urbanisation are extending the range of mosquitoes and the diseases they carry into areas with no previous experience of them, and no immunity or clinical familiarity.
Removing standing water, treated bed nets, housing improvements, and drainage prevent more disease than treatment cures. Nets are effective, cheap, and frequently unavailable or used for other purposes out of necessity.
Fever in anybody who has been in a malaria area is malaria until excluded, and it can kill within days. Not asking where somebody has been is a recognised cause of death.
Dengue thrives where water is stored in containers in dense urban settlements, so water insecurity and unplanned urbanisation drive it. The remedy is water supply and waste management rather than medicine.
People are exposed to many industrial chemicals through air, water, food, consumer products and work, and most have never been assessed for long-term health effects. That is a regulatory reality rather than a conspiracy.
Certain chemicals interfere with hormone systems and are associated with effects on fertility, development, metabolism and some cancers, with exposure in pregnancy and childhood mattering most. The evidence is developing and concerning.
Cleaning products, paints, glues, fuels and industrial processes release substances causing irritation, headache, nerve damage, liver and kidney injury and cancer. Ventilation and substitution are the answers rather than protective equipment alone.
Household chemicals, medicines, kerosene, cleaning products and pesticides poison very large numbers of children, and storage and packaging are what prevent it. Asking how chemicals are stored is a real preventive question.
What do you work with, what do you use to clean, what is stored in your home, what do you burn. Environmental chemical exposure is not detectable except by asking.
Tanks, pits, silos, manholes and slurry stores accumulate gases that displace oxygen or poison directly, and they kill workers who enter and then the colleagues who go in to rescue them, which is why multiple-death incidents are characteristic. Carbon monoxide from generators, stoves and blocked flues does the same in homes, causing headache, nausea and confusion that is regularly diagnosed as flu until a whole household is affected.
Lead damages the developing brain with no threshold below which it is safe, causing reduced intelligence, attention and behaviour problems, and the damage is irreversible. Very large numbers of children worldwide have harmful levels.
Old paint, contaminated soil and dust, water pipes, informal battery recycling, cookware, spices and cosmetics, and some traditional remedies. Informal lead-acid battery recycling is a major and growing source.
Abdominal pain, irritability, poor concentration, learning difficulty, anaemia and developmental delay — none of which suggests lead unless somebody thinks of it. Testing requires suspicion.
Mercury from small-scale gold mining and contaminated fish causing nerve damage; arsenic in groundwater causing skin disease and cancer; cadmium from industry and tobacco affecting kidneys and bones.
Removing the source is the intervention, because the damage from lead in particular cannot be reversed. Identifying the source protects the other children in the household and the community.
Pesticides cause a very large number of poisonings annually, both accidental and deliberate, and agricultural workers in poorer countries bear most of it with the least protection and information.
Sweating, excessive salivation, small pupils, vomiting, diarrhoea, muscle twitching, confusion and difficulty breathing after exposure to organophosphate pesticides. It is treatable and time-critical.
Pesticide self-poisoning is one of the commonest methods of suicide globally, and restricting access to the most toxic products has reduced national suicide rates substantially. That is a striking, well-evidenced finding.
Chronic exposure is associated with neurological disease, some cancers, respiratory and reproductive effects, and effects on children of exposed parents. Farmworkers are rarely followed up for any of it.
Advice about protective equipment is unusable in extreme heat, where equipment is unavailable, or where workers are not told what they are spraying. Saying what is actually achievable is more useful.
Ionising radiation from medical imaging, nuclear sources and naturally occurring gas damages DNA and causes cancer, while non-ionising radiation from sun and radio sources carries different and mostly lesser risks.
Imaging is the largest artificial source of radiation exposure for most people, and repeated scans in young people carry a small but real cancer risk. Justifying each examination is the safeguard.
Distance, shielding, time and dose monitoring, and particular care in pregnancy and childhood. Nurses in theatres, imaging and cardiology accumulate occupational exposure and are frequently not monitored properly.
Naturally occurring radioactive gas seeps into buildings in some geological areas and is a leading cause of lung cancer after smoking. It is measurable, and it is fixable by ventilation and sealing.
Ultraviolet radiation causes skin cancer and eye damage and the exposure is heavily occupational for outdoor workers who are rarely advised about it. Shade and clothing first, then sunscreen.
Long-term exposure to traffic, aircraft and industrial noise is associated with sleep disturbance, high blood pressure, heart disease and impaired learning in children. It is not merely an annoyance.
Noise fragments sleep even when it does not wake somebody, and chronic sleep disruption drives the cardiovascular and cognitive effects. That is why night-time noise matters more than daytime levels.
Children in schools near major roads and airports show measurably poorer reading and attention. It is one of the clearest examples of environment shaping a life course.
Artificial light at night disrupts the body clock, affecting sleep, mood and metabolism, and it particularly affects shift workers and people in brightly lit urban housing. Simple measures — blackout, screen habits — help.
Noise and light in hospitals at night fragment patients' sleep, contribute to delirium and slow recovery, and the sources are largely staff behaviour and equipment. That makes it directly correctable.
Damp, cold, overcrowding, poor ventilation, disrepair, mould, pests and lack of security cause and worsen respiratory disease, cardiovascular disease, injury, infection and mental illness. Housing quality predicts health powerfully.
Crowded housing drives transmission of tuberculosis, respiratory infection and skin infestation, and it prevents isolation when someone is infectious. Advice to isolate is meaningless in one room shared by six people.
Fear of eviction, repeated moving and temporary accommodation cause mental illness, interrupt healthcare and education, and are associated with worse outcomes independent of housing quality.
People who are homeless die far younger, of treatable conditions, and are excluded from services that require an address and appointments. Health outcomes here are among the worst of any group.
A patient's housing conditions are clinical information, and recording them allows a referral, a letter that supports a housing claim, and recognition of a pattern across a community. Nurses' letters have changed housing decisions.
Someone who cannot get out of a fourth-floor flat with a broken lift, or whose doorway will not take a wheelchair, becomes housebound, deconditioned, isolated and depressed, and it is recorded as reduced mobility rather than as a building. Asking specifically how they get in and out finds problems that no examination reveals.
Life expectancy differs by many years between neighbourhoods a short distance apart, driven by income, air, housing, food availability, green space, safety and access to care. Postcode outperforms most clinical predictors.
Where affordable fresh food is unavailable and cheap energy-dense food is everywhere, dietary advice that ignores that is unusable. Asking what is actually available near somebody's home changes the advice.
Access to parks and safe walking routes is associated with more activity, better mental health and lower mortality, and it is distributed along income lines. Advising exercise without asking where is hollow.
Car-dominated environments reduce activity, increase injury and pollution, and isolate people without cars; walkable neighbourhoods and public transport do the reverse. Transport policy is health policy.
People do not walk, let children play outside, or open windows where they do not feel safe. Fear of violence is a direct determinant of physical activity and air quality inside homes.
How far somebody must travel, what it costs, how long it takes and whether they must lose a day's pay to attend decides whether treatment happens at all, and non-attendance recorded as disinterest is usually a bus fare. In rural areas the journey itself is the barrier, and for women in many places travelling alone is not permitted or not safe.
Work provides income, purpose, structure and social contact, all of which are protective, and it also causes injury, illness and death on a very large scale. Both things are true simultaneously.
Work-related injury and disease cause a very large number of deaths annually, most from disease rather than accident, and most in informal and hazardous employment without any protection or recording.
Eliminating a hazard, substituting something safer, engineering controls and ventilation come before protective equipment, which is the weakest and most commonly relied-upon measure. Handing out masks is not a solution.
Occupational disease is almost entirely preventable and is nevertheless largely uncompensated and unrecorded, particularly in informal work. The person bears a cost the enterprise caused.
Workers conceal symptoms, decline investigation and refuse to report injuries because they fear dismissal, particularly where employment is insecure or undocumented. That fear is the main barrier to occupational health.
People working away from home, without secure status or the local language, take the most hazardous jobs, are least likely to be trained or insured, and cannot complain or seek treatment without risking their employment or their residence. They are the workers most exposed and least counted, and a nurse who treats their injury without asking how it happened loses the only record that will ever exist.
What do you do for a living, what did you do before, and what are you exposed to. That sequence uncovers causes that no test reveals, and it is omitted from almost every clinical history.
Occupational disease appears decades later, so a current office worker may have spent ten years in construction. A lifetime job history is what makes asbestos disease and occupational cancer findable.
A job title conceals the exposure. Asking what they physically do, what they touch, what they breathe and what the place is like produces the clinical information.
Symptoms improving at weekends and on holiday and returning at work is the single most useful clue to occupational asthma and dermatitis. One question, enormous yield.
If colleagues have the same symptoms, the cause is almost certainly the workplace, and that recognition protects everybody there. A single case is a clue; a cluster is a finding.
Asthma caused by something inhaled at work, with symptoms worse at work and better away from it. It is substantially under-diagnosed, and early removal from exposure can prevent permanent disease while delay makes it permanent.
Silica from stone, concrete and quartz worktops, coal dust, and other mineral dusts cause progressive irreversible lung scarring, and silica disease in young stoneworkers is resurging. It is entirely preventable by dust control.
Asbestos causes lung scarring, lung cancer and a cancer of the lining of the lung appearing thirty to fifty years after exposure. It is still present in buildings and still used in some countries.
A meaningful proportion of chronic obstructive lung disease is caused by occupational dust and fume exposure, including in people who never smoked, and it is attributed to smoking by default.
Once somebody is sensitised to a substance, even tiny future exposures provoke symptoms, which is why identifying it early and removing them matters so much. Continuing to work with it is not an option.
Work-related skin disease, mostly hand dermatitis, is among the commonest occupational conditions, affecting cleaners, healthcare workers, hairdressers, caterers and construction workers. It can end a career.
Repeated wetting, soaps, detergents, solvents and occlusive gloves damage the skin barrier, and once damaged it becomes sensitised to substances it previously tolerated. Prevention protects the barrier.
Sensitisation to substances such as certain metals, resins, rubber components and hair products is permanent, and after it develops even brief contact causes disease. Healthcare workers and hairdressers are particularly affected.
Reducing wet work, drying hands properly, using moisturiser regularly, gloves only as long as needed, and substituting irritants. Moisturiser is a genuine occupational health intervention.
Outdoor workers accumulate very large ultraviolet doses and have raised skin cancer rates, and they are rarely given any advice or provision. Shade, clothing and timing of work are the answers.
Loud noise destroys hearing cells that do not regenerate, so the loss is permanent and cumulative. It affects very large numbers of workers in industry, construction, agriculture, mining and music.
Reducing noise at source, enclosure, distance, limiting exposure time and properly fitted hearing protection prevent it completely. Protection that is uncomfortable, unavailable or not worn prevents nothing.
Early loss affects high frequencies and consonant sounds, so people struggle to follow conversation in noise long before they notice difficulty in quiet. Asking about that specifically finds it early.
Persistent ringing frequently accompanies noise damage, is deeply distressing, disturbs sleep and has no cure, though it can be managed. It is a reason to take noise exposure seriously before damage occurs.
Untreated hearing loss is associated with isolation, depression, reduced employment and increased risk of dementia. It is not a minor sensory inconvenience.
Musculoskeletal disorders from lifting, repetitive movement, awkward posture, vibration and static loading cause more lost working time than anything else, across almost every occupation including healthcare.
Sustained awkward postures, repetition, force, vibration and lack of recovery time all contribute, and a job with no heavy lifting can still cause severe disorder. Assessing the whole task is necessary.
Adjusting equipment, heights, layout, load and work organisation prevents more injury than training people to lift correctly. Training alone, without changing the task, has a poor record.
Prolonged use of vibrating tools causes numb, blanched, painful fingers with permanent loss of sensation and dexterity. It is preventable by tool selection and exposure limits and is frequently ignored.
Healthcare has among the highest rates of musculoskeletal injury of any sector, from moving patients, and staffing levels and equipment availability are the main determinants. It is a systems issue.
A meaningful proportion of cancers are caused by occupational exposures, and most are never recognised as such because of long latency and because nobody took an occupational history. They are all preventable.
Asbestos, silica, diesel exhaust, wood dust, certain chemicals and dyes, radiation, ultraviolet light, shift work involving night working, and many others. The list is long and each entry represents avoidable disease.
A cancer appearing forty years after exposure is attributed to age or chance, and the person's earlier employment is never recorded. That is why a lifetime job history matters even in a cancer clinic.
Identifying an occupational cause protects current workers at that site and may entitle the person to compensation. A nurse who asks and records has done something with effects beyond that patient.
Replacing a carcinogen with something safer prevents disease permanently, while monitoring and protective equipment manage it imperfectly for as long as the hazard remains.
Working against the body clock affects sleep, appetite, mood, digestion and hormone rhythms, and long-term shift work is associated with cardiovascular disease, diabetes, obesity, some cancers and mental illness.
Errors and injuries rise markedly on night shifts and in the early hours, and after long shifts and consecutive nights. That has direct implications for patient safety as well as for staff.
Road collisions after night shifts are a well-documented and under-discussed occupational hazard for nurses. Planning the journey home is a genuine safety measure.
Forward-rotating shifts, adequate rest between them, limiting consecutive nights, avoiding very long shifts and protected breaks reduce harm substantially. These are organisational choices.
Consistent sleep routines, a dark quiet room, strategic short naps, careful caffeine timing, eating patterns and light exposure. Useful, and no substitute for humane rostering.
High demand with low control, job insecurity, long hours, bullying, unclear roles, effort without reward, and moral conflict cause depression and anxiety. This is established, and it locates the cause in the job.
Exhaustion, cynicism and reduced effectiveness arising from chronic workplace stress is a work problem, not a personal weakness. Interventions aimed only at individual resilience have a poor record.
Knowing what right care is and being prevented from providing it, usually by staffing or resources, causes lasting harm to health workers specifically. Naming its cause accurately matters.
Job loss and precarious work are associated with depression, suicide, cardiovascular disease and worse health behaviours. Work is protective and its absence and instability are damaging.
Adequate staffing, reasonable hours, predictable rosters, genuine influence over one's work, protection from bullying, and being listened to. Individual coping strategies do not substitute for any of these.
Nurses experience verbal abuse and physical assault at high rates, particularly in emergency, mental health and community settings, and much of it is never reported because reporting changes nothing.
Assault is a workplace injury with physical and psychological consequences, and framing tolerance of it as professionalism is how it continues. Reporting it and expecting action is reasonable.
Layout, exit routes, lone working policies, staffing, waiting times, information and de-escalation training reduce incidents. Long unexplained waits are a documented cause of aggression.
Community nurses, health visitors and district staff work alone in unknown homes, and risk assessment, communication systems and the right to withdraw are basic protections that are frequently thin.
Harassment of health workers by patients, visitors and colleagues is widespread and under-reported, and tolerating it because a patient is unwell or senior is not an acceptable standard.
Infection, sharps injuries, back injuries, chemical and drug exposure, radiation, violence, shift work, latex allergy and psychological injury. The sector that treats occupational disease is bad at preventing its own.
Needlestick and blood exposure injuries are common, frequently unreported, and carry blood-borne virus risk with preventive treatment that works best given immediately. Reporting at once rather than at shift end matters.
Respiratory infection, tuberculosis and other transmissible disease are occupational risks, and adequate ventilation, protective equipment that fits, and staff vaccination are the controls. Sick staff working because of pressure spread infection.
Handling chemotherapy, anaesthetic gases, sterilising agents and cleaning chemicals carries real risks, with specific precautions and particular considerations in pregnancy. Knowing the local policy is a legitimate expectation.
Incidents that are not reported cannot be acted on, and a culture where reporting is pointless or punished guarantees repetition. Recording an injury is an act for the next person as well as yourself.
Lifting, night shifts, long standing, radiation, cytotoxic drugs, anaesthetic gases and infectious exposure all carry specific considerations in pregnancy, and a risk assessment with adjusted duties is an entitlement in many places rather than a favour. Nurses frequently conceal a pregnancy or continue unsuitable duties because raising it feels like asking for special treatment.
Farming has very high rates of fatal injury from machinery, vehicles, animals, falls, drowning and grain stores, plus pesticide exposure, heat, noise, dust and zoonotic infection. Much of it is unrecorded.
Very large numbers of children work in agriculture and other hazardous sectors, missing school and sustaining injuries and exposures with lifelong consequences. This is a health issue nurses encounter and rarely record.
Most of the world's workers are in informal employment with no safety regulation, no compensation, no records and no occupational health service. Their disease is invisible to every statistic.
Outdoor workers in hot climates develop chronic kidney disease from repeated heat stress and dehydration, in epidemics among agricultural labourers. It is a newly recognised and enormous occupational problem.
Disease transmitted from animals to people through farming, slaughter, veterinary work and wildlife contact, including the origins of several epidemics. Asking about animal contact in a febrile patient occasionally matters enormously.
Household, industrial and electronic waste is processed, burned and picked over by people, frequently children, in poor communities, exposing them to lead, mercury, dioxins and injury. Someone lives where waste goes.
Sharps, infectious material, chemicals and pharmaceuticals require segregation and safe disposal, and where that fails, waste pickers and communities are exposed to needles and toxins. Correct segregation at the bedside is where it starts.
Pharmaceuticals excreted and discarded enter water and soil, with effects on wildlife and a contribution to antimicrobial resistance. Reducing unnecessary prescribing is an environmental measure as well as a clinical one.
Health systems are responsible for a significant share of national carbon emissions through energy, transport, supplies, anaesthetic gases and inhalers. An industry devoted to health contributing to the largest health threat is a contradiction worth acting on.
Waste segregation, avoiding unnecessary single-use items where safe, reducing waste from unused supplies, switching to lower-impact inhalers and anaesthetic agents where clinically appropriate, and reducing unnecessary tests and journeys.
Several children on one street with asthma, a cluster of workers with the same rash, repeated admissions from one block of flats. Nurses see this before any surveillance system does.
Occupation, housing conditions and exposures recorded in notes and reported through the proper channels is what turns a suspicion into evidence. Unrecorded observations change nothing.
Residents who say something in their area is making them ill are frequently correct and are routinely dismissed as anxious, and the history of environmental health is largely a history of communities being disbelieved.
Demanding certainty about causation before acting has historically protected harmful industries for decades — tobacco, asbestos, lead. Acting on reasonable evidence while uncertainty remains is the appropriate standard.
Advocating about housing, air, water and workplace hazards is not politics intruding on nursing; it is treating the cause of the disease in front of you. Nurses have led on this repeatedly.
Taking an occupational history; symptoms better away from work; heat and cold as causes of death; air pollution effects; lead as having no safe level; and housing as a clinical factor.
Omitting occupation entirely from a history; asking only about the current job; attributing all chronic lung disease to smoking; treating advice about protective equipment as adequate hazard control; giving dietary or exercise advice without asking what is available where somebody lives; dismissing a community's account of local illness.
Ask what they do and what they did. Ask whether symptoms improve away from work. Control the hazard before protecting the worker. Ask about housing and record it. Act on reasonable evidence rather than waiting for certainty.
Ask about every job they have ever had. Ask whether colleagues have it too. Ask what they cook with and what they burn. Ask how chemicals are stored at home. Ask whether the house is damp. Write it in the notes.
The cause of a great deal of the disease a nurse sees is outside the room, in the air, the house or the workplace, and it becomes visible only when somebody asks. Nothing else in this manual matters without that question.
Written in plain sentences on purpose. Nursing is studied in a second language by a large share of the students who will read this, and a sentence that has to be decoded twice is a sentence that teaches less.
These are the twelve questions written with this SUNYRA nursing manual, to check what it teaches. They are not past papers and were not written to any one examination's pattern; an examination tag means only that the examination's published blueprint covers this subject. Difficulty was not graded in the source, so every question is marked medium.
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