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Overview and Summary: Environmental Health: Important Choices for a Greener World

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Susan Wilburn, MPH, BSN, RN

Citation: Wilburn, S., (May 31, 2007). "Overview and Summary: Environmental Health: Important Choices for a Greener World" OJIN: The Online Journal of Issues in Nursing. Vol. 12 No. 2, Overview and Summary.

DOI: 10.3912/OJIN.Vol12No02ManOS

How many "Green' magazine covers have you seen lately? Likely you've seen a number of these Green covers since there has indeed been an increase in the number of such covers recently. This increase is not just because of the annual Earth Day events celebrated in April, or the visibility of Al Gore and his movie, "An Inconvenient Truth." This increase is also a result of the growing recognition of the connection between health and the environment, a recognition which has changed the nature, the visibility, and the critical importance of this topic for public health. This OJIN topic takes a look at environmental hazards, particularly chemical hazards, and considers the health effects of these hazards and the role of nurses in protecting and promoting health through healthier environments.

Since Florence Nightingale recognized and statistically analyzed the impact of clean air and water on the survival rates of wounded soldiers, nurses have incorporated principles of environmental health into their practice (Butterfield, 2002; McDonald, 1987). Indeed the holistic approach to health embodied in the nursing process recognizes and acts on all determinants of health and disease, including those related to environmental conditions.

In 1995 the Institute of Medicine report, “Nursing, Health and the Environment,” called upon nurses to be prepared to integrate environmental health into nursing practice, research, education, and advocacy (Pope, Snyder, & Mood, 1995). This report is credited with revitalizing and reemphasizing environmental health in nursing. In the decade following the report, an explosion of activity occurred among nurses in the United States (US) as nurses and organized nursing worked to become more knowledgeable about, and engaged in, environmental health promotion (Wakefield, 2002).

This new era of environmental health activity in nursing moved beyond recognizing environmental factors that contribute to disease to more upstream thinking about prevention and precaution related to these diseases (Butterfield, 2002). Prevention now includes not only preventing of exposure to environmental contaminants, through the application of the hierarchy of controls in the workplace, but also to practicing source reduction, which involves replacing products and processes that create pollution with more environmentally healthy ones. Thus nurses and nursing have emerged at the forefront of the Green revolution in health care and are active in creating environmentally sustainable, health care practices. Terms, such as Green and ‘sustainable development,’ are becoming more common in the nursing literature. According to Wikipedia, “Green is the color symbolizing earth, nature, and in a broader sense, life. The term Green is used to mean environmentally friendly. For example, green cars are vehicles that have extremely low emissions that are harmful to the environment” (Green, 2007). The term ‘sustainable development’ was defined in a United Nations (UN) report titled “Our Common Future,” by what became known as the Brundtland Commission, which concluded that a global goal should be to make social and economic development sustainable, meaning that it “meets the needs of the present without compromising the ability of future generations to meet their own needs” (Report of The World Commission, 1987, p.54).

Over a decade ago, the United States Department of Health and Human Services (USDHHS) wrote, “The most difficult challenges for environmental health today come not from what is known about the harmful effects of microbial agents; rather they come from what is not known about the toxic and ecologic effects of the use of fossil fuels and synthetic chemicals in modern society” (USDHHS, 1990, p.312). In the ensuing decade, science has documented these toxic health effects. As American Nurses Association President Becky Patton said in her 2007 Earth Day editorial in The American Nurse, “Ignorance is bliss, but today we know the truth” about the hazards of mercury and disinfectant use in health care and the need to substitute less hazardous substances for those currently in use (p. 3). I first saw the film ‘An Inconvenient Truth’ in France; and the French translation of the movie title: ‘Une Vérité qui Dérang’, means a truth that confuses and disturbs. The truth, as Becky has written, should cause cognitive dissonance and spur us into action. Although progress has been made in improving the health of our environment in the last ten years, much work remains to be done. According to the World Health Organization (WHO) report, “Preventing Disease through Healthy Environments: Towards an Estimate of the Environmental Burden of Disease,” approximately one-fourth of the global burden of disease is attributable to environmental exposures and 23% of all deaths can be attributed to environmental factors (Prüss-Üstün & Corvalán, 2006, p.9).

This OJIN topic’s introductory articles cover a broad range of issues in environmental health nursing designed to inform and engage nurses on the subject. A predominate theme in all the articles is that the environment is a primary determinant of health, and environmental health hazards affect all aspects of life and all areas of nursing practice. This series of articles begins by highlighting the responsibility of nurses and the health care industry to first clean up our own house by demonstrating environmentally responsible practices, products, and policies in our hospitals and other health care settings. Three articles deal with environmental health in health care settings from the design, building, and operations of hospitals to the procurement, use, and disposal of the products used for caring.

Just as infectious diseases know no boundaries, chemical hazards such as persistent organic pollutants (POPs), described in the article by Barbara Sattler and Kathryn Hall in this issue, also know no boundaries. The dioxin produced by a medical waste incinerator in Baltimore easily travels across the state border north to Pennsylvania. However, even more easily, because of the nature of the chemical, it travels to the Earth’s poles where the fish in the human food chain are contaminated. That is why global treaties, such as the Stockholm Convention, or the treaty to limit the production of POPs as described in the article by Welker-Hood, Condon, and Wilburn are needed.

Hollie Shaner-McRae, Glenn McRae, and Victoria Jas remind us of the pioneering environmental legacy of Florence Nightingale in their article, “Environmentally Safe Health Care Agencies: Nursing’s Responsibility, Nightingale’s Legacy.” Shaner-McRae, a much respected environmental health nursing pioneer herself (Wakefield, 2001), and colleagues describe how nurses can become more aware of the number of products used and disposed of in the health care setting and urge the development of competencies in hospital waste management. From Shaner-McRae and colleagues, we learn about the U.S. regulation governing waste management, the Resource Conservation and Recovery Act (RCRA), and that good practice can reduce the volume of medical waste requiring treatment to 15% or less of the total waste stream by applying the 3 Rs (reduce, reuse, and recycle) to health care waste.

Healthy Buildings: Impact on Nurses and Nursing Practice,” by architect Robin Guenther and nurse Anna Gilmore Hall, invites nurses to get involved early in the building and remodeling of health facilities during the design phase. The authors provide information and terminology to help bridge the gap between nurses and architects so that nurses can help architects design and build healthy hospitals. They share many hopeful examples of hospital buildings which have used the “Green Guide for Healthcare” demonstrating that Green and healthy buildings can be both more efficient to operate and healthier as workplace and patient care environments.

Barbara Sattler and Kathryn Hall in their article, “Healthy Choices: Transforming Our Hospitals into Environmentally Healthy and Safe Places,” take another look at the hospital environment from the perspective of environmentally preferable purchasing of products. Their review of the Health Care Without Harm report on asthmagenic chemicals and the table describing principles for the selection of safer alternatives is critical to understanding the risks of harmful chemicals and to finding and using safer choices. As the authors write in their article, “Our awareness of the environment and its potential impact on human health has been growing. In addition to our emerging understanding of the macro-environment, including air and water pollution, global warming, and climate change, we are increasingly aware of environmentally related impacts of our micro-environments – our homes, schools and workplaces – and the effects created by the choices we make in these environments.” Both the Sattler and Shaner-McRae articles demystify hospital waste and provide methods and resources to reduce and manage the waste stream.

Allison Del Bene Davis takes us even closer to home with the article, “Home Environmental Health Risks,” which describes how nurses can identify five common hazards found in the home including: lead, carbon monoxide, radon, pesticides, and the broad chemical category of volatile organic compounds that can be found in paints, cleaning supplies, and laundry chemicals. It is frightening to learn how many poisons we knowingly bring into our homes without considering their short and long term consequences. Davis shows how to assess the associated health risks and eliminate or control these common hazards.

Brenda Afzal encourages us to think global and act local in her article, “Global Warming: A Public Health Concern,” dispelling the notion that there is a lack of scientific consensus regarding the impact of human activities on climate change. Afzal describes the personal and institutional changes that nurses and hospitals can make to reduce greenhouse gases and the policy advocacy for a healthier environment in which organized nurses have already been involved. Both Afzal and Sattler talk about the importance of ending medical waste incineration because it has an impact on climate change and increases dioxin production and emission, one of the “dirty dozen” persistent organic pollutants (POPs), in the air.

Regulatory, Institutional, and Market-Based Approaches Toward Achieving Comprehensive Chemical Policy Reform,” by Kristin Welker-Hood, Marian Condon, and Susan Wilburn provides an in-depth review of the major pieces of federal chemicals policy in the US and identifies gaps and failures in policy to protect human health. Examples of state legislation, often described as the laboratory for demonstrating models for national policy, include legislation of individual toxic chemicals, including mercury, and categories of hazardous chemicals, such as brominated flame retardants. The article also describes examples of European and international chemical policy which could be models for U.S. reform. A hazardous-chemical pyramid, presented in the article, suggests a system for identifying priority chemicals for phase out. As in all of the articles in this issue of OJIN, examples are provided of how nurses and health care institutions have been, and can continue to be active for change in chemical policy reform at the local, state, and national level. Nurses as educated professionals, trusted by the public to speak honestly about health issues, can be leaders in the area of health and the environment. A community of nurses is currently working together through the Health Care Without Harm ( nurses’ work group, the University of Maryland School of Nursing Environmental Health Education Center (, and ANA’s Center for Occupational and Environmental Health ( If you desire to obtain more information and/or to add your name to a list serve so that you will receive updates on environmental health and nursing, send your email address to any of the web addresses above.

The journal editors invite you to share your response to this OJIN topic addressing Environmental Health either by writing a Letter to the Editor or by submitting a manuscript which will further the discussion of this topic which has been initiated by these introductory articles.


Susan Wilburn, MPH, BSN, RN

Susan Wilburn, an international occupational and environmental health specialist, serves as the Coordinator of the American Nurses Association’s (ANA’s) RN No Harm program and as a technical consultant with the World Health Organization’s (WHO’s) Occupational Health Programme and the Making Medical Injections Safer health care worker study at John Snow, International. Ms. Wilburn has worked as a nursing consultant to the International Council of Nursing (ICN), coordinating the joint WHO/ICN Needlestick Prevention Project in Tanzania, South Africa, and Vietnam. Prior to that, Susan worked for ten years at the ANA, founding the Center for Occupational and Environmental Health. Under her leadership, ANA joined Hospitals for a Healthy Environment as one of the four partners along with the American Hospital Association, the Environmental Protection Agency, and Health Care Without Harm; and the ANA’s Safe Needles Save Lives campaign of education, capacity building, and advocacy led the effort nationally to pass the 2000 Needlestick Safety and Prevention Act. Susan received her undergraduate degree from the Kent State (Ohio) University School of Nursing and her Master’s of Public Health from the University of Washington


Butterfield P. (2002). Upstream reflections on environmental health: An abbreviated history and framework for action. Advances in Nursing Science, 25(1), 32-49.

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McDonald, L. (Ed.). (1987). Florence Nightingale on public health care. Volume 6 of the collected works of Florence Nightingale. Waterloo: Wilfrid Laurier University Press.

Patton, R. (2007). Ignorance is bliss but today we know the truth. The American Nurse. March/April, p. 3.

Prüss-Üstün, A., & Corvalán, C. (2006). Preventing disease through healthy environments: Towards an estimate of the environmental burden of disease. World Health Organization. Retrieved May 8, 2007 from

Report of the world commission on environment and development: Our common future. (1987). Retrieved May 8, 2007from .

United States Department of Health and Human Services (DHHS). (1990). Healthy people 2000: The surgeon general’s report on health promotion and disease prevention. Pub. No. 91-50212. Washington, DC: Government Printing Office.

Wakefield, J. (2001). Environmental Florence Nightingales: Nursing’s new frontlines. Environmental Health Perspectives, 109(3), A118-A123.

© 2007 OJIN: The Online Journal of Issues in Nursing
Article published May 31, 2007