Our awareness of the environment and its potential impact on human health has been growing over the last two decades. In addition to our emerging understanding of the macro-environment, including air and water

Of all places, health care institutions should be models of healthy environments…

pollution, global warming, and climate change, we are increasingly aware of the environmentally related impact of our micro-environments – our homes, schools, and workplaces – and the outcomes created by the choices we make in these environments. Of all places, health care institutions should be models of healthy environments, yet there is still much room for improvement in this regard in most health care settings. This article aims to identify environmental health risks for which risk-reduction solutions are within easy reach and nurses can take leadership roles to implement these solutions.

The health care sector comprises approximately 15.5% of the Gross Domestic Product. In the United States (US) we spend more than twice as much money on health care as we do on education, and almost 3.6% more of the national budget on health care than we do on defense (Adams, 2005). Nurses work in the largest and most robust sector in the U.S. economy. In addition to the direct health services that nurses provide, we and our institutions are also huge purchasers of a wide range of goods: food, equipment, paper and office products, batteries, linens, construction products, and the list goes on. The health care industry also purchases vast amounts of energy and produces enormous amounts of waste, including more than 2.4 million tons of waste each year (Health Care Without Harm [HCWH], n.d.b.).

Nurses can transform the health care sector into a model sector whose goals include promoting environmental health for patients, employees, and communities. This article will discuss some of the key areas where nurses can make a difference, transforming our health care facilities into environmentally healthy and safe places. This can be accomplished as nurses help our institutions adhere to environmentally preferable purchasing policies, follow environmentally conscious waste management strategies, decrease the use of chemical pollutants, promote the use of healthy foods, and provide leadership in environmental stewardship. By taking positive steps, however modest, nurses can begin to have a serious impact on the quality of our environmental health. The environmental health risks described below may be to patients, staff, and/or the community. The commonality is that nurses have the capacity to bring about changes that will reduce or eliminate these risks.

Environmentally Preferable Purchasing Policies

By understanding the health risks posed by the manufacture of health care products; the energy it takes to produce, use, and dispose of these products; and the health and environmental impact of these products, we can grasp the full "life cycle" of various health care products and their potential impact on our health and our environment which are intricately intertwined. Incorporating this understanding into decision making related to health care products we can simultaneously care for the sick, enhance health, and prevent disease through healthier product choices. This practice has been termed environmentally preferable purchasing (EPP).This section will focus on purchasing products that will decrease mercury use in hospitals, and decrease waste, so as to decrease environmental contamination. It will also present to the reader resources which will help to promote EPP.

Purchasing Products without Mercury

Ten years ago, if asked whether your hospital used mercury-containing fever thermometers and sphygmomanometers, you would likely have answered affirmatively. In a mere ten years, nurses have assisted almost all hospitals in implementing mercury-free alternatives to both of these products, thus reducing the

In a mere ten years, nurses have assisted almost all hospitals in implementing mercury-free alternatives

potential for mercury spills and eliminating these mercury-containing products from our waste streams. Nurses also continue to help eliminate the use of mercury in hospitals by recommending the use of "green tip" fluorescent bulbs which contain less mercury and insuring that they are recycled appropriately so that the mercury does not enter the waste stream.

Nurses have also helped eliminate the use of mercury-containing thermometers in their communities by holding community-based mercury thermometer exchanges. This has occurred in part through the efforts of Health Care Without Harm, an international campaign that is working to make hospitals as environmentally healthy and safe as possible. In Washington, DC, the DC Hospital Association, along with the local HCWH, the City Health Department, and the city firehouses, conducted a city-side mercury thermometer exchange whereby people brought their mercury thermometers to local firehouses and were given mercury-free thermometers. HCWH (2007) has created a helpful pamphlet to implement such an exchange, "How to Plan and Hold a Mercury Thermometer Exchange." A community exchange program which works to eliminate all mercury-containing medical equipment can make a significant impact on reducing mercury contamination in our rivers and lakes, which in turn enhances the health of our citizens (HCWH, 2007).

One of the important lessons learned from the mercury thermometer experience was the strategic use of our purchasing power to affect positive change in hospital environments.

One of the important lessons learned from the mercury thermometer experience was the strategic use of our purchasing power to affect positive change in hospital environments. Many hospitals purchase their products through large, group-purchasing organizations (GPOs). Stipulating that one wants effective products that are environmentally friendly can significantly change the number of environmentally friendly health care products available. While there is no single process by which health care purchase decisions are made, nurses are often in the loop of such decision making. For example, a head nurse of the operating room may be responsible for certain purchases, a staff nurse may sit on a hospital committee that reviews product safety, or an infection control nurse may participate in purchasing decisions about sterilants and disinfectants. Each of these nurses can bring environmental health considerations to the decision-making process regarding which products to purchase.

Purchasing Products That Decrease Waste

Other EPP considerations include the amount of packaging per product, whether or not the product is a single-use design, and the extent to which the product is made in part or entirely from recycled materials. For example, paper is a big purchase for most institutions. Choosing unbleached, recycled paper is a much preferred selection compared with chlorine-bleached, virgin-white paper because the process of manufacturingchlorine-bleached paper delivers dioxins into the water as a pollutant by-product. Some dioxins are highly carcinogenic and associated with endometriosis, immune, reproductive, and endocrine disruption - as well as behavioral problems in children. (Rier & Foster, 2002; Ryan, Amirova, & Carrier, 2002; Schettler, 2003). If the final disposition of this same bleached paper is incineration, then once again dioxins are unwittingly released as pollution – in this case as an air pollutant. Given that there are many options for non-bleached paper, choosing them will reduce the dioxins that would otherwise be created with chlorine-bleached paper during the production and incineration. Other considerations for EPP are listed in Figure 1.

Figure 1. Environmentally Preferable Purchasing Requests

Reduced packaging Bulk buying to reduce packaging Double-sided copiers Reusable (versus single-use) products Products with recycled content Latex-free products Mercury-free products Polyvinyl chloride–free products Diethyhexyl phthalate–free products

Additionally, the United States government provides designations for energy-efficient products through its Energy Star program (Environmental Protection Agency, n.d.). Use of these energy-efficient products is also recommended.

Resources for EPP

The Sustainable Hospital Project at the University of Massachusetts-Lowell has a web-based clearinghouse for selecting products and work practices that eliminate or reduce occupational and environmental hazards, while maintaining quality patient care. Information about latex-free gloves, safer needle devices, alternatives to polyvinyl chloride (PVC) products and mercury-free products can be found at their site, Sustainable Hospitals (Lowell, 2000). Hospitals for a Healthy Environment, (n.d.) another national organization committed to environmentally healthy hospitals, also provides guidance in doing EPP in hospitals.

Using Environmentally Conscious Waste Management Strategies

Busy health care workers rarely consider what happens to this waste they generate in the course of caring for patients, yet the waste is considerable and decisions about its final disposition can have a great impact on ecological and human health. Hospitals are the key institutions in health care and their waste-management decisions are just as important as their purchasing decisions. In the last 10 years, there has been remarkable progress in waste management from an environmental health perspective. The waste management efforts of the late 1990s have also included emphasis on thoughtful waste disposal as described by what environmental protection scholars like to call the "3 Rs" (below) to guide waste management:

• Reduce – overall reduction of the sheer mass of waste through less packaging, bulk purchasing without packaging, and less single-use devices
• Reuse – ending dependence on single-use devises whenever possible and selection of products that are durable and reusable
• Recycle – identification/selection of products that can be recycled, identifying recycling companies or non-profit organizations that will take your recyclables. For example composting hospital kitchen waste is a very useful form of recycling.

We now know about the risks that are posed when health care waste is incinerated. However, education

…education regarding safer alternatives to incineration continues to be essential.

regarding safer alternatives to incineration continues to be essential. The national group, Hospitals for a Healthy Environment, staff are available to consult with hospitals on the full range of environmentally sustainable practices related to waste incineration. This section will provide a brief review of the history and current status of environmental, infectious waste management in hospitals, the progress already made in recycling, the benefits of reusable products and single-use devices, and the dangers of incineration for waste management.

History of Environmental Infectious Material Waste Management

In the mid 1980s, the HIV/AIDS epidemic, and specifically the transmission of the disease, was poorly understood. By way of creating the most cautious approach to protecting hospital workers and patients, all hospital waste was treated as suspect. Red bags, those that should be limited to potentially infectious waste, were being filled with all matter of trash, including paper, plastic, and unused items, as well as items that were appropriate for red bags. This practice continued through the mid-90s, when new efforts were made to redirect waste management behavior in light of our better understanding of bloodborne disease transmission. Today only the following items are appropriate for red bag disposal: fluid blood, materials that are saturated in blood, IV bags and tubing containing blood, hemovacs, hemodialysis products, and human body parts and tissues.

Progress in Recycling

Paper comprises the largest proportion of both home and hospital waste and should be recycled. Hospitals use proportionately more plastic, and these too should be recycled. Other hazardous, large-quantity products that we use in hospitals include small batteries. Paper and plastic recycling is becoming a part of our culture in many nations around the world. Additionally HCWH has helped to developed "e-cycling" in health care for recycling computers. At the University of Maryland Medical Center, 97,000 small batteries were purchased in 2006; yet, as is true of most hospitals, there was no program to recycle these small batteries which contain a wide range of potentially toxic metals including cadmium, lithium, mercury, and lead (L. Taylor, personal communication, December 2006).

However, when Denise Choiniere, a nurse in the Coronary Care Unit (CCU) at the University of Maryland Medical Center, began to learn more about environmental health she began looking at her workplace in a new light. She discovered that the large number of batteries that were used in the CCU were tossed in the trash and the trash was being incinerated. She realized this meant that all of the metals in these batteries were winding up in the environment, either emitted into the air via the incinerator smokestack or falling into the incinerator ash bin. This was unacceptable to Choiniere. Spurred into action, she found a battery recycling company and worked with the facilities manager to develop the first battery recycling program in the hospital, in her own CCU. She is now helping to develop a hospital-wide program and will be helping to create a guidance document on small battery recycling for the national Hospitals for a Healthy Environment group (D. Choiniere, personal communication, January 2007). Choiniere’s story is strong evidence about the power that a single nurse has to create transformative changes within an institution. More about Choiniere’s story can be found on the Luminary Project’s (2005) website www.TheLuminaryProject.org.

Benefits of Single-Use Devices

Years ago the only bed pan or urinal you would find in a hospital would have been be one made of stainless steel. After each use, the bedpan would be cleaned in a steam cleaner, known as a "hopper" in some institutions, which could be found in convenient locations around the hospital. These sustainable products were never sent home with patients, but rather used over and over again.

Perhaps, use of reusable bedpans and urinals is one of the “old” practices we might want to re-introduce.

In more recent years, hospitals have switched to using plastic bedpans and urinals that still need to be cleaned after each use. However, now when the patient goes home, these plastic products are sent home with them even though there is limited use for plastic bedpans and urinals in the home environment. Perhaps, use ofreusable bedpans and urinals is one of the "old" practices we might want to re-introduce. Nurses are in the perfect position to engage in and lead this conversation. This conversation is very important because not only is it wasteful to send home these plastic bedpans and urinals, it is also environmentally hazardous as these are plastic products, and as such are not biodegradable. Yet they often find their way to the trash bin. Captain Charles Moore (2002) described the hazard of plastic particulates in the Pacific Ocean and gave permission to the authors of this article to summarize in the following paragraphs his observations as Director of the Algalita Marine Research Foundation in Long Beach, CA.

Plastic bedpans, like diamonds, are forever. Plastics are now virtually everywhere in our modern society. If plastic doesn't biodegrade, what does it do? It photo-degrades - a process in which it is broken down by sunlight into smaller and smaller pieces, all of which are still plastic polymers eventually becoming individual molecules of plastic, still too tough for anything to digest. These plastics travel down our fresh water ways and work their way into the ocean where, as they float around, they accumulate the non-water soluble poisons we manufacture for various purposes. It turns out that plastic polymers are sponges for dichlorodiphenyltrichlorethane (DDT), polychlorinated biphenyls (PCBs), and nonylphenols which are lipophilic toxics that don't dissolve in seawater. These are not like heavy metal poisons that affect the animal that ingests them directly. Rather, they are what might be called second-generation toxins.

In the middle of the Pacific Ocean, a trillion vectors for our worst pollutants are being ingested by the most efficient natural vacuum cleaners nature ever invented - the mucus web feeding jellies and salps (chordate jellies that are the fastest growing multi-cellular organisms on the planet). These organisms are in turn eaten by fish and then, certainly in many cases, by humans. We can grow pesticide-free organic produce, but can nature yet produce a pesticide-free organic fish?

Animals have evolved hormone receptors, which regulate brain activity and reproduction, among many other things. Hormone receptors cannot distinguish these plastic toxics from the natural estrogenic hormone, estradiol; and when the pollutants dock at these receptors instead of the natural hormone, they have been shown to have a number of negative effects in everything from birds and fish to humans. The whole issue of hormone disruption is becoming one of the biggest- if not the biggest - environmental issue of the 21st century. Hormone disruption has been implicated in lower sperm counts and higher ratios of females to males in both humans and animals.

The levels of plastic particulates in the Pacific have at least tripled in the last 10 years and a tenfold increase in the next decade is not unreasonable. Then, 60 times more plastic than plankton will float on its surface.

Nurses, recognizing the dangers of sending, unnecessarily, plastic products home with patients, products which will likely enter our waste stream, pollute the environment, and result in future health problems, can and must speak up about these dangers and change health care practices before it is too late.

Dangers of Incineration for Waste Management

When waste is incinerated, a variety of potentially toxic chemicals can be released into the air and subsequently enter our bodies. For instance, when mercury-containing products are incinerated, mercury can become airborne and ultimately end up in our waterways, in our fish, and subsequently in our bodies. An equally insidious problem occurs when certain kinds of plastics are incinerated. When polyvinyl chloride (PVC) plastics, which comprise myriad hospital products, are manufactured or incinerated, dioxins are created and emitted into the air. Human exposure to dioxin occurs through the food chain and begins when dioxin emissions settle in water or on plant life, are subsequently ingested by fish and livestock, and, in turn, eaten by humans. Dioxins, like many other persistent pollutants (including many pesticides), biomagnify, which means

When waste is incinerated, a variety of potentially toxic chemicals can be released into the air and subsequently enter our bodies.

they become increasingly concentrated in living tissues as move up the food chain (Oris, 2000).The very top of this food chain is the breastfeeding infant. According to the U.S. Environmental Protection Agency (EPA), beef and dairy products remain among the leading sources of dioxin exposure for adults (Consumer Reports, 1998). Additionally, an assay of the dioxin content in a dozen brands of baby food jars of meat projected that a baby who ate 2.5 ounces of an typical, meat-based baby food on a given day would consume around 100 times the EPA's daily limit of dioxins. No brand was significantly more contaminated than another (Consumer Reports, 1998). Dioxin is lipophilic; when dioxin is consumed by humans, it is stored in the fatty tissue. Human babies who are breastfed can receive 10% of their lifetime exposure to dioxin from their mother's fat-laden milk. Once dioxins get into the environment and into our bodies, they do not biodegrade or metabolize into something less toxic. They persist in the environment and persist in our bodies where they are believed to have a half-life of seven to twelve years (Wolfe, Michalek, & Miner, 1995). In biomonitoring studies, dioxins are commonly found in the human body, including women’s breast milk and umbilical cord blood (Environmental Working Group, 2007).

Animal studies confirm a wide range of undesirable reproductive and developmental effects of dioxin in different species, some occurring at very low exposure levels. These effects include changes in hormone levels, fertility, sexual behavior, litter size, and ability to carry pregnancy to term, as well as birth defects, learning disabilities, and endometriosis. A potential connection existing between exposure to dioxin and endometriosis is based on primate studies wherein dioxin exposure increased the incidence and severity of endometriosis in monkeys and in rodent populations (Birnbaum & Cummings, 2002). Women who suffer from endometriosis have higher blood levels of dioxins in their endometrial tissue (Mayani, Barel, Soback, & Almagor, 1997).

As nurses, we need to continue advocating for breastfeeding, as we simultaneously advocate for PVC-free products in the hospital and elsewhere. From a health care provider perspective, dioxins can be reduced as we (a) select plastics that are PVC-free, (b) recycle PVC products that are used, and (c) eliminate incineration as a waste disposal method.

As the primary users of PVC-containing products in hospitals, nurses can participate in both identifying products containing PVC and helping to develop a policy to reduce the use of PVC in their facilities. HCWH has developed a guide, "Preventing Harm from Phthalates, Avoiding PVC Use in Hospitals," (Ruzickcova, Cobbing, Rossi, & Belazzi, 2004) which offers information for dealing with existing products, selecting alternatives, and constructing/renovating buildings that are PVC-free.

Although progress in decreasing waste management by incineration has been made (as evidenced by the fact

Landfill is the environmentally safer choice but by no means perfect…

that the majority of the more than 3,000 medical waste incinerators in the country in 1995 have been closed, leaving approximately 89 nationwide as of this writing) continuing efforts to manage waste products are still needed. Hospital waste, particularly in urban areas, is still often sent to a municipal incinerator. Some hospitals have chosen technologies, such as autoclaves or microwaves to address the infectious risks of hospital waste streams. However, once these processes are completed the non-infectious waste still needs a final resting place. This usually means one of two choices: landfill or incineration. Landfill is the environmentally safer choice but by no means perfect, particularly as we run out of places to put our waste. No one wants a landfill in their backyard. Scrupulous waste reduction efforts are still needed to keep toxins out of the waste stream altogether.

Decreasing Use of Chemical Pollutants

Many of the chemicals we once thought useful in providing safe care in hospitals have been found to be dangerous for patients and health care workers alike. These include, among others, chemicals called persistent organic pollutants (POPs), which are some of the most dangerous chemicals that have been created by man and include pesticides, industrial chemicals, and chemical by-products. They are sustained in the environment for long periods of time, hence the descriptive term "persistent." Also included are compounds found to be asthma triggers, chemicals in the plastic family called di(2-ethylhexyl) phthalate (DEHP), and pesticides. These dangerous and polluting chemicals will be discussed below.

Persistent Organic Pollutants (POPs)

Many POPs are in current use today. One group of these chemicals includes the insecticides, such as Aldrin and Chloradane which target termites, DDT which targets mosquitoes, and Heptachlor which is used for mosquito and fire ant control. Other chemical insecticides, such as Dieldrin and Endrin, are used directly on fruit, soil, and seed crops, including corn, cotton, and potatoes. Toxaphene, a mixture of up to 670 chemicals, is used against ticks and mites. Hexachlorobenzene is a fungicide as well as a by-product of pesticide manufacturing. PCBs are also considered POPs. They are used primarily in capacitors, transformers, and hydraulic and heat transfer systems, but also in weatherproofing, carbonless copy paper, paint, adhesives, and plasticizers in synthetic resins. However, the majority of POPs are categorized as pesticides. They have been linked to a variety of health issues including disruption to reproduction, development, and the nervous system; suppression of the immune system; and cancer.

The Stockholm Convention on Persistent Organic Pollutants (n.d.), an agreement devoted to eliminating POPs worldwide, was formally adopted in Sweden in May 2001. It has been signed and ratified by more than 126 countries including most of Europe. The US signed the convention, but as yet there has been no ratification. This treaty has been supported by both the chemical industry trade associations and environmental/public health groups, including more than 300 non-governmental organizations (NGOs) participating in the International POPs Elimination Network. The treaty is based on precaution in the face of uncertainty about the nature and extent of toxic chemical threats. It requires that developed countries provide additional financial resources so that all nations can participate in treaty implementation. Furthermore it appeals to all participating parties to prevent the production and use of new POP chemicals and to eliminate dioxins and other hazardous chemical by-products. The treaty also calls for substitute products and processes rather than reliance on pollution scrubbers and filters.

Asthma Triggers

Given the prevalence of asthma in both children and adults in the US, the last thing one would want, or expect to encounter in a hospital setting, would be a chemical associated with causing asthma or triggering asthma symptoms. Bresnitz et al. (2004) reported that 10% to 23% of new adult onset

…the last thing one would want…in a hospital setting would be a chemical associated with causing asthma or triggering asthma symptoms.

asthma cases are due to workplace exposures including health care settings. HCWH recently commissioned a report, "Risks to Asthma Posed by Indoor Health Care Environment, A Guide to Identifying and Reducing Problematic Exposures," (HCWH, 2006) which describes common hospital chemicals and products that are associated with asthma. The report identifies 11 categories of chemicals that are either asthmagens (chemicals that are known to cause asthma) or asthma triggers (chemicals that cause asthma symptoms in a person who has asthma). In each instance, solutions are offered to reduce or eliminate exposures to these chemicals. Figure 2 summarizes the report’s findings. Armed with the information in this Figure, nurses can help to identify places in the hospital where asthma triggers can be reduced or eliminated.

 

Figure 2: Asthma risks posed by chemicals used in health care environments
Chemical	Use in hospitals	Asthmagen or asthma trigger?	How to reduce exposure	Safer Alternatives
Cleaners, disinfectants/ sterilizers	Cleaning products, equipment sterilizers	Asthmagen and asthma trigger	Use microfiber mops, refine cleaning practices, isolate chemicals	Products free of: Ethylene oxide Formaldehyde Glutaraldehyde Green Seal approved products
Natural rubber latex	Gloves, catheters, and other hospital products	Asthmagen, possibly asthma trigger	Use non-latex or powder-free latex gloves	Non-latex or powder-free latex gloves
Pesticides	Indoor and outdoor areas	Asthmagen	Integrated Pest Management programs	IPM* - using non-toxic pest control methods & products
Volatile Organic Compounds (VOCs)	Formaldehyde: building materials, paper products, tissue fixatives	Asthmagen, possibly asthma trigger	Increase general ventilation to diffuse VOC off-gassing	Low- or no-VOC products, Formaldehyde -free products
Baking flour	Kitchens and bakeries	Asthmagen and asthma trigger	Mechanical flour sprinklers, good ventilation systems, quick cleanup of spills with wet mop	Pre-combined dry ingredients, low-dust flour, ready-to-bake dough
Acrylics: methyl methacrylate and cyanocrylate	Acrylic resins used in medical and dental polymers and cement	Asthmagen and asthma trigger	Isolate, enclose, and automate processes that use acrylic compounds, improve ventilation systems	Products free of: Methyl methacrylate Cyanoacrylate Acrylic compounds
Perfumes/fragrances	Scented cleaners, fragrance-emitting devices, people wearing perfume	Asthma trigger	Institute fragrance-free policies	Fragrance- free products
Phthalates (plasticizers)	Widespread: plastics, medical devices	Undetermined	Improve ventilation for moisture control to decrease emissions	Phthalate- free products, (both medical & office products)
Environmental Tobacco Smoke (ETS)	Individuals who smoke	Asthmagen and asthma trigger	Maintain a smoke-free facility and grounds
Biologic allergens	Mold/fungus, indoor pollen, dust/dust mites, pet hair, cockroaches	Asthmagen and asthma trigger	Good housekeeping and building maintenance practices, moisture control
Pharmaceuticals	Antibiotics, laxatives, anti-hypertensives, antituberculars, H2 blockers	Asthmagen	Hoppers, ventilation hoods, personal protective equipment, respirators	Clinical substitutions if possible
* IPM – Integrated Pest Management is a systematic approach to managing pests provides a comprehensive framework for assessing pest problems, assessing the sources of food, water and nesting that support growth and reproduction of pests, determining the non- and least-toxic techniques and products to be employed, and evaluating success and/or need for additional considerations. For more information on IPM, see: www.beyondpesticides.org

Di(2-ethylhexyl) phthalate (DEHP)

A sub-culprit in the plastic family is di(2-ethylhexyl) phthalate or DEHP. This chemical alters development of the male reproductive system in laboratory animal studies, causing a spectrum of health effects including birth defects and infertility. It is also the chemical that is added to PVC plastic that allows it to be malleable, rather than brittle. In 2000, an expert panel of the National Toxicology Program raised "serious concern" that exposure to DEHP from medical therapy provided to sick infants in hospitals could adversely affect the male reproductive tract. The U.S. Food and Drug Administration followed up with a 2001 safety assessment on DEHP in medical devices; and in 2001, the agency issued a notification to health care providers recommending that DEHP-free medical devices be used on certain at-risk patients, including intensively treated male infants and pregnant women carrying male fetuses. A new study by researchers from the Harvard School of Public Health (Green et al., 2005) added weight to concerns about the use of medical devices, including IV bags and IV tubing, that contain DEHP. These researchers found high blood levels of DEHP in infants treated in Neonatal Intensive Care Units. The NICU infants had, on average, 25 times higher levels of DEHP than the general population, and 25 to 50 times higher levels for the most exposed infants. The study did not examine health consequences of DEHP, but it is the first to show a direct relationship between phthalate levels in babies and the intensity at which DEHP-containing medical devices were used in their treatment.

Many health care providers have responded by replacing DEHP-containing medical devices with safer alternatives. Kaiser Permanente, the largest non-profit health plan in the US, is using PVC-free/DEHP-free alternatives for IV bags, tubing, catheters, and feeding tubes. Other hospitals are also working to identify phthalate-containing medical devices and replacing them where possible. Many of these changes are being driven by nurses.

Pesticides

Pesticides are a category of chemicals that are generally formulated to either repel or kill an organism or prevent its reproduction. The following comprise the broad category of pesticides: insecticides, fungicides, biocides (including the antimicrobial soaps that are not only found in patient rooms, but also in many women’s purses), herbicides, and rodenticides. In 2003, Health Care Without Harm surveyed hospitals and discovered that 100% of them regularly used pesticides indoors, and/or outdoors (HCWH, 2003). Once again, given the relative vulnerability of the patients in hospitals, it’s appropriate to find substitutes for any and all of the toxic chemicals that we bring into health care settings.

Some hospitals are now adopting non-toxic and least-toxic approaches to pest management known as Integrated Pest Management (IPM) which has many elements that are familiar to nurses. The first step is to assess whether there is, in fact, a pest problem. Many hospitals that were surveyed used a regular pest management contractor that did not utilize a formal assessment. Once the assessment is complete, a plan is developed to: (a) remove sources of food for the pest, (b) remove sources of water, (c) remove access to "nesting" areas, and (d) to close off entry points, such as cracks and crevices. After these measures are taken, non-toxic pest repellents are selected and followed, if necessary, by highly selective use of contained, least-toxic pesticides such as "roach hotels" and other types of contained pesticide products. Finally, the success of such an intervention is evaluated and revisions in the process are made as needed (Environmental Protection Agency, 2006). Seven hospitals in Maryland associated with the Maryland Hospitals for a Healthy Environment Program are implementing pilot IPM programs, in collaboration with Beyond Pesticides, a non-profit organization with exceptional expertise in pest management. The results of these pilots will inform a set of guidance documents on effective IPM in health care. The website Beyond Pesticides (n.d.) provides additional information regarding the IPM program.

Promoting Use of Healthy Foods

The total health care market for food and beverages is about $12 billion, according to the National Society for Healthcare Foodservice Management (2007). These expenditures placed the health care industry third, behind K-12 schools and colleges/universities, as one of the largest institutional purchasers of food in the nation. Hospital food service typically has two components which include food preparation and delivery to patients, who often have special dietary needs, as well as food sold to staff and visitors in cafeterias, food courts, and coffee stands. Choices made in selecting food for these venues can have a profound effect on human health from an ecological health perspective, as well as that of individual health.

Health Care Without Harm (n.d.a) initiated a Healthy Food in Health Care program in 2005 which assists hospitals in adopting food policies and practices that take into account a range of environmental health issues – both human and ecological health. It includes promoting the use of local foods from farmers and distributors, organic foods, milk without synthetic hormones, meat and poultry raised

The strongest emphasis of the food program is in assisting hospitals to purchase their food locally.

without the use of non-therapeutic antibiotics, and fair-trade coffees, to name a few. The simple fact that a local strawberry will not have to travel 3,000 miles to get to a patient’s plate has its own small impact on global warming. Each of these small steps quickly accumulates, ultimately creating a sizable impact on sustaining our environment. Sustainable food practices include offering healthier foods in the vending machines, composting food waste (kitchen scraps), hosting farmers markets or farm stands, and having "kitchen gardens" on hospital grounds. The strongest emphasis of the food program is in assisting hospitals to purchase their food locally. Mitchell (n.d.) surveyed 22 hospital food service professionals in the greater Baltimore area and found great interest among these professionals in moving towards more sustainable foods. The percentage of food service professionals interested in various sustainable food practices is as follows:

• 94% - purchasing local foods
• 71% - buying hormone-free milk
• 65% - hosting a farmers’ market on their hospital grounds
• 65% - receiving individual assistance in finding resources to take next steps
• 65% - starting a Food Committee at their hospital with other hospital employees
• 65% - signing the Healthy Food in Health Care Pledge
• 53% - buying meat and poultry raised without the use of non-therapeutic antibiotics
• 53% - buying organic and other certified foods
• 53% - purchasing other locally prepared foods, such as breads, salsa, and honey

There are now several Kaiser hospitals that are hosting a weekly farmers’ market on their grounds, thus providing their employees, patients, and neighbors an opportunity to purchase fresh, local foods.

Promoting Nursing Leadership in Environmental Stewardship

Meaningful progress in transforming our hospitals into environmentally healthy and safe places cannot be successful without nurses engaging in the effort. Florence Nightingale began the work of making our hospitals environmentally safe over 100 years ago, and we encourage all nurses to further her foundational efforts. While many nurses implement environmentally responsible practices in their homes through recycling, purchasing reusable and non-toxic products, and using sustainable foods, they often have not felt they had the knowledge and/or the power to carry these efforts over to their work settings.

Yet the media has recently indicated a shift in both awareness and willingness to make these changes. As evidence of nurses’ growing concern and engagement, ten Constituent Member Associations (CMAs) of the American Nurses Association (ANA) including Alabama, Connecticut, Florida, Maryland, Michigan, New Jersey, New York,

Florence Nightingale began the work of making our hospitals environmentally safe over 100 years ago, and we encourage all nurses to further her foundational efforts.

Ohio, Oklahoma, and Washington, collaborated together to develop the document, "Guidance for Developing an Environmental Health Task Force" (Maryland Nurses Association, 2006). Other states are now in the planning stages for launching similar entities. These task forces are developing educational programs and activities that are steeped in environmental stewardship values which promote environmental health.

As patient advocates, nurses expect the environment in which they work to be safe for their patients, as well as themselves. Often, however, they may not realize the hidden dangers in their work environments. A pediatric nurse caring for a child admitted for an acute asthma attack may not consider that the cleaning solutions or wax being used on the unit’s floors could actually be compromising her patient’s condition. Once this connection is made, the nurse would certainly want to effect change. Likewise, the nurse in a coronary care unit may not initially consider that throwing away a tiny battery into the general trash could ultimately result in the release of toxic metals into the air he, his patient, and his family would be breathing. Again, understanding the connection could motivate the nurse to recycle the battery and possibly create a recycling program for his agency.

Transforming hospitals into environmentally healthy places necessitates forging and building relationships among various departments within a facility. Nursing input on committees addressing the purchase of equipment and supplies, environmental services, and waste management is essential. Nursing and hospital administration need to work together to support movement toward an environmentally safe workplace by supporting the education of staff as well as healthy changes in supply and waste practices. Over time these changes to protect human health may also have a positive impact on the bottom line of the facility as the facility learns how to be reimbursed for recyclables, explores free composting services for food waste, rethinks reusable products, and ultimately reduces the waste stream.

Summary

Nurses can take leadership in decreasing the use of chemical pollutants by helping purchasing and environmental services staff understand the connection between safe products and good health…

Nurses can be the catalyst to transform their workplace into an environmentally healthy and safe place by promoting environmentally preferable purchasing policies and suggesting environmentally friendly products. Even in a bustling hospital taking strides to reduce the amount of waste, properly disposing of potentially toxic materials such as batteries, and initiating recycling programs can work to improve environmental and workplace health. Nurses can take leadership in decreasing the use of chemical pollutants by helping purchasing and environmental services staff understand the connection between safe products and good health and working together with them to seek safe alternatives. What we put into our bodies is also key; supporting sustainable food programs, where the food is free of harmful chemicals, antibiotics, and hormones, is another area in which nurses can work with dietary departments to effect change. Nurses are the most appropriate discipline to demonstrate leadership in environmental stewardship as they are at the hub of all hospital activity. Nurses need to learn more about the health of the environment where they work and direct change to improve this environment for their patients and themselves.

Authors

Barbara Sattler, RN, DrPH, FAAN
E-mail: bsattler@son.umaryland.edu

Barbara Sattler is Associate Professor and the Director of the Environmental Health Education Center at the University of Maryland School of Nursing. The Environmental Health Education Center is a multi-disciplinary center engaged in training, education, and research related to environmental health. Dr. Sattler directs the first Environmental Health Nursing graduate program in the country, preparing nurses at the Masters, Post-Master's Certificate, and Doctoral levels. She has been an active member of Health Care Without Harm and Hospitals for a Healthy Environment. Dr. Sattler holds both Master's and Doctoral degrees in Public Health from the Johns Hopkins University School of Hygiene and Public Health.

Kathryn Hall, RN, MS
E-Mail: Khall003@son.umaryland.edu

Kathryn Hall is the Outreach Coordinator for the University of Maryland School of Nursing Environmental Health Education Center. She has worked on a variety of environmental health topics and has served as a resource to nursing groups in the area of environmental health. She received her baccalaureate degree from the University of Virginia in Charlottesville, VA, and her master’s degree from the University of Maryland.

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