Florence Nightingale and subsequent nurse scholars have written about the impact of the environment on human health. Nightingale described, and staked out, the nurse’s role in optimizing environments for healing. Since Nightingale’s time numerous scholars have documented that environmental conditions play a major role in the health of individuals and populations. As nurses become more informed about the environment as a determinant of human health, they will be able to advocate more effectively for environmental conditions that promote health. This article provides both theoretical and practical perspectives to integrate environmental concerns into nursing practice. It recommends specific actions nurses can undertake to improve the environment within the health care setting. In particular the article provides a historical review of an environmental focus in nursing, discusses ways to manage both upstream waste and downstream waste (solid, biohazard, and hazardous chemical wastes) so as to decrease environmental pollution, and recommends specific nursing actions to promote a healthy environment within our health care agencies.
Key words: environment, environment of care, environmentally responsible clinical practice, hazardous waste, JCAHO, Nightingale, waste, waste management
To recognize the unconscious nature of many of nursing activities that do impact the environment, such as waste disposal, nurses need to take a moment and reflect on the last time they worked. It helps to do an assessment of the many items handled in a given shift that could have a negative effect on the environment. Try this assessment yourself by replaying (assessing) the activities of a shift. For example, consider how many medications were administered, what types of supplies were used, how many units of blood were hung, how many forms were filled out, how many items went from a nurse’s hands to a sharps container, a trash can, a recycling bin, a red bag, or a hazardous chemical waste container. Ask yourself how many gallons of water were used to complete toileting and bathing patients? How much electrical energy was used in caring for patients? Then make your diagnoses, i.e., think about the environmental impact of all of these common, daily nursing activities.
To do an adequate assessment of the impact of nursing care on the environment, one must consider everything in the environment including the lighting, air conditioning or heating, electrical equipment and pumps, elevators, computers, electronic medication dispensing machines, monitors, and more. This exercise reveals the environmental infrastructure of health care and displays the 'ecological footprint' of health care, which is a metaphor used to depict the resources a person, institution, or community would hypothetically need to support itself and to absorb its wastes, given the known technology (Shaner-McRae, 2002; Wackernagel & Rees, 1996). Such reflection utilizes the basic skills of inquiry nurses use every day with patients and allows them to establish a holistic view of the conditions in their place of work that may need remediation.
However, nurses seldom do such assessments because environmental systems are generally silent partners in the work they do. It is only when systems break down that an environmental problem becomes obvious. It is only
| …environmental systems are generally silent partners in the work nurses do. |
True responsibility for protecting the health care environment lies with each one of us. Whatever type of nursing a nurse performs, he or she can make a difference by paying attention to health care waste management. Nightingale set the stage in her writings, encouraging nurses to be involved at all levels and all capacities in providing optimal health care settings. This is as much a challenge today as it was in 1860.
The intent of this article is to raise the awareness of nursing staff regarding the importance of proper health care waste management so as to enhance the quality of the health care environment. Today nurses must demonstrate competence in fire safety, the Health Insurance Portability and Accountability Act (HIPAA),
| Whatever type of nursing a nurse performs, he or she can make a difference by paying attention to health care waste management.
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The Roots and Branches of an Environmental Focus in Nursing
In a metaphoric sense, Florence Nightingale’s work can be viewed as the base root and trunk of a tree, and modern environmental scholars as branches from that tree leading into various areas of nursing practice. Florence Nightingale's book, Notes on Nursing (1946), first published in 1860, offers specific information on how environmental factors impact health. Air quality, water quality, noise, light, and nutrition were her priorities. Many of Nightingale's implications of the importance of a clean environment, derived from her experience in nursing, have been substantiated in contemporary work by public health researchers, occupational health professionals, and industrial hygienists (Centers for Disease Control, 2005; Pimentel et al., 1998; Steingraber, 1997).
Nightingale's attention to air quality represented some of the first modern thinking about the relationship of environmental conditions to human health status. In her Notes on Nursing (1946) she discussed how in the 1800’s England was plagued with poor air quality from the heavy use of coal as a fuel for home heating. She was concerned with indoor, as well as outdoor air quality. Nightingale was so adamant about the importance of indoor air quality and ventilation that she prioritized it in Notes as the "first cannon of nursing." Today poor air quality is still a health-related concern. In 1994, the U.S. Environmental Protection Agency (EPA) documented that citizens in the United States were spending as much as 90% of their lives in indoor environments, settings over which there is little or no federal regulation or standards for air quality. In work places and schools poor air quality has been cited as a significant contributor to the increase in asthma, a disease that is a leading cause of absenteeism (American Academy of Allergy, Asthma, & Immunology, 2004). Hospitals are emerging as the most common work site for reported cases of occupational asthma through the exposure to commonly used toxic materials such as glutaraldehyde (Di Stefano, Siriruttanapruk, McCoach, & Sherwood Burge, 1999) and latex (LaMontagne, Radi, Elder, Abramson, & Sim 2006).
Nightingale (1946) also wrote about the need for pure and clean water to promote health and healing. Nurses are often taught about the importance of hydration for patients, but are seldom taught how to protect and secure a clean water source in health care facilities and at home. There is an increasing need to attend to the safety of our water supply especially as the number and types of contaminants often found in water
| Nightingale's attention to air quality represented some of the first modern thinking about the relationship of environmental conditions to human health status.
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In the current health care setting Nightingale’s focus on the environment can be lost as nurses are pressured to focus on the myriad technologies surrounding them, and the numerous administrative and documentation tasks they must complete. Fortunately contemporary nurse theorists, such as Jean Watson (2004), are taking up Nightingale’s charge and addressing the importance of creating a healing environment, recognizing that the workplace environmental design should promote healing of patients and protection of the environment rather than degrading the environment. This emphasis is timely given the research published by Pimentel and colleagues (1998), who documented that more than 40% of deaths worldwide are caused by environmental pollution and degradation. Watson and Pimentel et al. are today building on Nightingale’s early work. The works of other environmental nurse leaders include Sattler (2005); Schuster and Brown (1994); Dossey (1999); Dossey, Selanders, Beck, & Attewell (2005); and Selanders (1998a, 1998b). Additionally a number of organizations have responded to the call to provide healthier workplace environments. These organizations and their activities include the following:
- The American Nurses Association’s (2003) environmental resolution to support the elimination of toxic pollution from health care
- The International Council of Nurses’ (2004) resolution calling for the reduction of the toxicity from health care wastes globally
- The Kellogg Foundation’s (University of Maryland, n.d.) grant to support a faculty development in environmental health collaborative among colleges of nursing
- The Planetree's Model (n.d.) to help health care organizations focus on unifying patient-centered care with healing environments
- The Center for Health Design’s (2007) health care quality movement for the design of health care facilities
These are just a few examples of the emerging trend toward refocusing on the environment as core to nursing practice. The ongoing relevance of Nightingale’s work continues to expand and guide nursing practice. The rest of this paper will focus on specific activities that nurses can promote to help achieve Nightingale’s vision of environmentally responsible health care.
Environmental Protection Through Waste Management
I believe that, as health care providers, we must strive to reduce the environmental impact of providing quality health care. That means being careful about the products we choose to provide health care, being responsible about waste disposal, and conserving resources such as water, energy, and other natural resources. I hope that other clinicians will become sensitized to the need to be environmentally responsible in the workplace (Shaner, 1994, p. 250).
Hospitals generate one of the most diverse and difficult to manage waste streams of any type of organization. They generate solid waste, biohazardous waste, and hazardous chemical waste in large quantities. Table 1 below illustrates different categories (streams) of wastes that must be managed so as to promote environmental health. Usually this waste is generated in close proximity to other human beings, whose well-being and safety must be safeguarded from any hazard related to the waste.
Unlike factories or other industrial facilities, hospitals don’t have the luxury of isolating the risky materials and wastes from their customers. Hospitals and health centers operate as integrated services, providing care to patients and their families amidst the use of potentially hazardous materials. This complex integration demands that all personnel be aware of what is necessary to maintain safe conditions for patients and workers.
In many communities the hospital is the largest employer, the largest user of water and energy, and the largest generator of waste. Unlike most other institutions, hospitals remain open 365 days a year, 24 hours each day. Hospital work utilizes a diversity of hazardous substances ranging from cleaning products, to laboratory chemicals, to pharmaceuticals (Shaner & McRae, 1995). Hospitals also provide services similar to those in large hotels, restaurants, and office buildings, in addition to their clinical services. By virtue
| Unlike factories or other industrial facilities, hospitals don’t have the luxury of isolating the risky materials and wastes from their customers.
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The waste picture at a hospital is more diverse and complex than any other industry or institution (Shaner, Leach-Bisson, & McRae, 1993; Shaner & McRae, 1995). For the purposes of discussing environmentally responsible clinical practice in health care agencies, we will explain the concepts of upstream waste and also downstream waste, which includes solid waste, biohazardous waste (also known as regulated medical waste), and hazardous chemical waste. Management strategies to promote a healthy environment for each will be discussed. These brief discussions are meant as introductions. Substantial resources to support nursing initiatives to further address health care waste management are available and summarized in Table 2 below.
| Table 2. Key Resources on Initiatives in Nursing and the Environment |
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Upstream Waste
Just as a well-functioning health system focuses on health promotion and disease prevention to avoid disease and injury, there is much that can be done to promote conservation and reduce waste by focusing “upstream” or at the source. If materials that will become wastes are never brought in to the facility, they do not have to be managed as downstream wastes later on. Efforts in this area, called Pollution Prevention (U.S. EPA, 2007a) or Source Reduction, (U.S. EPA, 2006) refer to “reducing or eliminating waste at the source by modifying production processes, promoting the use of non-toxic or less-toxic substances, implementing conservation techniques, and re-using materials rather than putting them into the waste stream” (U.S. EPA, 2007a, para. 1).
Nurses working through their departmental processes, through service on institutional committees, or through their unions can raise awareness of choices in purchasing practices for environmental reasons. Nurses can request their organization to use recycled paper, to buy locally grown organic foods, and to install energy efficient lighting and water conserving plumbing fixtures. Many of these actions save
| Nurses working through their departmental processes, through service on institutional committees, or through their unions can raise awareness of choices in purchasing practices…
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Another way to avoid bringing waste into the agency is to phase out mercury and mercury containing products from the health care agency. Although mercury thermometers are seldom seen in U.S. hospitals today, mercury can still be found in other devices, and also in many chemicals and pharmaceuticals. Hence much work remains to decrease pollution related to mercury-containing products. Nurses have been, and need to continue as, part of local and national efforts to promote “mercury-free” health care, a movement that has been institutionalized through Hospitals for a Healthy Environment (H2E) (n.d. [a]), a national organization that provides technical support for hospitals looking to reduce their adverse impact on the environment.
Additionally nurses can avoid bringing dangerous substances into the hospital by decreasing use of other potentially toxic products. Polyvinyl chloride (PVC)-containing products are an example of such products. Nurses have also been at the forefront of many small and large initiatives from advocating to reduce the use of PVC products, which result in toxic pollutants when incinerated; to encouraging the use of non-incineration technologies for the treatment of health care wastes, to simple steps, such as ordering formalin in pre-filled containers rather than in bulk so there is less spillage, waste, and accidental exposure (Shaner & McRae, 1995). Additionally, latex and glutaraldehyde are two other potentially problematic materials that have garnered a great deal of attention in such efforts and represent good source reduction efforts benefiting patient, clinician, and environmental health. Nurses need to be aware of those chemicals that could cause problems and to be part of team efforts to reduce the use of these materials.
Downstream Waste
This section will discuss Solid Waste, Biohazard Waste, and Hazardous Chemical Waste. Each of these waste streams must be managed in specific ways for worker safety and regulatory compliance. Each waste stream offers unique challenges and opportunities that will be reviewed.
Solid waste: Trash, trash, and more trash. The health care industry in the United States is responsible for 1% of all the solid waste generated in the US (Shaner & McRae, 1995) (See Figure 1). This waste consists primarily of common materials such as paper, cardboard, plastic, metal, and glass. Some hospitals have found cost-effective recycling or re-use outlets for magazines, newspapers, books, old linens, used furniture, old medical equipment, unused supplies, packaging materials, food service items, and even kitchen grease. These general trash items often account for up to 90% of what is thrown out from health care institutions (Shaner et al., 1993). Nurses can play a role in cost-effective and environmentally responsible waste management as they suggest reusable devices be segregated so that they can be reclaimed, support initiatives to recycle, and help their unit become a team player in any recycling efforts. Shaner and McRae (1995) offer other examples of clinical areas taking the lead in innovative recycling of batteries, dietary containers, and paper, as well as more diverse materials such as product packaging from surgical supplies and unused supplies.
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| Figure 1. Solid waste in hospital trash pick-up truck. |
Biohazard (red bag) waste: What about those red bags and needle boxes? In many cases, and of more direct concern to nurses, is the management of wastes that are potentially infectious. Biohazard waste, (also commonly referred to as red bag waste or infectious waste) (H2 E, n.d. [b]) includes materials that are contaminated with blood or body fluids to an extent that they have the potential to transmit disease. The 10-15% or less of hospital waste that is categorized as biohazard wastes, especially sharps waste, represents an immediate threat to workers. For this reason, nurses have a personal responsibility to
| …nurses have a personal responsibility to be aware of the rules and systems developed to manage biohazard wastes appropriately.
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There are many rules, standards, and guidelines that impact how nurses handle and dispose of biohazard waste materials. State regulations are the official rules that determine what is considered
| The individual nurse’s bedside disposal decisions, when magnified across the organization, can result in tens of thousands of dollars either being spent or saved on waste management.
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| Figure 2. Critical care room with well-positioned solid trash and red bag receptacles. |
Nurses are most helpful when they work proactively with their institutions and understand and participate in waste management programs. The safest management system for red bag wastes are systems limiting the generation of red bag waste to the smallest quantity, to retain a healthy respect for this waste stream (H2E, n.d. [d]). All too often, red bag waste containers are full of coffee cups, pizza boxes, clean packaging wrap, and other items that do not belong in this expensive category of waste. Very little waste generated in today’s health care setting is actually potentially infectious. Rigorous segregation means that there is less
| All too often, red bag waste containers are full of coffee cups, pizza boxes, clean packaging wrap, and other items that do not belong in this expensive category of waste.
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Hazardous chemical waste: Understanding the chemical soup in the health care workplace. Nurses, in the context of patient care, may use hazardous chemicals. The operational responsibility for the proper use, storage, and disposal of chemical hazards is usually assigned to a Facilities Management or Environmental Management Specialist. Environmental management is a new, and still somewhat underdeveloped, concept in hospitals, despite the fact that federal regulations mandating how hazardous chemicals should be handled have been in force for a number of years. The U. S. governmental 2006 regulation regarding waste management is called the Resource Conservation and Recovery Act, or RCRA (U.S. EPA, 2007b) (pronounced Rick – ruh). While the regulations are fairly clear as to what should happen with chemicals once they are used, they do not dictate who is responsible for monitoring and implementing the regulation in a specific health care setting.
Of all the health care acronyms familiar to nurses, RCRA is likely to be one of the least recognized. One reason for this lack of recognition is that RCRA is a regulation that was created with a focus on the manufacturing industry. Many of the regulations are based on quantities of chemicals associated with large vats and tankers of hazardous materials, not the type of quantities one would encounter on a nursing unit where one finds much smaller volumes of these chemicals, i.e., amounts found in vials and syringes, and where the chemicals are more diluted. Despite the considerably greater volume of the chemicals used in manufacturing compared to health care agencies, the regulations still apply to both settings. That makes it a challenge to implement RCRA hazardous chemical waste management regulations in the service-based, small-usage setting of most hospitals. Another challenge is that RCRA does not keep up with clinical practice. For example, RCRA regulations include various lists of hazardous chemicals subject to regulation; and one of the listed hazardous materials is uracil mustard, which is no longer in common use as a chemotherapeutic agent in health care today. Meanwhile, there are many chemotherapy drugs that are just as hazardous from a chemical perspective, but are not specifically listed by EPA.
The person responsible for identifying hazardous materials in a given health care facility is often poorly defined. One or more individuals may be responsible for labeling, maintaining containers, training others, maintaining material safety data sheets, and coordinating disposal of waste. However, the identity of the person(s) responsible for these activities is not always clear to agency employees. It is important for nurses to know who in their agency holds this responsibility; linking these individuals with nursing staff is critical to successful hazardous chemical waste management.
Region II (New York and New Jersey) of the Environmental Protection Agency recently listed the most common violations of environmental law made by hospitals during a two-year period of compliance focus on hospitals. The first most common violation was under RCRA (which had the majority of all violations observed in the 49 hospitals inspected) was failure to identify hazardous materials. If the hospital does not know what hazardous chemicals are in their own facilities, it is quite challenging to create a means to responsibly manage them. Nurses need to know what these materials are and what is required of them for regulatory compliance.
For a long time, JCAHO inspectors did not have these issues related to chemical hazards prominently on their radar screens. While many hospitals would receive glowing reports from JCAHO inspections and visits, they often could and did fail EPA inspections. This has begun to change. JCAHO inspectors are now asking for
| JCAHO inspectors are now asking for more information regarding environmental management systems…
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Another new challenge in dealing with hazardous chemicals is the complex world of pharmaceutical waste streams. Hospitals for a Healthy Environment (H2E) recently completed a blueprint for the management of pharmaceutical waste, called the H2E Blueprint for Managing Hazardous Pharmaceuticals, which is available online (Pines & Smith, 2006). While the day-to-day management of pharmaceutical materials is not the responsibility of nursing staff, nurses, who do the majority of medication administration in hospitals, do need to know what systems are in place in their hospital to safely use and dispose of these pharmaceutical chemicals. Most pharmaceuticals, whether chemotherapeutic drugs or commonly used drugs such as warfarin, cannot be simply disposed of down the drain, in a red bag or sharps container, or in the regular trash. New guides are now available to help facilities structure new waste collection practices (H2E, n.d. [e]; Pines & Smith, 2006). While regulations such as RCRA exist, and third party inspectors such as JCAHO are taking more interest in this subject, the full responsibility still falls to the hospital to identify and handle pharmaceutical materials responsibly and with the same ethical perspective with which it manages other resources, such as clean air and water for their patients (Bowen, 2007).
Other chemicals commonly used by nurses are listed in Table 3 below. They are technically hazardous materials, and in most cases produce hazardous wastes after they are used. Commonly, however, they are often not managed as hazardous materials and wastes in many hospitals. It is essential that all hospitals and health care agencies, even small facilities, fully embrace environmental management systems, to protect staff and patients and to comply with regulations. For nurses to do their job effectively these environmental management systems need to be in place and evident as part of daily practice.
Nurses make numerous waste disposal and material use decisions daily, decisions that can affect the health of our environment. They need to become and remain informed regarding the policies related to institutional environmental health and general state of the environmental health of their own institutions. Furthermore, they need to take a leading role in promoting the environmental health of their health care agencies (Graham, 2002; Maliha-Nebus, 2002; Sattler, 2005; Schuster & Brown, 1994). Key steps nurses can take to fulfill this role include:
- Meeting with the organization’s environmental services or environmental health and safety division to ensure that there is an effective process of sharing the most up-to-date environmental safety information and waste management policies with nursing
- Mastering and using JCAHO environmental guidelines, leveraging the need to be in perpetual, JCAHO-inspection readiness mode as a way of expediting compliance with RCRA regulations.
- Recommending the hospital join in with the “greening” of health care movement, and utilizing the partnership and recognition award opportunities promoted by the American Hospital Association and the U.S.EPA. through the programs at H2E (n.d. [e])
In 2007 all citizens are being confronted with a number of inconvenient truths about the world (People Will See The Truth, 2006). Less than a decade ago, the health care industry was among the leading
| It is well within the nursing scope of practice to be participants in and advocates for system changes that promote resource conservation and environmental responsibility.
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Summary
Nurses have an important role to play in general environmental management in the workplace. In this article the authors have reviewed the theoretical and historical foundations of environmental issues in nursing, showcasing our former and current nursing leaders who have led the way in addressing environmental conditions in health care facilities, and noting that today there is an even greater need to practice nursing in an environmentally responsible manner. This article has provided an overview of issues within the scope of everyday practice for nurses. It has also pointed to ways in which nurses can work to prevent the entry, into health care facilities, of materials that can be environmentally hazardous, and identified environmental problems related to solid, biohazardous and hazardous chemical wastes.
Authors
Hollie Shaner-McRae, RN, MSA, FAAN
E-mail: hollie.shaner-mcrae@vtmednet.org
Hollie Shaner-McRae is the Coordinator of Nursing Practice at Fletcher Allen Health Care in Burlington, Vermont. She has practiced as a nurse in a variety of clinical settings since 1977, and is responsible for pioneering health care environmental practices with hospitals, the health care supply industry, and the waste management and regulatory sectors. She has spoken at numerous national and international conferences and authored a number of articles and two manuals on the topic. She is currently enrolled in a Doctorate of Nursing Practice Program at Rush University (Chicago).
Glenn McRae, PhD
E-mail: glennmcrae@aol.com
Glenn McRae is founder and principal of CGH Environmental Strategies, a consultancy that has focused on environmentally responsible health care practice since 1991. He has worked for multiple clients in the health care industry and most recently has been a technical consultant to the United Nations Development Programme for an eight-country program on health care waste management. He co-authored two manuals on hospital waste management for the American Hospital Association.
Victoria Jas, MS
E-mail: Victoriajas@gmail.com
Victoria Jas was the Manager of Biosafety and Environmental Programs at Dartmouth-Hitchcock Medical Center (DHMC) in Lebanon, New Hampshire, from 1989 to 2006. Under her leadership, DHMC’s, environmental programs were recognized by the Environmental Protection Agency and others as leaders in Environmental Excellence. Ms. Jas has worked in hazardous material management since 1986 and is currently preparing for the ISO 14000 Environmental Management international environmental auditor examination. Ms. Jas is a doctoral candidate at Antioch University New England (Keene, New Hampshire) and is focusing her research on hazardous material management in small and rural hospitals in New Hampshire. She is a Hazardous Materials Contingency Planning instructor and has certification in Department of Transportation Hazardous Materials Handling and Shipping.
Article published May 31, 2007
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