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AJN, American Journal of Nursing:
doi: 10.1097/
Environments and Health

Greening the ‘Proclamation for Change’: Healing Through Sustainable Health Care Environments

Anderko, Laura PhD, RN; Chalupka, Stephanie EdD, RN, PHCNS-BC, FAAOHN; Gray, Whitney Austin PhD, LEED AP; Kesten, Karen DNP, RN

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Author Information

Laura Anderko holds the Robert and Kathleen Scanlon Endowed Chair in Values Based Health Care at the Georgetown University School of Nursing and Health Studies in Washington, DC. Stephanie Chalupka is a visiting scientist at the Harvard School of Public Health in Boston and associate dean of nursing at Worcester State University in Worcester, MA. Whitney Austin Gray is health practice research director at Cannon Design and an adjunct assistant professor at the Georgetown University School of Nursing and Health Studies. Karen Kesten is an assistant professor at the Georgetown University School of Nursing and Health Studies. Contact author: Laura Anderko, The authors have disclosed no conflicts of interest, financial or otherwise.

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Nurses advocate sustainable design to transform health care.

“Badly constructed houses do for the healthy what badly constructed hospitals do for the sick.” - —Florence Nightingale, Notes on Nursing: What It Is and What It Is Not

The influence of the environment on human health has been an important consideration in nursing since its inception. Florence Nightingale thought of environmental influences as fundamental causes of disease, and she focused her nursing interventions on modification of the environment—especially the provision of pure air and water, efficient drainage, cleanliness, and light—as a primary means of promoting health.1

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In the past three decades, researchers have learned a great deal about environmental effects on health, including the ways in which the design and operation of health care facilities can negatively affect the health of patients and employees, communities, and the environment at large. From health care–associated infections and medical errors to pollution caused by the incineration of hospital waste, health care institutions have much to rectify before they can become truly healing environments.

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In 2007, Kaiser Permanente and Ascension Health convened the Nurse Work Environment Innovation Summit, funded by a grant from the Robert Wood Johnson Foundation, to address inefficiencies in unit design and layout, work flow, and technology. The goal was to influence the design and construction of new health care facilities, identify evidence-based practices that reduce work stress, and increase patient safety and care quality through improved nurse work environments.2 The summit was a three-day gathering of more than 200 health care stakeholders from the United States, Canada, and Australia; three-quarters of attendees were nurses and nurse leaders, and others included physicians, architects, technology innovators, and vendors. Many at the summit represented hospitals and health systems, professional organizations, universities, and foundations.

The attendees sought to build on data and experience gained in previous initiatives, including the Time and Motion Study and the Technology Drill Down and Transforming Care at the Bedside initiatives.2 These had identified barriers to efficiency in nurses’ work environments, particularly in documentation, medication administration, care coordination and communication among providers, and problems related to equipment and supplies; they had also identified strategies for dealing with these issues. At the summit, “participants were able to simulate daily unit activities (e.g., medication administration), brainstorm means to improve nurse workflow, and then apply their ideas directly in an emulated medical–surgical unit.”2

One result of this process was the Proclamation for Change, a set of four principles that “support change through a focus on patient-centered design; the implementation of systemwide, integrated technology; the creation of seamless workplace environments; and the promotion of vendor partnerships.”2 The proclamation has since been endorsed by several major health care systems as well as the American Academy of Nursing, the Academy of Medical–Surgical Nurses, the American Nurses Association (ANA), and AARP.

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The purpose of this article is to suggest an expansion of the Proclamation for Change. We believe health care organizations and providers would do well to adopt the tenets of the proclamation to guide the transformation of health care practice and help realize the ideal of better patient-centered care. However, as the health care system grows and evolves, providers and institutions must take to heart the broader values of social responsibility and environmental health, conservation, and sustainability that have begun to transform 21st-century thinking in virtually every essential industry, including energy, agriculture, transportation, manufacturing, architecture and construction, and natural resource management.

We propose that nurses and other health care providers, in effect, view the Proclamation for Change through a green lens, adapting its four tenets, where necessary, to provide a socially responsible, environmentally sound framework for action within their own institutions and to ensure the environmental sustainability of health care facility design, construction, renovation, and operation. We believe nurses can and should take a leadership role in partnering with other health care providers and all those involved in operating health care facilities to effect this transformation, in which health care institutions become environmentally sustainable, promote good health and healing, and influence healthy public policy.

We propose the following ‘Green Addendum’ to the Proclamation for Change and urge all nurses, health care providers, hospital administrators, and other health care stakeholders to commit to these four principles. Hospitals and other health care facilities should

* adopt sustainable and human-centered designs that incorporate green building materials from the inception of all capital projects, both new construction and renovations.

* support vendor partnerships that promote the use of environmentally preferable purchasing (EPP) and require that suppliers disclose comprehensive hazard data on the chemical and material content of products.

* create healing environments that go beyond superficial visual amenities.

* provide the leadership to ensure and manage interdisciplinary sustainability efforts.

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Our thinking about greening the Proclamation for Change was shaped, in part, by the Hannover Principles, a set of guidelines for international design competitions commissioned by the City of Hannover, Germany, for the Expo 2000 World's Fair. Developed by William McDonough and Partners, an architectural firm in Charlottesville, Virginia, the Hannover Principles provide an excellent introduction to the concepts of sustainability and design for sustainability and are readily adaptable to health care facility design.3

Sustainability. The authors of the Hannover Principles adopted the meaning of sustainability put forth in 1987 by the United Nations World Commission on Environment and Development (also known as the Brundtland Commission): “Meeting the needs of the present without compromising the ability of future generations to meet their own needs”; however, they also noted that the original formulation “was stated solely from the human point of view” and “must be expanded to allow all parts of nature to meet their own needs now and in the future.”3, 4

Design for sustainability, the authors write, “requires awareness of the full short and long-term consequences of any transformation of the environment. Sustainable design is the conception and realization of environmentally sensitive and responsible expression as a part of the evolving matrix of nature.”3, 4

Designers of sustainable health care facilities, therefore, must consider human needs along with the capacities of the natural world to absorb the impact of human activity and develop strategies that address site planning and land use, clean energy and renewable energy sources, water conservation, air quality, selection of building materials, and indoor environmental quality.5 The benefits of resource use must be maximized while minimizing negative environmental impacts, both inside the built space and in the environment at large.

Although evidence-based design literature shows that both human error and environmental factors contribute to medical errors, there is a critical need for health care researchers to further examine how different approaches to environmental design can improve health care quality and outcomes.6 (The Center for Health Design [see] defines evidence-based design as “the process of basing decisions about the built environment on credible research to achieve the best possible outcomes.”)

Evidence-based physical design in health care facilities, including features such as single-patient rooms, improved unit layout, and easily accessible workstations, can help reduce patient falls, health care–associated infections, and medication errors while improving patient, worker, and community safety.5, 7 (By physical design we mean the design and arrangement of all physical elements in the built environment, including architectural elements, furnishings, and technology.) Improvements in lighting conditions, especially task lighting conditions, improve visual acuity and reduce medical errors related to reading fine print and prescriptions.8-11

Strategies for green health care alternatives. Green hospital construction focuses on cleaner air and more natural light. For example, systems have been designed to reduce the buildup of latex allergens in ceiling spaces, resulting in shorter patient stays and better health outcomes.12

A 2008 literature review by Ulrich and colleagues found “a growing number of rigorous studies that help establish the relationship between the physical design of hospitals and key [patient and provider] outcomes.”6 These included “patient safety issues, such as infections, medical errors, and falls”; “other patient outcomes, such as pain, sleep, stress, depression, length of stay, spatial orientation, privacy, communication, social support, and overall patient satisfaction”; and “staff outcomes, such as injuries, stress, work effectiveness, and satisfaction.” Further, the authors note that their study6

“confirms the importance of improving the health care outcomes associated with a range of design characteristics or interventions, including single-bed rooms rather than multibed rooms, effective ventilation systems, a good acoustic environment, appropriate lighting, better ergonomic design, and improved floor layouts and work settings.”

Access to a nature view and natural light in health care facilities can also improve patient outcomes and reduce nursing stress, and the replacement of small windows with larger windows that allow for more sunlight has also been shown to improve health care provider performance and reduce depression in patients.6, 9, 13

Floor coverings commonly used in health care facilities contribute to indoor air contamination; for example, polyvinyl chloride (PVC) flooring contains phthalates—chemicals added to increase flexibility and durability—which leach into the environment and potentially have negative health effects. Phthalates are a class of chemicals found in many consumer products, including cosmetics, pharmaceuticals, medical devices, children's toys, food packaging, and building materials, but efforts have been made to eliminate their use in North America and Europe because of their health effects.14 They are known to disrupt the endocrine system and may play a role in the development of such conditions as asthma, allergies, diabetes, and cancer. Children may be particularly vulnerable.15, 16 Recently, a Swedish study found that children can absorb phthalates from PVC flooring materials through the skin, by touching floor surfaces, and in breathing contaminated air.17 In addition to concerns about chemical additives such as phthalates in PVC flooring, contamination of the environment by hazardous chemicals during PVC manufacture is also a concern.18

Health Care Without Harm, the international coalition of hospitals, health care systems, medical professionals, environmental health organizations, and other health care stakeholders, has conducted extensive research on a variety of materials and practices associated with health care facility operation, including the use of toxic chemicals and poor waste management; among these studies is an analysis of the health and environmental impacts of flooring materials. The study examines the chemicals contained in the products as well as those used in obtaining and processing the raw materials needed in their manufacture and those that are emitted once the products are in use.18 The chemicals in the flooring materials were then evaluated for persistence, bioaccumulation, and human toxicity and exposure. Although there is currently no ideal “green” material for flooring, several alternative materials seem to be preferable to PVC flooring, including synthetic rubber, polyolefin, and linoleum, with linoleum presenting the fewest and most manageable disadvantages.

Case in point. Hackensack University Medical Center in New Jersey found that rubber, a safer floor covering than PVC, entailed a modestly more expensive initial cost, but the costs over the life cycle of the product were often lower. Rubber flooring also had lower maintenance costs as well as a positive impact on patient and employee health and safety because of a significant reduction in slip-and-fall accidents and decreased exposure to the chemicals used in stripping and waxing, which are known to be respiratory irritants and contributors to occupational asthma. Nursing staff preferred the change because the alternative material provided a quieter work environment and added comfort during long hours of standing.19

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It may seem ironic that in their day-to-day efforts to promote healing and wellness, health care facilities routinely use toxic chemicals. Emerging data suggest that serious health consequences and patient safety issues may be associated with common health care practices. In addition to phthalates, noted above, other examples of potentially hazardous chemicals to which patients and health care workers may be exposed are mercury (contained in some thermometers and sphygmomanometers) and toxic cleaners. Many chemicals in the health care environment are known or suspected carcinogens and asthma triggers. While it's well known that health care workers risk infection and physical injury on the job, the risks posed by exposure to the many chemicals present in the hospital environment are less appreciated.

In 2009, Physicians for Social Responsibility issued a report detailing the first-ever investigation of chemical accumulation in the bodies of health care professionals and found that all of the participants contained toxic chemicals associated with working in health care settings.20 The chemicals tested in this investigation are found in products commonly used in health care environments including hand sanitizers, medical gauges, and IV bags and tubing, and may contribute to the development of a variety of chronic diseases.

Nurses must work with pharmaceutical and medical supply vendors to provide the least harmful products for workers, patients, and communities. Hospitals can join group purchasing organizations, known as GPOs, to obtain discounts from vendors. Whenever possible, products should be made from biobased or recycled materials that are reusable, recyclable, or compostable and have no toxic chemical components.21

Strategies for green health care alternatives. EPP is an approach to procuring goods and services that are less harmful to the environment than competing goods and services.22 It is an important step in reducing the unintended harm that may result from health care practices. Efforts to align one's institution with EPP may begin by finding safer substitutes for a small number of carefully targeted workplace hazards, such as commonly used cleaning chemicals that are associated with asthma.23 Additional information on EPP can be found on the Environmental Protection Agency's Web site (see Another good source for decision-making guidelines for green materials purchasing is “Creating Safe and Healthy Spaces: Selecting Materials that Support Healing,” a paper presented by the Center for Health Design and Health Care Without Harm at a Robert Wood Johnson Foundation–sponsored conference in 2006.19

Case in point. In wielding large-scale purchasing power, the health care industry has the potential to leverage transformative changes in facility design and construction. The efforts of Kaiser Permanente to purchase high-performance, environmentally preferable carpet products for its facilities are illustrative. To determine whether carpet products were actually environmentally preferable, Kaiser approached leading carpet manufacturers for information about their products’ environmental impact from “cradle to grave.”21 Kaiser used several parameters to evaluate the carpets, including PVC content; the presence of other persistent bioaccumulative toxins, carcinogens, and postconsumer recycled content; sustainable manufacturing practices; and the potential to cause indoor air quality problems after installation.

Kaiser found that no existing product met their performance specifications and selected two vendors to develop a product that was PVC-free and met all performance standards. Only one vendor was able to meet performance criteria and manufactured the product using 75% postconsumer-recycled material that can subsequently be recycled at the end of the product's life. The achievement earned the carpet manufacturer a sole-source contract with Kaiser Permanente, whose efforts had catalyzed innovation in the carpet industry and consequently made a safer alternative available to hospitals nationwide.21

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A growing body of evidence supports the idea that healthier work and community environments can be created by providing the kind of basic natural amenities nurses have championed since the time of Florence Nightingale: clean air and water, healthy food, and natural light. Ulrich and others have shown that providing natural light and views of nature in the design of health care facilities can have a salutary effect on both patients and caregivers, improving patient outcomes and reducing nurses’ stress.24

Food is another important consideration in the creation of healing environments. Whenever possible, the food served in hospitals should be organic and locally grown.23

Pharmaceuticals have emerged as a major environmental and public health threat; they enter the environment through excretion, bathing, and undesirable disposal methods, such as being flushed down the toilet, poured down the drain, or disposed of in the trash.25 The past two decades have seen a steady increase in per capita consumption of medications, and some estimates put the amount of wasted drugs as high as 45% of the 3.8 billion prescriptions purchased annually.26 The more drugs are consumed, the more biologically active agents are in our water.

Current federal standards do not regulate pharmaceuticals in drinking water. A 2008 Associated Press investigation found pharmaceuticals, including antibiotics, antiseizure medications, antidepressants, and hormonally active medications in the drinking water supplies of 24 major metropolitan areas, serving more than 46 million Americans.27 Previous studies of source water, finished drinking water, and tap water from U.S. water utilities detected compounds including atenolol, atrazine, carbamazepine, estrone, naproxen, and sulfamethoxazole.28

Many pharmaceuticals migrate from hospitals and homes to water sources, adversely impacting drinking water and aquatic environments. Pharmaceutical compounds that are persistent in the environment can even bioaccumulate in the food chain. According to a recent report from the Environmental Protection Agency, the 1976 Resource Conservation and Recovery Act gives the agency authority to regulate hazardous waste pharmaceuticals, but since 1980 the agency hasn't used its authority to determine whether pharmaceuticals qualify as hazardous waste.29 A revised proposal for the regulation of hazardous pharmaceutical waste at health care facilities may be available for public comment this spring, but as of this writing, it isn't known whether comprehensive federal regulations to address the problem of pollution from improper pharmaceutical disposal will be forthcoming.

Strategies for green health care alternatives. Given the potential health and environmental consequences, it is critical that nurses and nurse executives lead efforts to educate the public and other health care providers on proper pharmaceutical disposal and advocate stronger disposal regulation. The important role that health care facilities play in managing pharmaceutical waste provides opportunities for such education and advocacy; similarly, hospitals could become centers for take-back programs that collect unwanted or unused medication for proper disposal. Practice Greenhealth, an organization that supports health care institutions in establishing more environmentally friendly practices, provides a blueprint for managing pharmaceutical waste (see

Case in point. There are a number of examples of successful nationwide efforts to reduce pharmaceuticals from entering our water supply. One example of innovative stewardship of the pharmaceutical supply chain is the Dispensary of Hope, which works to redistribute unused pharmaceuticals—often samples—to people who can't afford medications. A national pharmaceutical distribution center, the Dispensary of Hope supports a network of dispensing sites and direct-to-patient prescription solutions (see

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Nurses and other providers must make a coordinated effort with architects, engineers, and community leaders to adopt principles for health care facility design that will protect and promote the health of building occupants, the surrounding community, and the global community, including its natural resources.30 It is our hope that long-term efforts to promote sustainable practices in health care will move the industry and its vendor partners toward greater social responsibility.3

Strategies for green health care alternatives. In a 2005 publication of the Agency for Healthcare Research and Quality, Nelson and colleagues identified several challenges to evidence-based health care facility design as it relates to improved safety and health, including limited opportunities available for designers, architects, health care administrators, and health care professionals to collaboratively explore lessons learned from sustainable design innovations.31 We believe nurses can initiate research and networking opportunities that would provide a venue for a variety of stakeholders to share knowledge and explore lessons learned.

Case in point. One innovative academy–industry research partnership that includes health care, architecture, and engineering used a simulated critical care setting to evaluate the impact of two design features on nurses’ stress, alertness, comfort, and performance.32 Two relatively inexpensive and feasible design interventions were identified: spatial color patterning and lighting design. In the first, portions of the walls were colored in a standardized way (based on a horizontal reference or “datum line”) to indicate equipment placement and, thereby, improve speed of access and reduce stress concerning the location of equipment in acute care situations. The second design intervention used specially designed architectural lighting fixtures and full spectrum bulbs that better simulate daylight. Physiologically, increased exposure to full spectrum light and daylight affects internal body systems by increasing melatonin levels, which in turn decreases disruption of circadian cycles, as well as pineal and pituitary gland function (decreased pituitary gland function affects hormones and hence coping mechanisms, emotions, and stress reactions).13, 33 The study participants were RNs completing graduate NP or clinical nurse specialist programs. The Stress and Arousal Checklist was used to measure nurses’ stress and alertness, and the Occupant Satisfaction Survey for Healthcare was used to measure their satisfaction and comfort with the design of the room.32 It was hypothesized that nurses’ stress, alertness, comfort, and performance would improve after working in a patient room with the color patterning and lighting design interventions. Nurses reported a significant reduction in stress and an increase in alertness after exposure to the redesigned room.32 Academy–industry partnerships such as this are critical to understanding what can be achieved when environmentally sustainable design and operations are integrated into health care settings.

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As highly trusted health professionals, nurses can be instrumental in shaping environmental health policy, using the expertise and support offered by a range of national and international organizations (see Resources for Promoting Sustainable Health Care). There are many success stories that can help drive institutional policy to support environmentally sustainable health care. But beyond institutional policy changes, we need a national discussion about transforming the nation's health care system to embrace green alternatives in design, construction, and operations of our health care facilities, a discussion in which government agencies, health care nonprofits, and professional organizations with nurses in leadership roles, will participate.

We may not have to look abroad for environmental policies that exemplify the precautionary principle “first, do no harm,” but it behooves us to observe the efforts other nations are making to ensure the safety of their most vulnerable citizens. Consider, for example, how the European Union has taken the lead in adopting PVC- and diethylhexyl phthalates (DEHP)-free health care products, particularly those used in neonatal ICUs.34 This is the kind of leadership we advocate.

More than a decade ago, the ANA resolved that nurses must lead efforts to select products that are safe for humans and the environment.35 More recently, as part of the Safer Chemicals, Healthy Families coalition, the ANA has joined together with scores of nursing, public health, environmental, labor, community, and parents’ organizations; health care providers and research institutions; and businesses to advocate for a safer U.S. chemical policy to reduce the impacts of toxins such as DEHP.36 The time is now for greening the Proclamation for Change and transforming health care into an environmentally sustainable endeavor that heals.

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Resources for Promoting Sustainable Health Care


Transforming Hospitals: Designing for Safety and Quality

Offers comprehensive information on the evidence-based physical design of health care facilities.

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Executive Primer on Hospital Environmental Sustainability

Offers information on sustainability issues relevant to hospitals and guides health care executives through the proper channels to create sustainable hospitals and practices.

Sustainability Roadmap for Hospitals

Provides health care organizations—including hospital managers, staff, and health care facility designers—with sample actions plans, target-setting and tracking tools, and specific steps they can take to improve their sustainability efforts.

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Contains educational resources, including a Getting Started Guide and a ready-to-use PowerPoint presentation on environmental sustainability.

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Contains a variety of resources on sustainable health care architecture and design, including a tool kit of best practices to use in evaluating progress toward achieving a high-performance healing environment.

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Collaborated with the Green Guide for Health Care on a rating system for green health care facilities (available at

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An international coalition of concerned groups that informs health care communities of alternatives to current health care practices in an effort to reduce negative environmental effects on public health. It hosts a Nurses Workgroup and offers a tool kit for nurses interested in learning more about health care sustainability (go to

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Provides tools for hospitals to reduce energy use and waste, choose safer and less toxic products, and purchase and serve healthier foods.

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22. Sustainable Hospitals. Ten actions to promote environmentally preferable purchasing (EPP). Lowell Center for Sustainable Production, University of Massachusetts Lowell. 2000.

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26. Hemminger P. Damming the flow of drugs into drinking water Environ Health Perspect. 2005;113(10):A678–A681

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29. Environmental Protection Agency. Unused pharmaceuticals in the healthcare industry: interim report; 2008 Aug.

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34. Health Care Without Harm. Sweden NICUs phase out PVC/DEHP feeding tubes [press release]. 2004 Nov 9.

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© 2013 Lippincott Williams & Wilkins, Inc.