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Improving the environment of care: What every nurse manager can do

Jackman-Murphy, Kathryn P. MSN, RN

Nursing Management (Springhouse): January 2011 - Volume 42 - Issue 1 - p 14–16
doi: 10.1097/01.NUMA.0000390987.38216.82
Department: NEW: Risk Management

Kathryn P. Jackman-Murphy is an assistant professor of Nursing at Naugatuck Valley Community College in Waterbury, Conn., a member of the Alliance of Nurses for Healthy Environments, and a nurse consultant on chemical policy, Health Care Without Harm grant, Connecticut Nurses Association.

Every nurse manager can assist his or her nursing department and unit in becoming more environmentally friendly. A "greener" nursing unit will leave a smaller impact on the immediate healthcare environment, as well as on the global environment. And greener units are cost efficient because waste is reduced and fewer supplies are discarded unused at the end of a patient's stay. A few small, easy steps can make your unit greener by decreasing the toxins in the healthcare environment, decreasing waste, and encouraging appropriate waste management and recycling. The following are specific suggestions to assist nurse managers getting started on the environmental pathway to a greener nursing unit.

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Consider fragrance-free policies

Fragrance is a major source of indoor air pollution. Some fragrances contain phthalates, which have been shown to be endocrine disruptors and cause sperm damage. Fragrances can also contain synthetic musk compounds that have been associated with cancer in lab animals.1 The adverse effects of fragrance use include respiratory symptoms such as difficulty breathing, coughing, and asthma attacks. Other adverse effects of fragrance can include irritability, eye irritation, inflammation of mucous membranes, nausea, vomiting, and changes in BP. It's estimated that 20% of the population is adversely affected by fragrance.

Action: Encourage employees to use personal care and laundry products that are fragrance free and to refrain from using perfumes, colognes, aftershave, and other scented products while working. Consider developing a policy for all personnel regarding fragrance use, if one isn't already available at your facility. Patients, families, and staff will benefit from not breathing a variety of fragrance ingredients.

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Reduce waste

Hospital facilities generate more than 200 million tons of waste each year. The healthcare industry must manage its waste in a manner that protects patients, staff, and the environment and decreases the ecologic footprint of its institutions.2

Action: Start simply by encouraging staff to use ceramic coffee mugs instead of numerous paper or foam cups. Staff can express their personalities with their choice of mugs and will never be confused about whose cup is whose. In one nursing department, hooks were placed under a cabinet in the staff lounge for the mugs to be put up and out of the way.

A primary method to achieve environmental safety and health is to advocating for waste reduction and effective waste management.3 Educate staff on the correct use of red bags for biohazard waste. The cost for a facility to dispose of red bag trash is approximately three times higher than that of regular trash. Red bag waste is sent to an incinerator to be burned versus regular trash, which goes to a landfill. One of the consequences of the incineration of red bag trash results in the burning of plastics. The burning of plastics introduces dioxin, one of the most toxic substances, into our environment. Dioxin is a known carcinogen and endocrine disrupter.

Monitoring the supplies that are automatically placed at the bedside for patients is an important strategy to reduce waste. Many departments routinely stock water pitchers, bath basins, incentive spirometers, emesis basins, slippers, soap, and lotions at the bedside before a patient's arrival to the unit. Is it necessary to bring a stack of cups and straws for the patient when one cup is all that's needed? What about the handful of straws that are left on a bedside table, only to fall on the floor and be discarded? Does the patient even need the straws? Many of these plastic items are unnecessary, not utilized, and will be discarded. Involve staff in the decision of what's actually required at the bedside and what items should be distributed only when a need is indicated.

Another step to reducing waste is to encourage staff to reduce electrical waste. Turn off patient TVs when not in use and turn off computers and other electrical devices at the end of the day, including any items being recharged.

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Recycle

Many of the items utilized in a nursing department can be recycled to reduce waste and minimize the impact of the work environment on the global environment. Recycle whenever possible, even if not required by local ordinances. Glass, plastic, paper, and corrugated cardboard are some examples of recyclable material. This activity alone makes a significant impact on the environment. Cardboard is the largest component of solid waste in landfills.3 Check to see whether your facility has a recycling program; if not, suggest that a program is started. Meet with vendors about obtaining supplies with less packaging, reusable supplies, and products that utilize recycled materials.

Action: Utilize prominently placed color-oriented recycling containers for bottles and cans throughout the facility. Be sure all corrugated cardboard is recycled and not discarded into the regular trash. A facility can save money by recycling items such as corrugated cardboard and avoiding tipping fees for its disposal if not recycled. Provide recycling containers in your facility for newspaper and regular paper. Remember to recycle in the facility's cafeteria and coffee shop. Let the public know recycling is an important community initiative of your facility.

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Use environmentally friendly cleaning products

Hazardous chemicals such as formaldehyde can often be found in common cleaning products utilized in the healthcare environment. The consequences of exposure to cleaning products for patients, nurses, and other staff include respiratory irritation; allergic reactions; skin irritation and burns; eye, nose, and throat irritation; dizziness; sleepiness; nausea; mental status changes; liver damage; and cancer.

Action: Check with your cleaning service to determine whether the supplies used are environmentally friendly products. It's important that staff members read labels for ingredients and warnings, use products appropriately, and utilize appropriate protective equipment. There are many "green" cleaning products that do an effective job that staff members can utilize.

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Become mercury free

Health Care Without Harm (HCWH) has resolved to "make medicine mercury-free." In 2006, Practice Greenhealth, formerly Hospitals for a Healthy Environment, made a goal of eliminating virtually all mercury from facilities. Mercury is a heavy metal and a potent neurotoxin that's used in medical equipment such as thermometers, sphygmomanometers, and gastrointestinal tubes. Exposure to mercury can occur by inhalation of vapors and absorption through the skin.5 Symptoms of mercury exposure include irritability, weight loss, nervousness, memory loss, tremors, and loss of coordination. Mercury poisoning can cause permanent damage to the brain, heart, lungs, immune system, kidneys, and even death. For a pregnant woman, exposure to mercury can cause a miscarriage or damage to the fetus.

Action: If not already a member of Practice Greenhealth, suggest your facility partner with the organization to eliminate mercury from its environment. Monitor your areas for any mercury-containing devices that remain in the facility. Broken or obsolete equipment is a primary source for mercury in healthcare settings. Be sure to contact the appropriate department in your facility to dispose of these items properly.

Does your facility have a recycling project in place for batteries? Batteries can contain mercury that will leach into the environment if discarded in the regular trash. Eventually, this toxin will reach our water and food supply. Actions such as these will protect your staff, your patients, your community, and the environment.

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Use PVC and DEHP-free materials

The manufacturing and incineration of polyvinyl chloride (PVC) products can form dioxin, a known cancer-causing agent. Di(2-ethylhexyl)phthalate (DEHP) is used to soften PVC plastic, making it more flexible. DEHP can leach from medical devices such as I.V. tubing and oxygen delivery devices into the patient's body. DEHP is linked in animal studies to reproductive birth defects.

Action: Encourage your facility to use PVC/DEHP-free alternatives. If your facility has a NICU, urge it to become a partner in eliminating these toxins by signing HCWH's NICU pledge to reduce the use of these products, thus protecting vulnerable neonates from harm.

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Implement environmentally preferable purchasing

HCWH reports that every year facilities purchase thousands of different products requested by dozens of different departments, often purchasing items that are proved to be toxic. Some of these products can have serious environmental impacts, and patients and healthcare workers can experience adverse health effects from exposure to them. Environmentally preferable purchasing (EPP) identifies such hazards and can be utilized to avoid resulting health problems. The Sustainable Hospitals Project (http://www.sustainablehospitals.org) is a source of information on safer products and supplies, while also helping to contain costs and maintain high-quality patient care. This site provides information on a variety of hazards in the workplace and offers links to safer alternatives to reduce occupational and environmental hazards.

Action: Avoid purchasing furniture or materials made with brominated fire retardants (BFRs). These BFRs slowly leak into our environment from such products and accumulate in the food chain and humans. In a report to the Environmental Protection Agency in 2005, Liz Harriman of the University of Massachusetts, Lowell, cited animal studies that link BFRs to immune suppression, endocrine disruption, and cancer.6 Products are available utilizing alternate flame retardant chemicals that don't contain bio-accumulative toxins. Volunteer to join your facility's purchasing committees and work with the purchasing department and vendors to choose safer products that have been tested for health and safety and will be disposed of in an appropriate manner.

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Utilize available resources

HCWH is an excellent source of information on the impact of healthcare on the environment and offers many strategies to help protect the environment (http://www.noharm.org). Its Environmentally Preferable Purchasing for Hospitals program is an excellent resource to use for guidance in purchasing policies, with the goal to reduce healthcare's environmental impact and to increase patient and worker safety.7 Information is available on such topics as mercury, PVC and DEHP, medical waste segregation, healthy buildings, BFRs, food, electronics, food purchasing, pesticides, cleaners, disinfectants, fragrances, and green purchasing.

Practice Greenhealth is creating a national movement for environmental sustainability in healthcare. This organization was jointly founded by the American Hospital Association, the U.S. Environmental Protection Agency, HCWH, and the American Nurses Association. Practice Greenhealth, through its Partners for Change program, is educating healthcare professionals about pollution prevention opportunities and provides significant tools and resources to facilitate the industry's movement toward environmental sustainability on its website (http://www.practicegreenhealth.org).

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Educate and involve staff

Promoting and maintaining a healthy environment are the responsibilities of all direct care nurses, nurse managers, and nursing administrators. Nurses should utilize members of the healthcare team as advocates to reduce toxic exposures, minimize waste, and increase recycling on the unit. Start by establishing a Green Team with members from all departments of the healthcare environment, including representatives from nursing services. If your facility has an environmental committee, advocate for staff to attend and represent your department. Meet often with staff and give positive reinforcement for all progress, large and small, toward making your facility a healthier environment.

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Be a role model

Nurses can help control the working environment of their departments or units. Through reducing the use of toxic products, eliminating fragrances, recycling and managing waste, utilizing environmentally preferable purchasing, and educating themselves and their colleagues, nurses can create a healthier environment of care and help protect the environment. All of this can be accomplished while saving critical funds by reducing red bag waste and regular trash disposal fees and managing the quantity and type of supplies utilized in the delivery of nursing care. Ultimately, nurses must become essential partners in creating a healthier environment of care for patients and staff so that the facility will be a healthy and nurturing environment where "first, do no harm" becomes a reality.

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REFERENCES

1. National Resources Defense Council. Healthy milk, healthy baby .
2. Health Care Without Harm. Issues: waste management .
3. Sattler B. Environmental Health and Nursing Practice. New York, NY: Springer Publishing Company; 2003.
4. Sanders M. Are you wasting a hull lotta cardboard?.
    5. Environmental Protection Agency. Mercury .
    6. Harriman L. Brominated fire retardants .
    7. Health Care Without Harm. Issues: Green purchasing .
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