Principles to live and work by: ANA Crafts document to guide RNs in environmental health practice

There’s an old saying, you are what you eat. You also may be what you’re exposed to—and for nurses, that’s quite a lot.

Looking at the big picture, about 100,000 chemicals are currently used in energy production, manufacturing, and consumer products in industrialized nations, according to the 2004 policy statement known as the Louisville Charter for Safer Chemicals. Environmental health researchers also report that of the 2,800 chemicals being produced in quantities greater than 1 million pounds per year, only 7% have been tested for developmental effects and only 43% have been tested for human health effects. Furthermore, studies by the Centers for Disease Control and Prevention confirm the presence of hundreds of potentially harmful chemicals, such as heavy metals, dioxins and pesticides, in the blood, urine, and breast milk of a broad sample of the U.S. population.

RNs work with—and are surrounded by—a range of chemical products, including medications, solvents, disinfectants, sterilizing agents, and hazardous waste. Some of these products, as well as certain healthcare industry practices, jeopardize the health of workers, patients, and the planet. And once the environment is harmed, community health is at risk.

To protect nurses and help them advocate for safer products and workplace practices, ANA has created a comprehensive document called Principles of Environmental Health for Nursing Practice. The document lists 10 guiding principles, which articulate RNs’ rights and responsibilities when it comes to ensuring environmental health. It also includes useful background information on the issue, as well as strategies nurses can implement to meet the principles.

“Nursing is a holistic discipline and one that emphasizes preventive care,” says Marian Condon, MS, RN, senior staff specialist in ANA’s Center for Occupational and Environmental Health. “Currently, nurses are seeing many patients whose diseases are caused or exacerbated by different environmental pollutants. So it’s vital that nurses become aware of this link and work within the healthcare industry to stop contributing to an unhealthy environment.”

The principles take shape
In 2004, ANA’s House of Delegates passed a resolution asking ANA to create a document that could guide RNs in environmentally sound practice. A work group of ANA’s Congress on Nursing Practice and Economics (CNPE) developed the document on environmental health principles, which subsequently was approved by ANA’s Board of Directors in March.
When crafting the principles, the CNPE work group reviewed ANA’s other position statements on environmental health.

“Throughout those documents and the association’s history, it was clear that ANA has a long-standing dual mission,” says Karen Ballard, MA, RN, chairperson of the CNPE work group and a New York State Nurses Association member. That dual mission involves promoting efforts that keep patients and nurses safe.

“If we say it’s the nurses’ role to protect patients, then it would be foolish to ignore that nurses have a right to work in an environment that is safe and healthy, and with products that don’t harm them,” Ballard says. “When drafting the principles, we knew we had to address both sides. And what’s good for the nurse is good for patients, the community, and the planet.”
Condon adds, “Historically, nurses have sacrificed their own health and well-being to provide care. These principles show nurses that they can incorporate strategies into their practice that will keep themselves safe as well.”

On closer inspection
Members of the CNPE work group stress that all 10 principles are equally important. The following is a look at just a few, along with the rationale for promoting them.

One of the cornerstones of the entire document and a principle itself focuses on the “Precautionary Principle,” which means that healthcare practices and products should be deemed safe to humans and the environment before they are implemented. The document notes that current thinking within the healthcare industry centers largely on how much harm is allowable. Using the precautionary approach, nurses are asked to consider how they can meet their workplace goals in a way that is least harmful and protects the public and the environment.

Recommended strategies that could help RNs meet the spirit of this principle include advocating fora review of the potential effects of new and old products, pharmaceuticals, and technologies; urging healthcare facilities to phase out toxic materials such as poly­vinyl chloride; and participating in product purchasing committees.

Another principle addresses nurses’ right to know about harmful products and other hazards to which they are exposed. The principle also extends this right to know to other healthcare workers, patients, and the community.

“When you get into a car to drive across the country, you accept a certain amount of risk,” Ballard says. “It’s a choice you make. But when you go to work, how much risk are you willing to tolerate?”

Unfortunately, nurses and other workers generally don’t know what they’re truly exposed to, according to Kristen Welker-Hood, ScD, RN, an ANA staff expert on environmental health issues. Although there are laws designed to inform the public, and specifically workers, about chemical hazards, these measures have limitations.

“Neither of the laws supports or provides for public or worker participation in determining which chemicals can be used in the environment or workplace,” Welker-Hood says. Furthermore, many manufacturers don’t have to disclose all the ingredients in a product, and documents meant to inform workers about hazards often are incomplete, inaccessible, and difficult to understand.

Two suggested steps to help RNs address this right-to-know principle include collaborating with facility administrators to create a nursing staff-management committee to identify all workplace hazards, and ensuring that personal protective equipment is available for staff.

Gaining knowledge
As a family nurse practitioner, Esther Acree, MSN, RN, saw the importance of including a principle promoting nurses’ participation in assessing the quality of the environment in which they work and live.

“This principle asks nurses to really look at their practice, their patients and their families, and the community, and how they all may be affected by environmental factors,” says Acree, a member of the work group and an Indiana State Nurses Association member.

“Applying this to the workplace, nurses on any given day can be exposed to something that can harm them,” Acree says. “That exposure can affect nurses for the rest of their lives.”

This principle also reflects the need for RNs to have the knowledge and tools necessary to perform thorough environmental assessments on individuals, which include obtaining detailed workplace histories from patients, as well as on communities, which include interviewing key community representatives.

Another principle that focuses on education states that “knowledge of environmental health concepts is essential to nursing practice.”

“One of the first things we learn in nursing school is our responsibility to advocate for patients,” says Cathalene Teahan, MSN, RN, a member of the work group and Georgia Nurses Association member. “And as nurses, we are in a unique position to educate people because we work in so many different settings.”

But to advocate and educate effectively, nurses must gain information on basic concepts in general environmental health. These concepts include understanding the ways people can be exposed to environmental hazards, basic prevention and control strategies, and the latest research.

Environmental health must be integrated into basic nursing education for student nurses and continuing education for practicing nurses, Teahan says.

The winds of change
Another principle addresses the need for ongoing research in best practices that promote a safe and healthy environment.

“Today, there are more and more potential threats to the environment being discovered, but there also are many inventions and interventions that can help protect nurses and patients,” Acree points out.

Teahan agrees, saying, “There are still many things we don’t know even in terms of everyday products like coatings on cookware—and that’s why ongoing research is so important.”
Nursing research, education, and advocacy have always played an important role in creating workplace and community change, Ballard says. For example, it was ANA and others in the nursing community who pushed for safer needle devices to prevent the transmission of human immunodeficiency virus and other bloodborne pathogens.

Ballard recalls a quote from cultural anthropologist Margaret Mead that says, “Never doubt that a small group of thoughtful, committed citizens can change the world.”
“We want to encourage nurses to take on the issue of environmental health,” Ballard says. “These ANA principles are designed to guide RNs, so they can change their practice and the world.”

Susan Trossman, RN, is the senior reporter in ANA’s Communications Department.

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