Environmental Stewardship in Healthcare:A Nursing Perspective

Elizabeth Schenk, PhD, MHI, RN-BC, FAAN

Map of Conversation

Planetary Environmental

Crisis

What does it

have to do with

Nursing?• Environment impacts health

• Healthcare impacts environment

Framework for Nursing to address

it

• Resources

The Problem

Planetary Health…Planetary Disruption

• Planetary Boundaries: Stockholm Resilience Centre

Planetary Health…Planetary Disruption

Three areas of concern to Healthcare

• Climate Change

• Biodiversity Loss

• Resource Depletion

Lead to Health Risks

Healthcare Contributes

Healthcare’s Contributions

Healthcare pollution creates harm on same order of magnitude as other HACs (Eckelman,

Sherman, 2016)

Healthcare is not held accountable for its pollution. It is not regularly measured or reported.

Healthcare focuses on reducing harm in other ways: HROs, Quality outcomes, Rankings, Reimbursement

Healthcare’s Environmental Footprint

Complex waste stream

• Regulated

• 7,000 tons per day in US (14,000,000 pounds)

• 29 pounds per patient day (PGH, 2019)

Energy/Water

24/7 operations-energy intensive

10% of GHG

2nd highest user of energy

2-3X as energy intensive as office buildings

Transportation outpacing buildings for GHGs

Chemicals of Concern• Nurses 2nd most exposed• Impacts to patients, staff,

community, planet

Solutions

The WE ACT, PLEASEFrameworkfor Environmental Stewardship in Healthcare

Beth Schenk, PhD, MHI, RN-BC, FAAN

What is Environmental Stewardship in Healthcare?

The use of responsible practices, processes and products that decrease pollution and harm to the natural environment, communities, individuals, other species, and future generations.

Of environmental stewardship in healthcare

Why Nurses?

Largest profession: Many points of contact

Professional obligation

Most trusted voice

Timing: Environmental crisis is worsening

Healthcare (and thus nursing practice) is significantly polluting

Growing awareness of environmental impacts of healthcare among nurses and others

Waste

• Waste streams in healthcare:• Biohazardous

• Chemo

• Pathological

• Pharmaceutical hazardous

• Pharmaceutical non-hazardous

• Narcotic

• Waste anesthesia gas

• Recycling

• Compost

• Landfill

Opportunities

• Segregation

• Source Reduction

• Reusable products

• Reprocessing

• Leaner Processes

• Using less

• Overstocking

• Linen

• Reformulate kits

Climate Impacts of Waste• Waste in landfills creates methane• Overproduction, shipping, use and disposal of goods contributes GHGs• Overutilization of resources reduces resiliency of ecosystems

Waste Optimization

Waste Type Price/pound Target (lbs/APD)

Recycling $ 0.05 10

Landfill $ 0.11 10

Infectious Waste $ 1.45 0.75

Hazardous Waste $ 8.52 0.03

Reaching optimal tons and percentages of waste streams to minimize environmental impacts and reduce costs

Energy and water

• Fossil Fuel Based Energy

• Air pollution: Mercury, NOx, SOx

• Water pollution: solvents, mercury

• Greenhouse gases (GHGs) from burning of fossil fuels

• Excess water usage

• Stresses aquifers and surface water

• Requires energy to treat and pump

Opportunities

• Renewable energy

sources

• Energy conservation

through efficiency and

behaviors

• Water conservation

Climate Impacts of Energy and Water• Fossil fuel burning is the primary driver of climate change• Coal is most polluting; natural gas less GHGs, but pollutes water and soil• Treatment and distribution of water is energy intensive

Agriculture/foodChallenges

• Food waste- 30-40% of food supply: 133 billion pounds: $161 billion. Food waste in landfill causes GHG emissions (8% of total GHGs)

• Meat – GHGs, antibiotics, waste

• Produce – large scale ag or local, sustainable - finding balance

• Processing, packaging, shipping food add to pollution

Opportunities

• Local and sustainable foods

Supporting local economies

Self-sustaining communities

• CSA’s, Gardens

• Reusable dishware

• More organic foods; Avoid added

hormones and antibiotics

• Healthier beverages

• Avoid single use plastics

• Reduce, compost food waste

Climate Impacts of Agriculture and Food• Animal agriculture contributes 14-18% of GHGs globally (Lamb, Beef, Cheese, Pork…)• Food waste an important contributor of GHGs• Land use important (deforestation, loss of croplands, carbon sequestration in soil)

Chemicals• Chemicals of concern:

• Mercury

• Glutaraldehyde

• Flame retardants

• PVC, DEHP

• BPA, BSA, Phthalates

• Triclosan

• High risk pharmaceuticals

• High-level disinfectants, cleaning agents

• Herbicides, pesticides

• Careful disposal required

OpportunitiesProtect self

• Learn about risks• Use proper protection

Reduce/eliminate• Identify opportunities• Track volumes/dollars

Educate• Request justification for

use of harmful chemicals

• Teach others about health risks

Climate Impacts of Chemicals

• Waste Anesthesia Gas (WAG) up to 3600 times as potent as CO2

• Petrochemicals, Hydrogen production, and ammonia manufacturing highest GHG emitters

• GHG forms: CO2, N2O, Fluorinated GHGs, Methane

Transportation

Challenges

• Has passed buildings as largest source of GHGs

• For now employees are very dependent on SOV

• Difficult to curb...up to each employee. Yet one of the largest aspects of work-related pollution

Opportunities

• Public transport

• Reduce personal dependency on SOV

• Commuter club

• Electric vehicles

• Incentives for not using SOV

Climate Impacts of Transportation• Largest sectoral contributor to climate change• In addition to GHGs, significant air pollution• Electric vehicles coming, but need to run on renewable energy

Key Domains: WE ACT

Levels of Action

WE ACT Circle:Driving toward Environmentally Safe and Healthy Practice

Professional Obligation• Nursing Social Policy Statement

• Promotion of the Health of the Public

• Caring Service

• Hazardous Service

• Code of Ethics

• The nurse promotes, advocates for, and protects the rights, health and safety of the patient (Individual, family, group, community, population)

• Nursing Scope and Standards of Practice

• Standard 17 “The registered nurse practices in an environmentally safe and healthy manner.”

Leadership• Formal

• Organizational decision making• Shared Governance and Strategic Planning• Move the Boulders• Reward/Recognize

• Influencers/Thought Leaders• Role models• Champions• Grassroots Passion

• Advocacy• Community leadership• Elected office• Communicate with legislators

Education

• Formal: ES content frequently lacking

• Practice-Based: • Policies, Improvement projects,

purchasing

• Journal Clubs, Lectures, Peer training

• Lifelong Learning/CNE

• Conferences

• Webinars-Available from ANHE, others

• Content rich sites: HCWH, PGH

Accountability• Metrics!

• WE ACT Content Areas, GHGs

• Compare to national, regional and local benchmarks

• Dashboards and reporting

• Identify who is accountable

• True to Purpose

• Community Benefit

• Sustainable Procurement

• Weave into other measures of success

• Organizational Goals and Mission

• Quadruple Aim

Science

• Use Evidence

• Stay abreast of current science

• Share source material to enhance knowledge base

• Precautionary Principle

• When not fully clear, use best evidence available

• Contribute to Body of Knowledge

• Support/conduct research

• Disseminate findings

Engagement

• Communicate

• Seven routes

• Buzz

• Help people address

• What they are interested in

• Meaning and Purpose

• Link environmental care to health

• Include all: staff, patients/family and the public

• Advocacy-Encourage nurses to communicate with elected officials, run for office, engage others

•Professional obligation

•Leadership

•Education

•Accountability

•Science

•Engagement

PLEASE

Schenk, 2019, Creative Nursing

Do not be daunted by the enormity of the world’s grief.

Walk humbly now.

Do justly now.

Love mercy now.

You are not expected to complete the work,

but neither are you free to abandon it.

R. Shapiro/Talmud

Thank youas

WE ACT, PLEASE

ReferencesAmerican Nurses Association (2010). Nursing’s social policy statement: The essence of the profession. Silver Spring, MD.

American Nurses Association (2015-a). Nursing scope and standards of Practice, third edition. Silver Spring, MD.

American Nurses Association (2015-b). Code of ethics for nurses with interpretive statements. Silver Spring, MD.

Centers for Disease Control and Prevention. (2014-a) Retrieved from https://www.cdc.gov/climateandhealth/effects/default.htm

Centers for Disease Control and Prevention. (2014-b) Retrieved from https://www.cdc.gov/healthywater/drinking/public/water_diseases.html

Chivian, E., & Bernstein, A. (Eds.). (2008). Sustaining life: how human health depends on biodiversity. Oxford University Press.

Eckelman, M. J., & Sherman, J. (2016). Environmental impacts of the US health care system and effects on public health. PloS one, 11(6), e0157014.

Fazzo, L., Minichilli, F., Santoro, M., Ceccarini, A., Della Seta, M., Bianchi, F., ... & Martuzzi, M. (2017). Hazardous waste and health impact: a systematic review of the scientific

literature. Environmental Health, 16(1), 107.

Healthier Hospitals. (2016) Retreived from http://www.healthierhospitals.org/

Leffers, J., Levy, R. M., Nicholas, P. K., & Sweeney, C. F. (2017). Mandate for the nursing profession to address climate change through nursing education. Journal of Nursing Scholarship, 49(6),

679-687.

McMichael, A. J. (2013). Globalization, climate change, and human health. New England Journal of Medicine, 368(14), 1335-1343.

National Institute of Environmental Health Science. (2018). Retrieved from https://www.niehs.nih.gov/health/topics/agents/air-pollution/index.cfm

Occupational Safety and Health Administration. (2018). Workers. Retrieved 12-22-18 from https://www.osha.gov/workers/

Practice Greenhealth (2018). Less Waste. Retrieved from https://practicegreenhealth.org/topics/less-waste

Practice Greenhealth (2019). Topics. Retrieved from https://practicegreenhealth.org/topics

Richardson, J., Heidenreich, T., Álvarez-Nieto, C., Fasseur, F., Grose, J., Huss, N., ... & Schweizer, A. (2016). Including sustainability issues in nurse education: A comparative study of first year

student nurses' attitudes in four European countries. Nurse education today, 37, 15-20.

Schenk, E., 2011. Environmental Sustainability in Nursing Practice: The EWT-E Wheel. Poster presentation at the International Conference on Community Health Nursing Research, Edmonton,

Alberta, Canada, May 6, 2011.

Schenk ( 2019). Environmental Stewardship in Nursing: Introducing the “WE ACT – PLEASE” Framework. Creative Nursing. In press.

Steffen, W., Richardson, K., Rockström, J., Cornell, S. E., Fetzer, I., Bennett, E. M., ... & Folke, C. (2015). Planetary boundaries: Guiding human development on a changing

planet. Science, 347(6223), 1259855.

Su, F. C., Friesen, M. C., Stefaniak, A. B., Henneberger, P. K., LeBouf, R. F., Stanton, M. L., ... & Virji, M. A. (2018). Exposures to Volatile Organic Compounds among Healthcare Workers: Modeling

the Effects of Cleaning Tasks and Product Use. Annals of work exposures and health.

Union of Concerned Scientists. (2018). https://www.ucsusa.org/clean-vehicles/vehicles-air-pollution-and-human-health/cars-trucks-air-pollution#.XEsmGlxKiUl

United States Environmental Protection Agency. (2017). Sources of greenhouse gas emissions. Retrieved from the Environmental Protection Agency website:

https://www.epa.gov/ghgemissions/sources-greenhouse-gas-emissions

United States Environmental Protection Agency. (2018, December 10-a). Nutrient Pollution. Retrieved from the Environmental Protection Agency website:

https://www.epa.gov/nutrientpollution/problem

United States Environmental Protection Agency. (2018, December 14-b). Sources of greenhouse gas emissions. Retrieved from the Environmental Protection Agency website:

https://www.epa.gov/ghgemissions/sources-greenhouse-gas-emissions

U.S. Department of Agriculture. (2018). Food Loss and Waste. Retrieved 12-23-2018 from https://www.usda.gov/foodlossandwaste

U.S. Energy Information Administration. (2016, May). Commercial buildings energy consumption survey. Retrieved from

https://www.eia.gov/consumption/commercial/data/2012/bc/cfm/b29.php

U.S. Energy Information Administration. (2018, May-a). Residential energy consumption survey. Retrieved from https://www.eia.gov/consumption/residential/data/2015/hc/php/hc6.6.php

U.S. Energy Information Administration. (2018, October 29-b). Frequently asked questions: What is U.S. electricity generation by energy source? Retrieved from

https://www.eia.gov/tools/faqs/faq.php?id=427&t=3