Recent news reports about the chemical bisphenol A (BPA), widely used in products such as baby bottles, water bottles, and soda cans, have raised questions, but provided few answers, about whether exposure to it adversely affects health.1, 2 Researchers from the Centers for Disease Control and Prevention in 2005 indicated that the urine of 95% of people in the United States contains BPA at biologically active levels.3 In response, in 2006 experts appointed by the National Institutes of Health and Environmental Protection Agency (EPA) reviewed the literature on BPA and concluded that laboratory animals exposed to low doses of the chemical, which mimics the effects of estrogen in the body, show a wide range of adverse effects that parallel recent negative developments in human health.4 They concluded that BPA exposure in humans is "a great cause for concern." In contrast, a 2008 National Toxicology Program assessment of BPA's reproductive and developmental effects deems those effects to be of "some concern [horizontal ellipsis] in fetuses, infants, and children,"5 and the Food and Drug Administration declined to restrict or ban the use of the chemical,6 although its investigation is continuing. Still, faced with public concern and scientific uncertainty, in March legislators introduced bills in Congress that would ban BPA use in food and beverage containers. Six baby bottle manufacturers have also pledged to stop using BPA.7

Disparate findings about a chemical's safety aren't unusual, and they complicate the job of nurses who seek to preserve the health of both people and the environment. As a result of most nurses' lack of education about environmental health matters, the nursing profession has been slow to translate research findings into practice.8, 9 But the link between environmental exposure to hazardous substances and human health problems is sufficiently established that all nurses, regardless of specialty or setting, can make a significant impact on their patients' health by becoming competent in environmental health matters.

How might a nurse go about this? A good first step is to study the landmark 1995 Institute of Medicine primer Nursing, Health, and the Environment: Strengthening the Relationship to Improve the Public's Health. The book sets out the following four aspects of environmental health that nurses should incorporate into their practice 10:

* basic knowledge and concepts

* assessment and referral

* advocacy, ethics, and risk communication

* legislation and regulation

Nurses who achieve proficiency in these areas will be able to implement best practices within a variety of settings and specialties.

BASIC KNOWLEDGE AND CONCEPTS

Nurses need to know how the environment affects the health of patients and, in turn, how patients affect the environment. For example, the improper disposal of unused medications by consumers (by flushing them down the toilet or tossing them in the trash) has polluted tap, surface, and groundwater across the country. Scientists are finding concentrations of antibiotics, antidepressants, birth control pills, chemotherapeutic agents, and other pharmaceutical products in our water supplies.11-13 Although the concentrations are very low, the effects on human health aren't fully understood and concerns are mounting. The EPA is studying the problem (see http://www.epa.gov%2fwaterscience%2fppcp for details).14, 15

Best practice recommendations and resources. Nurses must become more knowledgeable about how pollutants enter the environment and come into contact with humans. They can then improve their own facilities' practices and direct patients to return unused medications to pharmacies. Nursing education must integrate environmental health content into the nursing curricula, and it's vital that nursing students, student organizations, the National League for Nursing Accrediting Commission, and the Commission on Collegiate Nursing Education work for this change.8 Practicing nurses can learn about environmental issues online at

* EnviRN (http://envirn.umaryland.edu), the University of Maryland School of Nursing's online Environmental Health Education Center.

* Health Care Without Harm's Nurses Workgroup page (http://noharm.org%2fus%2fnurses), which offers links, a toolkit for hospital nurses, and information on applying for a grant to start an environmental health program.

ASSESSMENT AND REFERRAL

When conducting health assessments, nurses should consider the possibility that the patient has been exposed to environmental hazards and should identify any health consequences. When environmental pollutants are implicated in disease, nurses will have to alter their case management accordingly.10

If a patient who has been in generally good health over the years presented to your primary care clinic complaining of ataxia, memory loss, blurred vision, and slurred speech that developed over two weeks, for example, would you begin your assessment by asking about changes in her or his diet? Probably not. In fact, these symptoms indicate mercury neurotoxicity that developed as a result of eating two cans of tuna per day for two weeks to lose weight. Case management strategies would include having the patient eliminate fish from the diet and take a vitamin B complex supplement. It's important for nurses to teach patients how to reduce risks by, for example, choosing fish that contain lower amounts of mercury (such as catfish or pollock) and that the frequency and amount of intake also influence the risk to health. Helpful consumer guides can be found at http://www.nrdc.org%2fhealth%2feffects%2fmercury%2fprotect.asp.

Best practice recommendations and resources. Being aware of the multitude of toxins present in the workplace, home, and school allows nurses to build a comprehensive picture of a patient's risk factors for disease. Doing this requires familiarity with detecting illnesses that have an environmental etiology and assessing for environmental health risks. The resources available to accomplish these tasks include

* Case Studies in Environmental Medicine (http://www.atsdr.cdc.gov%2fHEC%2fCSEM), which is a series of self-learning modules from the Agency for Toxic Substances and Disease Registry (ATSDR) that teaches about hazardous substances, how to take a general exposure history, and how to manage exposure to a number of specific toxins.

* the National Environmental Education Foundation Web site (http://www.neefusa.org%2fhealth%2findex.htm), which offers information designed to improve health care and public health. The group sponsors several environmental health initiatives and offers free downloads of pediatric asthma and environmental health history forms.

ADVOCACY, ETHICS, AND RISK COMMUNICATION

Nurses should demonstrate care for the environment and teach others about the potential health risks associated with exposure to environmental hazards. One of us (LA) did just this when she testified before a local governing board about the risks associated with building homes and a playground on land that had been used as an illegal hazardous waste dump. The site had high levels of carcinogens and neurotoxins, including polychlorinated biphenyls, from transformers that had illegally been buried there. The board ordered the developer to have the EPA certify that the site was clean before building could begin.16, 17

Best practice recommendations and resources. Nurses become effective environmental health advocates when they adhere to the precautionary principle, which embraces the notion of "first, do no harm." When actions have the potential to cause severe or irreversible harm to the environment or human health, the precautionary approach must be implemented even when cause-and-effect relationships are not fully established.18, 19 Rather than dealing with environmental or health damage after it has occurred, the precautionary principle seeks to prevent it.

Nurses can practice this approach by, for example, advising pregnant women to avoid consuming unsafe levels of mercury in fish and shellfish. Mahaffey calculated that pregnant women's fish consumption exposes more than 630,000 fetuses annually to unsafe levels of mercury.20 The EPA's guidelines for safe consumption of fish and shellfish can be found at http://www.epa.gov%2fwaterscience%2ffish%2fadvice, and the ATSDR offers guidance on effectively communicating health risks at http://www.atsdr.cdc.gov%2frisk%2friskprimer.

LEGISLATION AND REGULATION

All citizens can participate in the development of environmental regulations. One place their input is needed is in pollution control, which has been sporadic at best. For example, researchers recently found that the current National Ambient Air Quality Standards (NAAQS) for lead inadequately protect children.21 Airborne lead remains a significant threat to children's neurologic development. As part of a recent review of the current NAAQS for lead, the EPA solicited public comments about the adequacy of the current standards, giving nurses and others the chance to push for better protection. On October 15, 2008, the final ruling substantially strengthened the NAAQS for lead. The revised standard of 0.15 micrograms per cubic meter, measured as total suspended particles, is 10 times lower than the previous standard and will better protect the health of vulnerable populations, especially children. Learn more about the new standard at http://www.epa.gov%2fair%2flead%2factions.html, where the text of the ruling can also be downloaded.

Best practice recommendations and resources. Information about environmental health policies and legislation can be found through a variety of organizations, such as the Environmental Defense Fund (http://www.edf.org), the Center for Health, Environment, and Justice (http://www.chej.org), and the American Nurses Association (ANA; http://www.nursingworld.org). These groups provide background information and opportunities for citizens to take action on legislative and regulatory issues by contacting the public officials involved. Many nurses also promote a healthier environment by serving on advisory committees, such as the EPA's Children's Health Protection Advisory Committee.

The time to act is now. Many environmental exposures are preventable, and nurses are in the right place to disseminate health- and life-saving information. Consider adopting the ANA's Principles of Environmental Health for Nursing Practice with Implementation Strategies22 as a guide to your environmentally responsible nursing practice.

REFERENCES