Each April 22, Earth Day serves to remind us that we can be better caretakers of our environment. As a society, we have a dismal track record. Our water supply has been contaminated by sewage, agricultural runoff, and the dumping of industrial and chemical waste products. Polluted air blankets our cities and raises our risk of respiratory and cardiovascular diseases. And increasingly warmer temperatures have changed the migration patterns of some species, making vector-borne diseases such as West Nile virus and dengue fever more common in regions where they were once rare. While protecting the environment is everyone's responsibility, nurses have a special duty to do so, since promoting a healthier environment is central to public and personal health advocacy. Indeed, managing the patient's environment was the basis for Nightingale's nursing model-she referred to it as "nursing the room." Fresh air, sunlight, and cleanliness formed the foundation of early nursing practice (see this month's From the AJN Archives.)
In this issue, authors Laura Anderko and colleagues make a strong case for why hospitals and other health care facilities must become exemplars in reducing the negative impact of their processes and waste products on the environment. We have abundant evidence linking various substances to illness, and products containing such substances should be banned in health care facilities. There have been successful efforts toward this end. For example, after the U.S. Food and Drug Administration issued a warning and the American Public Health Association issued a resolution against the use of polyvinyl chloride (PVC), citing evidence linking this plastic and its various additives to the development of reproductive cancers, asthma, and other illnesses, many U.S. hospitals stopped using IV bags or tubing containing PVC. And in January, in keeping with the terms of the United Nations-backed Minamata Convention on Mercury, more than 140 governments agreed to remove mercury-containing devices from the world's hospitals by 2020.
But protecting our environment means more than just doing it no further harm. In our health care facilities, we need to foster an environment that is soothing and restorative for everyone. Incorporating natural light and colors and using clean air technology and sound-absorbing materials are all elements of "green" design. The hospital portrayed on our cover is one of a growing number of health care facilities that are doing just that. As Anderko and colleagues explain, evidence-based design elements such as better lighting, cleaner air, and improved unit layout can be factors in reducing falls and health care-associated infections.
Finally, if hospitals are to be truly healing environments, then concern must extend not only to the patients seeking treatment but also to the people working in these facilities. Research has repeatedly demonstrated that working in hospitals exposes staff to numerous health risks, including those associated with exposure to toxic chemicals (such as anesthesia gases and chemotherapeutic agents), infectious diseases, and the lifting of heavy patients and objects. Poor workflow design (for example, locating a medication preparation area in a busy nurses' station), inadequate lighting, and noise make it easier for clinicians to make errors-and this compounds the stress inherent in the work itself. After all, lives often really do hang in the balance. Add to this chronically overburdened staffs working on units with high patient-to-nurse ratios-is it any wonder that medical errors are rampant?
We know that nurses' stress and burnout levels and inadequate nurse staffing are intertwined with patient outcomes. Research by Linda Aiken and colleagues, reported in JAMA a decade ago, found that the more surgical patients a nurse was assigned, the greater the patients' risk was of dying within 30 days of admission and of dying of complications (failure to rescue), and the greater the odds of nurse burnout. More recent research by McHugh and Ma links higher hospital readmission rates to poorer nurse work environments and lower nurse staffing levels.
Hospitals that have committed to sustainable designs and practices should be lauded. But they must also ensure adequate nurse staffing and resources so nurses can give safe, high-quality care. Otherwise, what's the point?