According to the World Health Organization, close to one fourth of the diseases experienced by the world's population can be attributed to environmental exposures.1 The healthcare industry contributes to this by producing more than 2.4 million tons of waste each year and is one of the largest consumers of energy in many communities.2 Hospital waste and energy consumption affect the health of the environment and, consequently, the health of each human being within the environment. While hospitals have the responsibility to treat the sick within their walls, they are also responsible to make sure their "walls," their environmental practices, promote the health of clients, staff, and the environment. The duty of maintaining an environmentally friendly hospital is shared among numerous stakeholders within the organization.

Nurses, having a holistic viewpoint, responsibility to serve the public, and strong desire to care, have a duty and, importantly, the opportunity to make the hospital an environmentally sustainable environment. On the basis of the holistic perspective of nursing, this article examines how environmental, psychological, ethical, political, and international health issues directly affect hospital efforts to go green. The article provides specific ideas for how nurses can become vanguards for hospital greening initiatives, in both hospital and community settings.

METHODS

A comprehensive search of the literature was conducted for this review. Databases searched were PubMed, EBSCOhost, and Ovid. Key words used in the search process were "hospitals," "waste management," "conservation of natural resources," and "refuse disposal." Criteria for inclusion were currency, relevance to the topic, and peer review. Of the 60 sources found, 20 were analyzed for this article. In addition, governmental and policy Web sites rounded out the information captured for this review. The question, "To what extent can hospitals go green?" provided the focus for the literature search.

TERMINOLOGY

Multiple terms are seen in the literature related to this topic: "greening," "environmental health," "resource conservation," and others. Environmental health nurse activist Gary Laustsen defines greening as those "behaviors or activities that improve environmental outcomes."3^(p727) The definition of going green involves waste reduction and energy and resource conservation. The Association of Perioperative Registered Nurses (AORN) defines resource conservation as the "preservation of natural resources, waste and hazardous agent management, recycling, reprocessing of single-use devises [horizontal ellipsis] and supply conservation and management."4^(p380)Sustainable development is defined by the United Nations Brundtland Commission report as "meeting the needs of the present without compromising the ability of future generations to meet their own needs."5^(p2) For the purpose of this article, the terms "environmentally sustainable" and "environmentally friendly" are used in conjunction with that of "sustainable development" because the authors believe this broad definition is incorporated in all of the previous definitions.

PRESENT PERSPECTIVE

The situation with regard to creating an environmentally sustainable healthcare arena is complicated and critical. Environmental health activists Shaner-McRae et al explain,

Hospitals generate one of the most diverse and difficult to manage waste streams of any type of organization. They generate solid waste, biohazardous waste, and hazardous waste in large quantities. Usually this waste is generated in close proximity to other human beings, whose well-being and safety must be safeguarded from any hazard related to the waste.6^(p3)

As organizations that operate 24 hours a day and 365 days a year, hospitals produce large quantities of waste and utilize large sums of energy. Until recently, the disposal of hospital hazardous waste existed as the leading contributor to dioxin and mercury pollution in the United States.3 According to the AORN,4 hospitals spend more than $5 billion a year on energy, a figure that is increasing due to enhanced technological dependence. Yet, only a limited number of US hospitals possess environmental health officers or staff to consider the environmental health impact of the hospital as a community member.

ENVIRONMENTAL PRINCIPLES FOR RNs

Environmental health has been a key factor in the nurse's holistic view of health from the beginning of the nursing profession. One of Florence Nightingale's main pillars of health was strict environmental control. Nightingale knew that putting the patient in the healthiest environment was essential for healing to occur.7

As environmental health nurses Sattler and Hall2 explain, nurses today are in excellent positions to effect environmental health change because they serve on hospital boards and committees that directly affect greening initiatives. Occupational and environmental health nurse Karen Bowman, MN, COHN-S notes that nurses represent the largest number of professionals in the healthcare field, with more than 2.9 million nurses in practice, and are some of the most trusted healthcare professionals.8 As Florence Nightingale might argue: who better to initiate hospital greening programs than those persons who manage care every hour in that environment.

Medicine is also aware of the potential holistic influence nurses can have on healthcare environments. In 1995, the Institute of Medicine released a report called Nursing, Health, and the Environment, which spurred increased environmental awareness among nurses across the globe and focused on the holistic complexity of environmental health. The report asked nurses to understand how environmental health issues could be integrated into nursing through practice, research, education, and advocacy.1 Shortly after 1996, 28 US organizations formed Health Care Without Harm (HCWH), an organization largely dependent on the voice and expertise of nurses.9 The American Nurses Association (ANA) and another nursing organization, Hospitals for a Healthy Environment (H2E), began to tackle hospital environmental health issues. These national nursing organizations sought to understand the issues of hospital waste and energy management from various and holistic perspectives, just as one would care for a client.

ENVIRONMENTAL HEALTH

The concept of environmental health, of which Nightingale spoke, remains a key issue in the discussion of hospitals going green. According to the 1995 Institute of Medicine report, as quoted in Sattler, environmental health is "freedom from illness or injury related to exposure to toxic agents and other environmental conditions that are potentially detrimental to human health."10^(p43) As aforementioned, hospitals directly affect the health of those within their walls and the environment itself. In today's world, issues of environmental health are aided by using the 3 R's of reduce, reuse, and recycle. Laustsen3 explains that hospitals can positively affect environmental health only by focusing on a combination of the 3 R's of change in waste management, resource conservation, and recycling. One of the largest detriments to human health exists in the waste produced and disposed of by hospitals.

To understand the process of hospital waste management, one must understand the various types of waste produced and the potential human and environmental hazards involved in waste production. Table 1 presents the 4 types of wastes produced in the hospital setting. Waste management remains a complicated process. Hospitals produce numerous toxins and pollutants in various forms. Until recently, chemicals such as polyvinyl chloride (PVC) and mercury were common in hospital intravenous tubing, infusion bags, and other hospital equipment. These 2 toxins possess specifically detrimental effects when incinerated, and PVC's incinerated form, dioxin, has been linked to cancer and birth defects.2 If mercury from measuring equipment is inhaled, it can damage the liver, kidney, and central nervous system. Long-term exposure to mercury can even lead to death.6 In 2007, hospitals emerged as the most common work site for reported cases of occupational asthma due to frequent exposure to toxic substances such as glutaraldehyde and latex.6 If disposed of incorrectly, hospital pharmaceuticals can seep into ground water systems and cause detrimental effects to anyone who comes in contact with this water.6 As Laustsen3 explains, not only does waste management remain a complicated process due to the various types of waste produced, but staff, many of them nurses, complicate this process by disposing of wastes incorrectly. For example, the more waste that is thrown in red biohazard bags, the more waste that has to be incinerated, leading to increased environmental pollution.

TABLE 1. Types of waste

While hospital waste can lead to environmental harm, increased energy consumption and the lack of recycling programs enhance environmental resource depletion. In the hospital environment, resource conservation includes issues of energy, water, and equipment consumption. Nurses have been on the forefront of recognizing energy consumption issues; turning off unused lights, monitors, pumps, and computers; switching to compact fluorescent lights; and promoting natural light in building designs to conserve energy. Fixing leaking plumbing fixtures and investing in low-flow faucet heads and low-flow toilets can aid tremendously in the goal to conserve water. Nurses and staff at Caritas-Norwood, a community hospital in Boston, Massachusetts, modified the campus water system, which now returns more than 15 million gallons of unused water to the community each year.5 By choosing minimally packaged goods, opting for reusable products rather than disposable ones, and enhancing training on how to properly sort waste, hospitals can tackle certain equipment conservation issues.3 As environmental health nurse Carol Brody explains, enhanced education about equipment conservation can induce a "know before you throw" mind-set that works to reduce the amount of waste produced and to lower costs used to dispose of waste.11^(p20) Lack of hospital recycling programs also enhances the amount of waste that is incinerated or that reaches community landfills. Stawell Regional Health in Australia estimated that about 4 tons of its waste material that was recyclable went to the landfill instead.11

Environmental health research has helped nurses and hospital staff progressively tackle issues of waste management, resource conservation, and recycling within the hospital. Nurses associated with the HCWH have demonstrated their commitment to mercury-free alternatives by creating community-based mercury thermometer exchanges to eliminate mercury in their communities.2 Nurses have also advocated for federal regulations limiting the use of PVC in hospital products.2 Hospitals no longer remain the leading contributor to mercury and dioxin pollutants in the environment. In terms of resource conservation and recycling, nurses have implemented various recycling programs in the United States, including recycling monitor batteries, light bulbs, and paper from unit meetings.2 Nurses have remained on the forefront of water conservation and natural lighting initiatives.5 International environmental health nurse specialist Wilburn1 explains that nurses must also provide leadership in preventive system processes, such as source reduction, which works to promote early adoption of greener products and practices.

PSYCHOLOGICAL ISSUES

While waste management and resource conservation issues introduce significant barriers to going green, numerous psychological barriers exist, which prevent green hospital movements. Guenther and Hall5 touch upon various myths that can dissuade hospital staff from implementing green initiatives. These myths are as follows:

(1) Healthy building is the architect's responsibility; (2) Healthy buildings are more expensive; (3) Healthy buildings do not perform well and will make my work environment more difficult; (4) Healthy building is a passing fad; (5) Materials needed for healthy building are not available; and (6) Interest in sustainable buildings is not in my area.5^(p10)

According to environmentalist nurse Topf,12 denial, groupthink, ignorance, and diffusion of responsibility also defer staff from taking on greening initiatives. Denial has different forms: pure denial is the failure to acknowledge that one's hospital generates pollution and is contributing to the overconsumption of energy and natural resources. Other forms of denial are avoidance and procrastination. Groupthink serves as a barrier to greening when a person is doubtful of one self and does not possess courage to oppose other members on the team. Ignorance is also an obstacle to going green because many individuals lack basic knowledge about issues of overconsumption. Diffusion of responsibility can result in one staff member being aware of an environmental issue but mistakenly assuming that another nurse or department would deal with the issue.12

Various methods have been used to tackle some of the psychological barriers to going green. According to Guenther and Hall,5 in environmentally conscious communities, sustainable buildings often are viewed as an important component of corporate leadership, and many environmental health innovators cite community support as an important reason for their decision to move toward green initiatives. The Lacks Cancer Center at St. Mary's Healthcare, Grand Rapids, Michigan, cited a tour of a federally environmentally certified Leadership in Energy and Environmental Design (LEED) furniture manufacturing facility as initiating its interest in going green.5 Other methods to tackle greening myths include lectures and conferences centered on the issue of going green, as well as more published research on the topic; enhanced education can increase psychological comfort with greening measures.

Topf12 sheds further light on the psychological push to go green when she notes that true environmental change may require forced compliance and cognitive dissonance. Cognitive dissonance is the perception that there is conflict between what an individual believes and new information; the individual needs to acknowledge new ideas to accept the new information as reality. A primary example of this combination is when the US Environmental Protection Agency (EPA) established a federal mandate to improve hospital waste incineration within 5 years.12

Another method to tackle psychological barriers could be to use evidence from research studies that shows that initiating environmental sustainability positively affects hospital staff's psychological health. One research study revealed that well-designed healthcare buildings contribute to enhanced performance and motivation among workers.5 Preliminary work, such as Ovitt's 1996 master's thesis (unpublished data, Graduate College of the University of Illinois at Urbana-Champaign), suggests that natural light decreases medical error rates, potentially saving lives and money, while also contributing to energy conservation.5 According to Laustsen,3 nurses acknowledged a discordant feeling between their desire to live an environmentally sustainable life and barriers to this practice in the workplace when their workplace lacked environmental health initiatives. The implementation of environmental health initiatives can be directly beneficial to the physical health of hospital staff, clients, and the environment as well as indirectly beneficial by positively affecting the psychological health of staff within hospital walls.

ETHICAL ISSUES

Florence Nightingale stated, "No amount of medical knowledge will lessen the accountability of nurses to do, that is, manage the environment to promote positive life processes."4^(p380) This idea of accountability shifts the focus of the nurse's ability to promote "going green" to a responsibility, due to their job description. Ethicist and philosopher Heidegger is quoted as saying, "We are world. The world is us, and to sicken and destroy it is to sicken and destroy ourselves."13^(p1) As the environmental health movement grows, more and more individuals and nurses are ethically compelled by this historical view as a way of life.

While barriers exist to the acceptance of an ethical duty, nurses and hospitals are beginning to frame environmental efforts as ethical responsibility. Nurses who work for the Catholic Healthcare System remain explicit that they uphold both human dignity and environmental health through mercury-reduction projects in Michigan, recycling programs in Kentucky and New York, and energy-reduction programs in California.14 The AORN agrees that nurses possess an ethical duty to promote environmental health through recognizing the political, economic, and public health components of environmental health.4 Nurses Dinkins and Sorrell explain, "Every nurse can identify a path, whether through educating patients, students, or nurses; joining an environmental advocacy group; or making some other contribution, to expand the circle of ethical concern."13^(p1)

The nurse's ethical duty to promote environmental health translates into today's nursing world via professional nursing organizations. In 1997, the ANA adopted the Precautionary Approach, which states that there is an ethical imperative to prevent rather than merely deal with elements and actions that may harm the environment and human health.15 The ANA also created the Code of Ethics for Nurses With Interpretive Statements, which reminds nurses of their responsibility to promote health across various spectrums.16 The code describes the nurse's duty to promote the health of individual clients as well as that of larger entities, such as the environment.

Other ethical frameworks, such as the American Association of Colleges of Nursing professional practice values, suggest that there is a nursing duty to act on environmental issues in practice. The essential values of altruism, integrity, and human dignity directly support the nurse's duty to promote environmental sustainability. As altruistic professionals, nurses are challenged to work toward environmental sustainability to promote the human dignity of today's society and the next. The value of integrity encourages the nurse to not only promote environmentally friendly initiatives but also accept responsibility for environmental wrongs and encourage this responsibility among others.

GOVERNMENTAL ISSUES INVOLVED IN GOING GREEN

Just as environmental sustainability of the healthcare arena exists as an ethically charged issue, it remains similarly politically charged. According to nurse environmental activists, 2 specific barriers exist to implementing positive environmental health policy. Sattler10 argues that one of the major barriers to initiating greening programs is that various policies may be created and administered at different levels of government. As Sattler explains, "The federal EPA promulgates regulations affecting air, water, food, and soil and land, but state agencies are the primary enforcers."10^(p43) Similarly, Shaner-McRae et al6 explain that several legal documents and organizations exist to regulate hospital waste management. The Resource Conservation and Recovery Act (RCRA), established by the EPA, exists as the hazardous chemical management document for hospitals. However, The Joint Commission recently published environmental and waste management standards for hospitals in 2007. Between state organizations, the RCRA, and The Joint Commission regulations, implementing and upholding greening initiatives can remain extremely challenging. Shaner-McRae et al6 identify the second barrier to implementing initiatives as lack of assigned personnel to uphold such policies within the organization and monitor implemented conservation and waste management programs. Without such a regulator, implementation and evaluation remain void.

It remains crucial for nurses and hospital environmental health activists to understand the programs established on the federal level by the EPA. The EPA has developed Elements for Green Building, which provides general environmental guidelines for facilities to follow. The Top 5 Green Building Strategies for Healthcare include (1) establish energy efficiency, (2) process water efficiently, (3) utilize sustainable floorings, (4) improve indoor air quality, and (5) establish lighting efficiency.17 The EPA has also collaborated with the Department of Energy to launch Energy Star for Healthcare, which aims to achieve cost savings by decreasing energy consumption. Energy Star for Healthcare provides a benchmarking starter kit for any hospital choosing to go green. The program also offers facts, workshops, and sustainable product lists for use throughout the hospital.18Table 2 provides a list of other resources.

TABLE 2. Greening resource Web sites

Nurses and other staff interested in establishing greening initiatives can take guidance from LEED and the H2E to establish policy-level changes. LEED is a voluntary national standard certification program set up by the US Green Building Council. The program provides information regarding environmental and financial benefits of green buildings. Healthcare facilities, including hospitals, are eligible for certification, and this certification depends on fulfillment of categories such as sustainable development, energy efficiency, water savings, material selection, and indoor environmental quality.19 Hospitals such as Winship Cancer Center at Emory University in Atlanta, Georgia, and Providence Newberg Medical Center in Providence, Oregon, have become LEED certified as part of a commitment to their communities and community membership.5 One of the most influential organizations in going green is the H2E. This is a nonprofit organization created to educate healthcare providers about pollution prevention. Developed in conjunction with the EPA and the American Hospital Association, a Memorandum of Understanding outlines the goal of H2E-to decrease healthcare's impact on the environment.20 H2E does promote healthy environments through programs to eliminate mercury, decrease hazardous chemicals, and support sustainable facility design.

COSTS OF GOING GREEN

One of the greatest psychological barriers for hospitals to consider when going green is the myth that creating healthy buildings costs more money.5 According to H2E,21 the accounting processes of a majority of hospitals focus on the up-front costs of what it would take to "go green" and disregard the essential "life cycle costs" of green products. Laustsen3 describes the life cycle cost as the cost benefit of a product over the span of its life. He and other specialists agree that while improving current hospital systems will initially require additional funding, after a few years, the additional amount spent is returned via energy and time-savings and increased product longevity.3 The EPA notes that every dollar a nonprofit healthcare organization saves on energy is equivalent to generating $20 in new revenues for hospitals or $10 for medical offices.22

Two specific methods exist for a hospital organization to introduce both green products and cost savings to the hospital. Environmentally preferable purchasing (EPP) is defined by H2E as choosing those products and services whose environmental impacts are preferable to those of others.23 The EPP involves considering the amount of packaging per product, whether or not the product is single use, and the extent to which the product is made from recycled materials. The Energy Star for Healthcare program exists as a wonderful resource for obtaining EPP products and information, and numerous state organizations sponsor energy-efficient programs that partner with Energy Star for Healthcare. H2E can help hospitals perform EPP through their portfolio planner, available on the organization's Web site. CleanMed conferences provide any easy, hands-on method for hospitals to know how much they will spend and what EPP products they will receive. Along with EPP, the H2E also promotes pay-as-you-throw contracts for waste management. In these contracts, hospitals are charged on the basis of the actual amount of waste disposed. Pay-as-you-throw contracts entice hospitals to reduce solid waste, which consequently decreases disposal costs.24 These contracts also easily allow hospitals to track exactly how much waste they produce and dispose of, which provides necessary data for greening program evaluations (see Table 2).

Staff nurses can introduce economic-based incentives and tackle the myth of costly change. At Alfred Hospital in Victoria, Australia, nurses helped implement a waste-segregation and -recycling program that environmental officer Bob Dowal proposed would save the hospital $70 000 for the financial year.11 At Fletcher Allen Health Care in Vermont and Children's Hospital in Seattle, Washington, nurses are helping implement buying local food campaigns that provide numerous benefits: saving the hospital money involved in transport, decreasing the pollution involved in shipping, and promoting the health of local businesses.25 Nurses are often directly involved in product review committees that decide the products hospitals purchase and can, therefore, use their voice to promote the financial incentives of going green.

INTERNATIONAL ISSUES IN HEALTHCARE ENVIRONMENTAL SUSTAINABILITY

Hospitals worldwide face dilemmas in the process of becoming environmentally sustainable, and evidence suggests that developing nations experience more obstacles in this area. One of the most influential obstacles is the lack of hospital infrastructure to control waste disposal. In Gaza, limited administrative responsibilities toward environmental and public health are attributed to deficient organizational structures in managing hospital waste.26 This phenomenon is similar to the lack of hospital environmental health enforcement personnel.6 Yet, unlike the United States, national policies and guidelines regarding medical waste management and standardized disposal methods are often scant in many countries.27 Even when government regulations are in place, it may be difficult for low-income countries to enforce them because there is little public pressure to do so.28,29 Also, hospitals in developing countries often lack proper supplies, personal protective equipment, and appropriate refuse collection services and storage facilities.26,29 Lack of equipment contributes to pollution and undoubtedly predisposes hospital staff to contracting various pathogens, creating a public health concern.

Patil and Pokhrel30 explain that, in India and other developing countries, lack of environmental awareness and insufficient appreciation among staff make waste management initiatives difficult to implement. The authors also acknowledge that the bedside nurse is responsible for the initial segregation, disposal, and storage of hospital waste and thus possesses a crucial position in minimizing environmental harm. In Indonesia, awareness among staff, including the experienced nurses, may be low for several reasons: unwillingness to participate, minimal motivation, and improper training and education regarding waste disposal.28 Reasons for poor medical waste management in Dhaka City, Bangladesh, can be attributed to a lack of awareness, dearth of appropriate policy and laws, and apathy.29 In Iran and Tanzania, the staff's unwillingness to participate, lack of motivation, and deficient training and education about green initiatives were reasons why waste management programs did not succeed.28

Researchers and environmental activists believe that resolution of these issues is possible. Activists believe that a key step in doing so is to raise hospital staff awareness because, as Chaerul et al state, "the performance of the waste segregation process depends on the knowledge of the hospital's staff at the points of generation."28^(p445) If nurses are to be accountable for waste disposal, it is imperative that they understand the waste life cycle, no matter where they are. When environmental awareness in developing countries is established, strong environmental controls and legislative policy are more likely to be enacted and higher standards regarded when considering the disposal of waste.31 Once government and hospital policies are introduced, refuse management projects can be categorized as such: source reduction, solid waste recycling and reuse, solid waste treatment, and solid waste incineration and disposal, according to Karamouz et al.32 Within these categories are the concepts of color-coded bins for different types of wastes and the implementation of multiuse, sterilized supplies.27,29,30 By joining the environmental sustainability bandwagon, US hospitals can hopefully become trendsetters for other countries to follow.

PROPOSED RESOLUTION

The ethical duty of a nurse to promote environmental health is one that persists not only in the hospital working environment but also in the community and world at large. As Dinkins and Sorrell13 note, this duty can take shape through educating patients and staff, performing research, and joining environmental health advocacy groups. Whether in the hospital or community, nurses can use the nursing process in education and policy efforts to promote "going green."

Education

Perhaps the most integral and basic education method for nurses is self-education, including continuing education. Environmental health nurse Ballard33 strongly encourages continuing education workshops on environmental health in the hospital setting. Nurses need to strongly advocate for required continuing education that includes basic information on environmental sustainability in the healthcare workplace. Basic information should address the environmental impact of hospitals, safe pharmaceutical disposal, PVC materials, recycling and energy conservation efforts, and those hospital committees that affect change. At the preventive level, nurses can advocate for this education to occur as part of new staff orientation and serially, with annual updates. Nurses and nurse educators could utilize the resources provided by the H2E, such as educational teleconferences, the technical assistance hotline, and the online waste priority planner, to enhance educational sessions.

As more nurses gain environmental health awareness, the shift must be from not only educating one's self but also transferring this knowledge to allied healthcare staff. Nurses retain the duty of working with top hospital officials and key hospital stakeholders to improve the hospital's environmental impact and create positive change. Nurses can use current literature to advocate for the environmental health, economic, political, and ethical incentives of going green. Sattler and Hall2 encourage nurses to demonstrate how "going green" remains a goal of The Joint Commission, the EPA, and the Institute of Medicine. As holistic practitioners, nurses must remain aware of the psychological phenomenon of unfreezing, moving, and refreezing in the change process. They must be prepared to educate staff about new "greening" practices and ways to become involved in these practices. As units introduce new, green products, environmentally aware nurses can provide needed education about their use and benefit.

In addition to advocating for integral environmental health education within the hospital, inpatient nurses can advocate for increased education in the community. Specifically, nurses can petition to the American Association of Colleges of Nursing to promote environmental health education as part of the core curriculum in nursing programs throughout the United States. Nurses could provide evidence that early education can prevent environmental health violations and introduce a passion for environmental health among the future nurses of America. The concepts of going green could be incorporated into all levels of nursing curricula, both in teaching and in practice, to promote increased environmental awareness. One such highly successful college-based environmental health program exists at the University of Maryland and has produced numerous environmental health nurse leaders and hospital-based greening programs.34 By writing petitions to state nursing boards, nurses can hopefully receive funding for continuing environmental health education. The H2E Web site provides a plethora of educational material to assist in implementing successful educational programs.

Policy

While nurses can educate themselves and others about environmental change, they can work to institute these changes on the policy level. According to environmental and occupational health nurse Karen Bowman, MN, COHN-S (oral communication, July 3, 2008), common hospital committees, such as Product Review and Health & Safety, provide 2 of the best and most fundamental forums in which to institute change. Nurses frequently sit on committees, which determine products and equipment used in the hospital as well as how the facility can improve health and safety for clients, staff, and the environment. Through these committees, nurses can advocate for reusable devices, support initiatives to recycle, explore methods to reduce energy consumption, educate about better waste management, and introduce a variety of other environmentally friendly initiatives. Shaner-McRae et al6 also encourage the voices of nurses in individual departments as well as in unions to raise awareness about environmentally friendly purchasing practices. Unit-based management and unions can provide avenues for nurses to negotiate for sustainable initiatives at the broader level of hospital administration.

Nurses can advocate for the creation of environmental health committees and a hospital environmental health liaison. The purpose of an environmental health committee would be to share innovative ideas regarding waste management, energy reduction, recycling, and the provision of environmental health education. As Topf12 and other nurse advocates agree, the issue of implementing environmentally friendly changes involves numerous stakeholders in the hospital. Representatives from medicine, housekeeping, employee health, laboratories, clinical leadership, public relations, and patient safety would be asked to join the committee, as well as a nursing representative from each hospital unit. Two of these representatives could join the Product Review and Health & Safety committees to facilitate clear communication. Shaner-McRae et al acknowledge that while hospitals may understand certain environmental health requirements, "they do not dictate who is responsible for monitoring and implementing the regulation in a specific health care setting."6^(p6) Nurses' holistic perspectives make them optimal candidates to become hospital environmental liaisons. The environmental liaison could head the environmental health committee and exist as the communication link between the state and federal environmental regulations and the hospital.

Nurses have the opportunity to join various local and national nursing organizations to advocate for environmental health changes on a large scale. Numerous state nursing boards throughout the United States have been vanguards in promoting greening initiatives in local hospitals. For example, in Washington State, environmental health nurse activists promote greening initiatives and greening education (Karen Bowman, MN, COHN-S, oral communication, 2008). On a national level, both HCWH and H2E provide enriching experiences for nurses to share success stories, environmental health education, and new initiatives in greening. HCWH possesses Nursing Workgroups (Table 2), a specific forum in which nurses can perform the aforementioned tasks and provide support to continue with greening initiatives.9

An organized approach: ADPIE

Nurses can initiate assessment, diagnosis, planning, and implementation of green changes in conjunction with education and policy-level work. H2E provides a detailed list of ADPIE strategies on its Web site. In the assessment phase, the Web site suggests researching current policies and practices upheld by one's hospital and gathering data on current waste management and product purchasing practices. A key step in the assessment process would also be to assess and understand the hospital environmental health policy requirements upheld by The Joint Commission, the EPA, and state and local governments. H2E provides a Self-Assessment and Education guide (Table 2) and a Waste Priority Planner to assist in assessing one's hospital. After assessing one's hospital's policies and areas for growth, a diagnosis of needed change can be made. The next step, as H2E23 and environmentalist Topf12 note, is to set measurable and specific goals for change, just as a nurse would establish these specific goals for a client. In newly emerging greening projects, focusing on objectives that will help the facility reduce costs and promote positive publicity should be considered first, in an attempt to convince often-weary hospital administrators of the benefit of the program. As the H2E explains, setting measurable and specific goals assists not only in the achievement of these goals but also in the evaluation of the program as a whole.23

To bring the ADPIE approach full circle, the process of evaluating green changes should include an evaluation of program benefits, progress, and reaction to instituted programs. Step 10 of H2E's Guide to EPP (Table 2) states, "let facility staff, patients, and administrators know about the success of your efforts."23 Sattler and Hall2 and Topf12 agree that publishing or reporting evaluated benefits is one of the key steps to instituting enduring environmentally friendly programs. Nurses or environmental health liaisons can take charge and evaluate both the financial and environmental health benefits of current programs by crunching numbers and introducing data collection methods for designed projects. The environmental health committee could be a great resource not only in collecting these data but also in publishing and presenting it to key hospital stakeholders. The H2E Web site provides a Tracking & Assessment guide that assists specifically in tracking both environmental benefits and cost savings. Along with measuring program benefits, progress assessment remains a key point of the evaluation process. Step 6 of H2E's Guide to EPP suggests that an individual be appointed to audit the progress of greening programs as a method of evaluating ongoing needs and implementing program changes midstream. H2E also suggests developing a feedback system for employees implementing the programs, such as hospital-wide surveys, community forums, or in-person interviews.

In performing a review of literature, the authors found a scant amount of literature that provided research on specific types of greening measures initiated and the efficacy of these programs. The Luminary Project (see Table 2), a Web site composed and run by environmental health nurse specialists, provides one such example of how greening initiatives could be shared with the public and the healthcare community. The Web site provides a forum for nurses to share ideas for greening projects as well as to discuss benefits and fallbacks from projects already begun. With their skills in utilizing ADPIE, nurses in the community remain in the prime position to research and publish information comparing and measuring the efficacy of various greening programs. Nurses can conduct qualitative studies looking at the best methods to get nurses and healthcare facilities involved in implementing green changes.

CONCLUSION

Nightingale began the charge toward implementing environmental change, and nurses today are called to continue this integral mission. As holistic practitioners, it remains extremely important for nurses to consider the issue from a holistic perspective, and nurses possess excellent personal and professional resources to do so. In working toward environmental health in the hospital, nurses can promote the health of 3 interconnected entities: the patient, the worker, and the environment. As world environmental health issues continue to grow, the nurse's opportunity to promote greening initiatives becomes an ethical duty and an expected part of the job description.

REFERENCES