American Nurses Association, October 15, 2003


[Rachel's introduction: In October, 2003, the American Nurses Association formally adopted a precautionary approach, focusing on the prevention of hazards. "The precautionary principle states that if it is within one's power, there is an ethical imperative to prevent rather than merely treat disease, even in the face of scientific uncertainty."]

EXECUTIVE SUMMARY: This report provides background information and direction for the American Nurses Association's (ANA) environmental safety policy formation and advocacy through a precautionary approach that focuses on prevention of hazards. The precautionary principle states that if it is within one's power, there is an ethical imperative to prevent rather than merely treat disease, even in the face of scientific uncertainty. The ANA Board of Directors adopted the precautionary approach in October 2003.

1. ANA will broaden its work in occupational and environmental health and apply a precautionary approach when an activity raises threats of harm to human health or the environment.

2. ANA will advocate for public policy that utilizes the precautionary approach that focuses on prevention of hazards to people and to the natural environment.


While Florence Nightingale spoke about the importance of clean air, water and environment; modern day nursing has not paid as much attention to the relationship between health and the environment. ANA's involvement in environmental health has focused on the work environment (occupational health and safety) and the toxic byproducts of the health care environment. ANA's work on the environmental impacts of the health care industry has been implemented primarily through ANA's membership and involvement in the international coalition, Health Care Without Harm (HCWH), the campaign for environmentally responsible health care ( As a result of the success of the Health Care Without Harm coalition, and visibility of ANA in HCWH and the Hospitals for a Healthy Environment (H2E) partnership (, ANA is increasingly in demand to be a leader in environmental health issues.

ANA needs to develop a foundation in policy for these activities beyond the 1997 House of Delegates Report: Reduction of Health Care Production of Toxic Pollution, incorporating the recommendations from the 1995 Institute of Medicine Report: Nursing, Health and the Environment.


In 1860, Florence Nightingale provided the foundation for nursing attention to environmental exposures and health effects when she wrote about the need for fresh air and clean water in Notes on Nursing (Nightingale, 1860).

The International Council of Nursing (ICN) published a position statement in 1986, The Nurse's Role in Safeguarding the Human Environment. It states: "The preservation and improvement of the human environment has become increasingly important for man's survival and well-being. The vastness and urgency of the task place on every individual and every professional group the responsibility to participate in the efforts to safeguard man's environment, to conserve the world's resources, to study how their use affects man, and how adverse effects can be avoided."

This position statement was incorporated into the recommendations of the Institute of Medicine (IOM) Committee on Enhancing Environmental Health Content in Nursing Practice published in 1995 in its report: Nursing, Health and the Environment (IOM, 1995). The IOM report recommended environmental health competencies for nurses to include: 1) Basic knowledge and concepts; 2) assessment and referral; 3) advocacy, ethics, and risk communication; and 4) legislation and regulation. That same year the National Institute of Nursing Research (NINR) convened a second workgroup to develop an environmental health research agenda for the profession. The group emphasized that because nurses are employed in so many settings, the profession is uniquely suited to conduct applied research addressing the impact of environmental hazards on vulnerable populations and communities.

Precautionary Principle

The precautionary principle is explained thus: "when an activity raises threats of harm to human health or the environment, precautionary measures should be taken even if some cause and effect relationships are not fully established scientifically" ( The principle includes taking action in the face of uncertainty; shifting burdens of proof to those who create risks; analysis of alternatives to potentially harmful activities; and participatory decision-making methods. The precautionary principle takes the life cycle of products or chemicals into account and adds the proactive step of pre-market analysis of environmental harm.


As nurses, who are educated in disease prevention, we can appreciate and should advocate for a precautionary approach when it may prevent injuries and illness. Nurses, as trusted and credible sources of information and education regarding environmental health issues, have the potential to lead patients and communities. ANA can assist nurses in educating and guiding policy makers, including elected officials, to a new way to see the relationship between life's choices (both individual and societal) and their impact on health.

ANA will advocate for a precautionary approach to environmental health that provides an opportunity for prevention instead of focusing most of our resources on curing disease resulting from preventable exposures.