American Journal of Nursing (Vol. 4, #4) [Printer-friendly version] March 1, 2004 THE PRECAUTIONARY APPROACH; THINKING LIKE A NURSE [Rachel's introduction: What does it mean for a nurse to take a precautionary approach to occupational hazards and to the health of patients? Charlotte Brody and Ann Melamed offer five specific steps a nurse can take to implement precaution.] By Charlotte Brody, RN, and Ann Melamed, MA, RN Q. I heard that the ANA [American Nurses Association] adopted the "precautionary approach" to address environmental health hazards. What does this mean? A. In October 2003 the ANA board of directors adopted the "precautionary approach" based on the "precautionary principle" developed by German policymakers in the 1970s to address strongly suggestive but unproven links between air pollution and the death of trees. The result of this effort to save trees includes principles that nurses promote daily: early detection and monitoring; reduction of stressors; preventive action where the likely benefit justifies the costs; and reducing risks before full proof of harm is available if the effects could be serious or irreversible. In "Late Lessons from Early Warnings: The Precautionary Principle 1896-2000," a review of radiation illustrates what can happen when we wait for irrefu--table proof before taking preventive action. Thomas Edison warned about the harm that could result from overexposure to X- rays in 1896, only a few years after the discovery was made. The possibility of fetal damage from pelvimetry (an X-ray method of diagnosing pregnancy) was documented as early as 1908. These warnings continued to be discounted, though, and it was only after other studies affirmed these findings that the practice of pelvimetry stopped and requirements were added to other medical exposures to radiation. By then, the damage had been done. A 1989 study estimated that 5% of all childhood cancers were caused by pelvimetry. If health care practitioners and the government had heeded the warnings 30, 40, or 50 years earlier, how many cases of cancer could have been prevented? The history of radiation shows how the precautionary principle could have been used to prevent, not merely treat, disease. Through the ANA's long involvement with coalitions, including Health Care Without Harm, occupational health and pollution prevention are being promoted simultaneously. As part of the ANA's prevention philosophy, when research demonstrates a possible toxic relationship between chemical exposure and health effects, nursing should be an advocate for a precautionary approach. Actions should include reduction or elimination of exposures as well as continued scientific investigations. Nurses can implement the precautionary approach in their work and apply it to all areas of nursing practice, policy, research, education, and workplace strategies. Here are five activities to help apply the precautionary approach in nursing practice. ** Get involved on product committees and be an advocate for reviewing the potential effects of new and old products and therapies on workers and the environment before they are implemented. ** Negotiate contract language that includes staff nurse input on product selection with criteria that includes patients, workers, and long-term environmental impact. ** Organize a product fair with PVC- and DEHP-free products and include educational materials about their hazards. Develop a plan to phase out the use of PVC, beginning with the NICU [neonatal intensive care unit] and maternal-child units. ** Research alternatives (see www.sustainablehospitals.org) to toxic cleaning products, disinfectants, and sterilants and develop a plan to use them instead. ** Encourage nursing research to "clarify the complex relationship between human disease and the physical and biological effects of environmental hazards with the goal of facilitating social and behavioral changes," as stated in the 1995 Institute of Medicine report. Using a precautionary approach will help all of us see through the fog of controversy to discern what the science is trying to show. Then we can determine what we can reasonably do to protect ourselves and our planet. What better way to celebrate Earth Day on April 30? Resources Institute of Medicine (IOM) Report, 1995. Nursing, Health and the Environment. Washington, DC: National Academy Press. Late Lessons from Early Warnings: The Precautionary Principle 1896-2000. Environmental issue report no. 22, European environmental agency. Wingspread Statement on the Precautionary Principle. Charlotte Brody is coexecutive director of Health Care Without Harm (www.noharm.org) and executive director of Commonweal (www.commonweal.org). Ann Melamed is an environmental health specialist with the ANA. Copyright 2006 The American Nurses Association, Inc.