Nursing, Waste Management and the Hospital

Waste management and the hospital. Introduction Nurses are educated to interact with patients based on knowledge of various sciences (biological and social) and to a lesser degree on nursing theory (McCrae 2011). It is probably fair to say that issues of procurement and waste management are not their main preserve and the knowledge and skills around these issues are seen to be peripheral to their direct patient care. Therefore the immediate small win that comes from nursing for clinical waste management will have to focus on what nurses are doing in everyday practice. However this has to be placed in a wider context if nurses are to, in future, take their place in a hospital’s sustainability practice. This wider context involves an understanding of material resource use and the systems (e.g. take-make-waste) that bring clinical materials to wards and takes them away again. Clinical waste operates within legislative frameworks and EU directives (e.g. the Waste Framework Directive 2008 and the Waste Hierarchy) which will reflect particular views and understandings of how society should deal with its waste. What follows is an outline of the two main systems for resource use and waste management (take-make-waste ‘TMW’, and closed loop), an understanding of which forms the basis for the design of any waste management process. Then we will discuss the stages hospitals may go through to move from unsustainable to sustainable waste management. The role that nurses can play in this process will be based on their understanding of their place in the hospital’s waste management and sustainability governance systems and of how these systems function. The Waste Framework Directive and the waste hierarchy The waste hierarchy (WH) sits within and relates to the European Union ‘Waste Framework Directive’ (WFD 2008) whose overall aim is to embed the EU as a ‘recycling society’. The WH refers to 5 steps outlined in the WFD: 1. Prevention - preventing and reducing waste generation. 2. Reuse and preparation for reuse - the products to have a second life 3. Recycle waste materials are reprocessed into products, materials or substances. Composting is recycling but incineration is not. 4. Recovery – this includes some incineration 5. Disposal – this includes landfill, incineration, pyrolisis, gasification. The take-make-waste (TMW) process common in many organisations (and of course individuals) tends to quickly channel products to step 5. Whereas the 3Rs approach (Reduce-Reuse-Recycle) reflects steps 1-3. The closed loop system attempts to cut out step 5 altogether. Hospitals will have their own processes in place which will reflect aspects of the WFD. Clinical nurses will use and dispose of resources within the process set up by their hospital and individual clinical area probably without a second thought as to where ‘stuff’ comes from or where it goes. A sustainability literate (Stibbe, 2009) nurse will be aware of this process and may begin to suggest better processes that move us from TMW to closed loop. ‘Take-make-waste’ and ‘closed loop systems’. The current common model for resource use and waste management for many enterprises (whether public or private sector) is based on the ‘take-make-waste’ linear process (Clift and Allwood 2011) in which we extract natural resources, then fashion them into products that are used/consumed and then, when finished with, end up in landfill or incinerated. This process involves the mixing together of biological, technical and chemical elements into a useful product but which then becomes very difficult to deconstruct back into reusable essential elements. A transition within the take-make-waste model was the intention of using natural resources but doing so more efficiently but this may lead to accusations of ‘greenwash’. In this model businesses may still be doing the wrong things but they are doing them better. However, they need to re-think the whole business process and consider closed loops where we avoid TMW and re-use what has been used already. This however is a challenging prospect especially for public sector hospitals which may not have research and development departments which will fund innovation in this area, or have the clout to encourage their suppliers into doing so. The ‘reduce-reuse-recycle’ inherent in the WFD model is an improvement on the linear process in that we have three stages to consider our product use. It still relies ultimately on taking, making and then wasting albeit at a reduced rate. What it may not do is consider the mixing of core chemical and biological elements in products in such a way as to facilitate their reuse when the useful life is over if that product cannot be used again. It is the avoiding of the mixing of chemical, biological and technical elements in products that prevent reuse that is a core focus of closed loop. The closed loop model or ‘ecology of commerce’ (Hawken1993), aims to continuously recycle products and materials avoiding as much as possible the use of primary resources by keeping materials in the natural ecosystem. If however we need to extract materials for use they should be designed and manufactured to ensure the core elements can be separated easily and reused again and again. This is also known as the cyclical, cradle-to-cradle, or circular model (Clift and Allwood 2011). However this is a strategic aim which will entail root and branch rethinks of every aspect of practice and resource use. Nurses as system components themselves. Clinicians are not trained in product design, procurement and waste management or in the principles of sustainability including the notion of circular economies or closed loop (whether that it is at local or national scale). They are therefore an uncritical part of the wider take-make-waste system that underpins clinical practice. Any step in dealing with clinical waste has to therefore address the actual daily practice of resource use but also be part of a much longer term strategy to include clinicians into sustainability principles as part of a hospital’s overall sustainability governance. Not to do so locks nurses into a system they don’t comprehend or can critique from within. Innovation and creativity regarding waste management might/will be stifled as a result of uncritical acceptance of a take-make-waste process that they are a part of.  Stage shifting to sustainability Moving the hospital from unsustainable practice (take-make-waste) to sustainable (closed loop), may require a 5 stage process (Willard 2011). Stage 1 is ‘pre compliance’ where corners are cut and regulations ignored. At the moment, many Trusts will be in stage 2 (compliance to the national labour, health and safety, environmental regulations) but also working within the NHS Sustainable Development Unit’s framework (NHS SDU) for carbon reduction and sustainable practice, leading it toward stage 3. Stage three is the key stage that moves the organisation forward. The question is to what degree nurses can take part in this process: 3.0: Eco-efficient processes and products In this stage, the hospital designs its energy, water, materials, and waste handling eco-efficiencies within the hospital’s current internal operations and processes. Energy efficiencies and waste handling improvements have the biggest payback for most hospitals, which is why, according to Willard, press releases on eco-efficiency savings always include one or both of these areas. One may argue that here nurses can be involved in designing waste handling improvements as they are numerous professional group with direct experience of resource use and disposal. In this stage the hospital should increase its engagement with employees (and other stakeholders such as its suppliers). The hospital still provides the same services, and uses the same processes; but, it does these more efficiently and produces savings. Stage 3.1: Improved supply chain conditions This is where a large organisation such as the NHS could make some impact. The hospital implements sustainable procurement practices in its relationships with suppliers. It works with suppliers to help them reap the same eco-efficiencies and stakeholder engagement that the hospital has itself achieved in the previous step (3.0). Suppliers are encouraged—or coerced—into cleaning up their acts, or else they risk losing the firm as a business-to-business customer. Nurses need to be involved in procurement decisions as they (with clinical colleagues) can argue that there is a need to match clinical needs, e.g. infection prevention and control, with resource use. Stage 3.2: New eco-effective processes and products In this step nurses could innovate and create with colleagues in the hospital and elsewhere (an HEI?) to re-design its products and re-engineer its processes to be radically more productive. Nurses could co-create new green products and services with diverse stakeholders. This should encourage innovation which is spurred on by internal and external creative ideas. The hospital saves money because it uses less energy and new material in the provision of its services. Its employees are more energized, engaged, and productive as they share in the pride of working for a hospital that is leader in sustainability. The hospital basks in the glow of an enhanced reputation with important stakeholders. Stage 3.3: Sustainable governance The hospital has sustainability as a core principle in decision-making, its policies, and its culture. The hospital embeds sustainability principles into its financial measurement and management systems. It aligns its recognition, reward, evaluation, and remuneration systems to ensure that everyone understands that sustainability considerations are important. Executive teams and Trust boards redesign the hospital’s governance system to assess—and transparently report on— how the hospital is contributing to a sustainable global economy, society, and the environment. Nurses because they are a core professional group in the delivery of that service can be co-opted into this process of governance. Transformation: The 4th stage of moving into an integrated sustained strategy is transformative and requires people and organisations to internalise sustainability ideas in profound ways. Hospitals that reach Stage 4 earn the right to rebrand themselves as sustainable enterprises. Sustainability-based thinking, perspectives, and behaviours are integrated into everyday operating procedures and the culture of the organization. When these migrations happen, the metamorphosis is complete. The company has adopted an exciting, sustainable, winning, and cyclical, cradle-to-cradle, ‘closed loop’ model of healthcare. The bottom-line payoff comes from increased revenue, innovation, and productivity, as well as risk-mitigation and eco-efficiency cost-savings. It is the transformative aspect that we need to grasp as our strategic aim in which waste management plays a part. We are currently very far off the ‘cradle to cradle’ (closed loop) system that should underpin sustainable waste practice. Oppenheim (2011) argues that there are only 32 products that have been certified as ‘cradle to cradle’ products. This small number is irrelevant are not going to transform the global economy. For example, only 10% of polypropylene gets recovered. Steel is recaptured at less than 35% globally. Oppenheim, suggests that if we are going to close the gap between this strategic imperative, (i.e. the requirement to push up material productivity improvement from less than one percent to two, three or four percent a year and do it every single year for the next 20 or 30 years) then we are going have to redesign at the micro level and re-design the products from scratch. We are also, and probably more importantly, going to have to rethink how business and hospitals’ cultures and practices embed circularity into their everyday activities. Willard’s stage 5 is where the hospital achieves its purpose and passion from sustainability principles based on a values driven approach by a sustainability literate CEO. Nurses can play an important role in this process as their direct patient care activities can be a source of innovation and rethinking of processes that managers may not think of. Small bedside changes based on changed thinking helps to cement the foundations of sustainability in practice. This exemplifies bottom up as well as strategic top down leadership. Current tools such as the PDSA model (Langley et al., 2009) could be used to explore waste management practices and assist nurses in starting with the small wins of waste management  References Clift, R. and Allwood, J. (2011) Rethinking the Economy. Ellen Macarthur Foundation. http://www.ellenmacarthurfoundation.org/about/circular-economy/rethinking-the-economy Hawken. P. (1993) The Ecology of Commerce. Harper Collins McCrae, N. (2011) Whither Nursing Models? The value of nursing theory in the context of evidence-based practice and multidisciplinary health care. Journal of Advanced Nursing. Sep 12. doi: 10.1111/j.1365-2648.2011.05821 epub. Langley, G., Nolan, K., Nolan, T., Norman, C. & Provost, L. (2009) The Improvement guide: A Practical Approach to enhancing organizational performance (2nd edition). San Francisco: Jossey Bass. Oppenheim, J. in Nissanka, M. (2011) Transforming business systems: from take make waste to closed loop (cradle to cradle) systems September 30th. Highlights from the Closed Loop business models for the future discussion at the B4E Climate Summit London. http://ecocloud-sv.com/profiles/blogs/transforming-business-systems-take-make-waste-to-closed-loop-crad?xg_source=activity Stibbe, A. (2009) The Handbook of Sustainability Literacy. Skills for a changing world. Dartington: Green Books. Waste Framework Directive (2008) Directive [2008/98/EC] of the European Parliament and of the Council on waste. Willard, B. (2010). Sustainability The 4 step transformation from step 3 to step 4. http://sustainabilityadvantage.com/2010/08/17/the-4-step-transformation-from-stage-3-to-stage-4/ Further reading Allwood, J.M., Cullen, J.M. & Milford, R.L., Options for achieving a 50% cut in industrial carbon emissions by 2050, Environ. Sci. Technol. 44, 1888-1894, 2010 Allwood, J.M., Ashby, M.F., Gutowski, T.G. & Worrell, E., (2011) Material efficiency: a white paper, Resources, Conservation & Recycling 55, 362-381 Clift, R. Clean Technology and Industrial Ecology, in Pollution – Causes, Effects and Control, ed. R.M.Harrison (2001) Royal Society of Chemistry, pp. 411-444. Stahel, W.R. (2010). The Performance Economy, Palgrave-MacMillan, 2nd edition. Web: The Ellen MacArthur Foundation http://www.ellenmacarthurfoundation.org/ for the circular economy Watch: Ray Anderson on the Take-Make-Waste model . See also: http://www.storyofstuff.org on take-make-waste NHS SDU http://www.sdu.nhs.uk/