Including Sustainability Issues In Nurse Education: A Comparative Study of First Year Student Nurses’ Attitudes In Four European Countries

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Including sustainability issues in nurse education: A comparative study of
first year student nurses' attitudes in four European countries
Janet Richardson
a,
⁎,ThomasHeidenreich
b,1
,CarmenÁlvarez-Nieto
c
, Fabienne Fasseur
d
, Jane Grose
a
,
Norma Huss
b
,MaudHuynen
e,2
, Isabel M. López-Medina
f
, Angélick Schweizer
g
a
Faculty of Health and Human Sciences, Plymouth University, 8 Portland Villas, Drake Circus, Plymouth PL4 8AA, UK
b
Faculty of Social Work, Health Care and Nursing Sciences, Hochschule Esslingen —University of Applied Sciences, Flandernstr. 101, 73732 Esslingen, Germany
c
Department of Nursing,Faculty of Health Sciences Institution, University of Jaén, Edif. B3, Dep. 243, Campus Las Lagunillas, s/n, 23071 Jaén, Spain
d
Institute of Psychology, Research Center in Health Psychology (CerPsa), Faculty of Social and Political Sciences, University of Lausanne, Geopolis —4530 Dorigny, 1015 Lausanne, Switzerland
e
Universiteit Maastricht, Minderbroedersberg 4–6, 616, 6200 MD Maastricht, The Netherlands
f
Department of Nursing, Faculty of Health Sciences Institution, University of Jaén, Building B3, Dep. 265, Campus “Las Lagunillas”, s/n, 23071 Jaen, Spain
g
Research Centre for Health Psychology, Faculty of Social and Political Sciences, University of Lausanne, Geopolis —4530 Dorigny, 1015 Lausanne, Switzerland
summaryarticle info
Article history:
Accepted 2 November 2015
Available online xxxx
Keywords:
Education
Sustainability
Nurse education
Attitudes
Social norms
Climate change
Introduction: Education in sustainable development is a goal recognised by a largenumber of countries and a vital
concept in healthcare. It is therefore important that nurse education incorporates elements of sustainable devel-
opment intonursing educationcurricula. However, there is limited research on studentnurses' attitudestowards
sustainability and no comparison of attitudes towards sustainability and its inclusion in the nursing curriculum
across Europe.
Aim: This project aims to assess student nurses' attitudes towards sustainability, its relevance to nursing and its
inclusion in the nursing curricula.
1. To assess base-line attitudes at the start of nursing and midwifery training;
2. To compare sustainability awareness between students participating in training in a number of European
universities.
Design: A comparative survey design using the Sustainability Attitudes in Nursing Survey (SANS_2) question-
naire.
Settings:Nursing classes of Universities and Nursing Schools infour European countries were investigatedusing a
questionnaire consisting of five sustainability-related items.
Participants: 916 nursing students (UK: 450, Germany: 196, Spain: 124, Switzerland: 146).
Data analysis: Standard descriptive and inferential statistical methods were used to establish psychometric
quality (Principal Components Analysis, Cronbach's alpha, Pearson correlations) and compare student nurses
from the four countries.
Results:The reliability o f SANS_2 was good (Cronbach's alpha = .82) and the fiveitems loaded on a single factor which
explained 58% of variance. ANOVA of the SANS_2 total score showed significant differences between countries with
German nursing students showing more sustainability awareness than students from the UK and Spain.
Conclusions: SANS_2 is a reliable instrument to assess nursing students' sustainability awareness; there are significant
differences in sustainability awareness of students of different European countries.
Limitations of the study include non-random sampling, possible method effects and social desirability effects.
Relevance to clinical practice: Sustainability will become increasingly important in clinical practice; greater knowledge
about the attitudes of nurses towards sustainability can support the development and testing of sustainability-focused
teaching and learning materials.
© 2015 Elsevier Ltd. All rights reserved.
Nurse Education Today xxx (2015) xxx–xxx
⁎Corresponding author at: School of Nursing andMidwifery,Plymouth University, Drake Circus, Plymouth PL4 8AA, UK. Tel.: +44 1752 586535.
E-mail addresses: janet.richardson@plymouth.ac.uk (J. Richardson), Thomas.Heidenreich@hs-esslingen.de (T. Heidenreich), calvarez@ujaen.es (C. Álvarez-Nieto),
Fabienne.Fasseur@unil.ch (F. Fasseur), jane.grose1@plymouth.ac.uk (J. Grose), Norma.Huss@hs-esslingen.de (N. Huss), m.huynen@maastrichtuniversity.nl (M. Huynen),
imlopez@ujaen.es (I.M. López-Medina), Angelick.Schweizer@unil.ch (A. Schweizer).
1
Tel.: +49 711 397 45 86.
2
Tel.: +31 43 388 4840.
YNEDT-03112; No of Pages 6
http://dx.doi.org/10.1016/j.nedt.2015.11.005
0260-6917/© 2015 Elsevier Ltd. All rights reserved.
Contents lists available at ScienceDirect
Nurse Education Today
journal homepage: www.elsevier.com/nedt
Please cite this article as: Richardson, J., et al., Including sustainability issues in nurse education: A comparative studyof first year student nurses'
attitudes in four European c..., Nurse Educ. Today (2015), http://dx.doi.org/10.1016/j.nedt.2015.11.005

Introduction
Sustainable development is a concept vital to healthcare: due to its
relatively large CO
2
emissions, the use of toxic materials andthe produc-
tion of vast amounts of waste, healthcare is ultimately compromising
public health and damaging the ability of future generations to meet
their needs (Healthcare Without Harm, 2010). In the EU, the health
sector creates at least 5% of total CO
2
emissions, the equivalent of the
region's international aviation and shipping industries combined
(KPMG, 2012). Hence, reductions in energy use and improvements in
resource efficiency are vital elements of a more sustainable health
sector. Recent research commissioned by Health Care Without Harm
and Health and Environment Alliance (Healthcare Without Harm,
2010) puts forward a strong case for greater EU leadership in climate
change policy that puts peoples' health first. Higher Education has a
role to play in developing students of all disciplines with skills that sup-
port sustainable development. For example, one of the five priority
actions for the Global Action Plan (UNESCO:ESD after, 2014) is to inte-
grate sustainability practices into education and training environments
through whole institution approaches.
Background
High CO
2
producingsectors across the EU are responding to the need
to take a lead on sustainability. For example, the German Government
reaffirmed its commitment to reduce Germany's greenhouse gas
(GHG) emission by 40% by 2020 and to increase renewable energies
to 18% by 2020 and 60% by 2050.
The Spanish Climate Change and Clean Energy Strategy aims to
support clean energies, while improving social welfare, economic
growth and environment protection; according to official data on the
Spanish GHG emissions Inventory data for 1990–2005, gross emissions
increased by 52.2% with respect to the base year. The Spanish strategy
includes objectives to develop measures to increase the capacity of
citizens to take action through education, professional training and
public awareness, to approach climate-related issues in the best possi-
ble way.
In Switzerland, following the Federal Council's 2011 decision to
abandon nuclear energy, an action plan has been developed which
places greater emphasis on renewable energies. The new action plan
aims to increase the share of total energy consumption accounted for
by renewable energies by at least 50% by 2020, and to cut greenhouse
gas emission by at least 20% by 2020 (compared with their 1990
level). Moreover, the planincludes measures to ensure a broader under-
standing of the principles of sustainable development by everyone
through education and also fiscal policy (Sustainable Development
Strategy).
In the UK, the National Health Service (NHS) produces approximate-
ly 19.7 million tonnes of CO
2
equivalent (NHS Sustainable Development
Unit, 2012); significant work needs to be done in order for the NHS to
meet its CO
2
reduction targets for 2020. Ninety percent of senior NHS
leaders agree that sustainability is important, 60% believe it is essential
for the running of their organisation (Naylor and Appleby, 2012).
Sustainable development is becoming increasingly important for
healthcare in other countries in Europe as well. For example in January
2012, MVO Nederland (Corporate Social Responsibility Netherlands)
established the MVO Netwerk Zorg (CSR Network Health Care) with
the objective to enhance Corporate Social Responsibility (CSR) and
sustainability within the sector. The associated Manifest ‘Voor een
gezonde toekomst van de zorgsector’(‘For a healthy future of the health
care sector’) is currently signed by more than 80 health care institutions
(Klimaatagenda, 2013).
The important role of education in sustainable development (ESD)
has long been recognised, supported by many initiatives under the
United Nations (UN). Decade of Education for Sustainable Development
(2005–2014). At the 2012 UN Conference on Sustainable Development
(Rio+20) Member States resolved to “promote education for sustain-
able development and to integrate sustainable development more
actively into education beyond the Decadeof Education for Sustainable
Development”. In response, the Global Action Programme (GAP) was
endorsed by the General Conference of UNESCO in 2013 and launched
at the World Conference on Education for Sustainable Development in
Aichi-Nagoya (Japan) in 2014 (UNESCO, 2014).
Addressing climate change and sustainability requires specific
training and action for mitigation and adaptation. For example the
Andalusian Environmental Health Plan states that it is necessary: to
promote information and basic knowledge of environmental health
aimed at the health professionals of the Andalusian Public Health
System (primary care professionals, specialists, etc.); to help to inform
healthcare professionals of the activities of the environmental health
services in their area; to encourage healthcare professionals to give
true and evidence based information; and to contribute to the manage-
ment of environmental risk perception intheir area. Nursing is a specific
professional group that requires information and training to participate
in meeting these objectives and promote sustainability behaviour. For
example, sustainability has been included as a topic in the recently
formulated Dutch nurse education profile Bachelor Nursing 2020
(LOOV, 2015).
Despite the widely acknowledged importance of both education for
sustainable development (ESD) and a more sustainable healthcare
sector, there is limited European literature on nursing and climate
change/sustainability; nursing students are poorly prepared to under-
stand the connections between resources, climate change, sustainability
and health (Kirk, 2002; Goodman and Richardson, 2010). Sustainability
can be embedded in the healthcare curriculum through a range of
learning opportunities; for example in the context of public health and
health inequalities, poverty, food security, infectious diseases, and skills
development (Richardson and Wade, 2010; Richardson et al., 2014).
Each learning programme should have sustainability literacy for its
nursing students nested within a broader context of links between
health and the natural environment, including inequalities in health
and opportunities for chronic disease prevention (Barna et al., 2012).
Arguably, as climate change and fossil fuel dependency pose serious
threats to future healthcare we have an obligation to prepare our
students for the consequences, to ensure that they are able to deal
with the associated healthcare planning and resource issues.
Nurses are agents of change, have a remit to promote health and
control the use of health resources; nursing is one of the largest profes-
sions in Europe. Anaker et al. explored nurses' perceptions of climate
change and environmental issues in an attempt to understand how
they view their role in sustainable development (Anaker et al., 2015).
This Swedish interview study concluded that nurses have a responsibil-
ity to address climate change and environmental issues. An earlier
concept analysis (Anaker and Elf, 2014) concluded that sustainability
has far reaching implications for nurses, and recommended that the
health sector incorporate sustainability and promote sustainable devel-
opment. As energy saving and Corporate Social Responsibility are being
increasingly taken up by healthcare institutions across Europe, nursing
staff need to be equipped with knowledge and skills to support this
transition towards a more sustainable heath sector.
Nurse educators have a responsibility to embed this learning using
practical (vocational) examples; a nurse who cannot make the links
between clinical waste, resource use, carbon reduction and health
inequalities will not be able to devise solutions for future healthcare
challenges in the face of climate change and sustainable development
(Richardson et al., 2014). Yet there is little evidence to suggest that
nursing students would welcome this or view sustainability as relevant
to nursing. In contrast, sustainability as a topic for inclusion in the
Higher Education curriculum has been explored more generally. For
example a study conducted with UK students in 2005 found that the
majority of respondents think sustainability is “agoodthing”but their
positive response did not correlate with their degree of familiarity
2J. Richardson et al. / Nurse Education Today xxx (2015) xxx–xxx
Please cite this article as: Richardson, J., et al., Including sustainability issues in nurse education: A comparative studyof first year student nurses'
attitudes in four European c..., Nurse Educ. Today (2015), http://dx.doi.org/10.1016/j.nedt.2015.11.005

with the concepts of sustainable development or sustainability
(Kagawa, 2007). More recently, a survey conducted for the UK HEA
found that 70% of students believe that sustainability should be covered
by their university (Drayson et al., 2012). Discipline specificstudies,for
example researchers at Northumbria University (UK) investigating staff
and studentperspectives of embedding sustainability into the engineer-
ing curriculum, found that students had awareness but limited under-
standing of sustainability yet they felt sustainability was a key part of
an engineer's role (Penlington et al., 2013).
Promoting behavioural change will increase respect for the environ-
ment and lead to sustainable use of natural resources and improved
efficiency. Social Psychology has provided a number of theories that
help understand the complex link between attitudes and behaviour. In
their classic publication on the ‘theory of reasoned action’,Fishbein
and Ajzen (1975) argued that a person's behavioural intention (e.g.
“try to produce as little toxic waste as possible”)isdeterminedby
both the person's attitude about the behaviour (e.g. “producing toxic
waste is something that should be avoided”) and the person's subjective
norms (e.g. “mypeers thinkit is desirable to reduce toxic waste”). In his
revision of his earlier theory, Ajzen (1991) added control beliefs as a
further determinant of behavioural intention (e.g. “Icanmakea
difference by trying to produce as little toxic waste as possible”). Thus,
programmes designed to enhance sustainability awareness in nurses
and nurse students should aim at changing behavioural beliefs,
normative beliefs and control beliefs. However to evaluate the efficacy
and effectiveness of such training programmes, it is necessary to
assess sustainability-related attitudes reliably. A recent meta-analysis
(Kormos and Gifford, 2014) reported a substantial correlation (r =
.46) between self-reported sustainability attitudes and pro-
environmental behaviour. While the studies included in this meta-
analysis focused mainly on energy use and water consumption, it can
be expected that a comparable relevance of self-reported attitudes
exists with regard to nurses.
This Sustainability Attitudes in Nursing Survey (SANS) was piloted
and psychometrically evaluated across several EU countries (England,
Spain and Germany). Richardson et al. (2015) used the survey to
measure nurses' attitudes towards including climate change and sus-
tainability in the nursing curriculum and compared students who had
received a session on sustainability with students who had no session.
The aim of this current study was to compare student nurses'
attitudes towards including climate change and sustainability in the
undergraduate nursing curriculum across four countries in Europe. An
additional aim was to further assess the psychometric properties of
the SANS questionnaire.
Methods
Sample
First year student nurses in Universitiesand Schools of Nursing in 4
European countries (UK, Spain, Switzerland, Germany) participated in
this study at the start of their training. Ideally, respondents could be
sampled across all European countries and, within countries, by random
selection. However, this study design would be too large and expensive
in the current framework. Thus, we decided to sample first-year
students from cooperating universities across countries participating
in the NurSus project. Sample size was chosen in a way that allows to
detect small to medium differences (Cohen's d = .30) between
countries.
Measures
Development of Item Content
The Sustainability Attitudes in Nursing Survey (SANS) questionnaire
employed in this study was developed and piloted at Plymouth Univer-
sity (UK) with 2nd year student nurses in order to evaluate a
sustainability skills session. Con struction of the SANS is ba sed on a social
constructivism approach, thus emphasisingthe influence of context and
culture on understanding what occurs in society, and the construction
of knowledge based on this understanding. Learning in this paradigm
occurs when students are engaged in social activities towards a shared
understanding (Kim, 2001). Questions were designed to elicit agree-
ment or disagreement with statements regarding climate change and
sustainability, and the inclusion of these topics in the nursing curricu-
lum. Development of the items was based on discussions with experts
from nursing education and sustainability and took the form of group
discussions. Preliminary versions of the items were discussed with
nursing students with regard to item formulations. Education experts
rated the content validity to assess the desired construct. Formulation
of the items was designed to ensure that only one unit of meaning
was included.
Pilot Phase: Psychometric Analysis
The 7 item SANS questionnaire was piloted with 363 nursing
students in three universities (one each in Germany, Spain and UK).
Analyses were based on standard psychometric and statistical proce-
dures. To determine factorstructure, a factor analysis (Principal Compo-
nent Analysis) using the Scree Test was used. For internal consistency,
Cronbach's alpha was used. Pearson product–moment correlations
were computed to assess linear dependence of items. Group compari-
sons were performed by ANOVA and chi-square test according to the
assumed level of measurement. Psychometric analyses were performed
for the whole sample and for the individual countries. Item intercorrela-
tions were all positive and highly significant and ranged from .28 to .80.
A Principal Components Analysis yielded two components with Eigen-
values larger than 1 (3.85, 1.04). The Scree Plot indicated a marked
drop after the first component. Given that the second Eigenvalue of
1.04 is barely above 1.0, a one-factor solution was chosen. Factor Load-
ings of individual items ranged from .32 (Item 7) to .78 (Item 3). Reli-
ability Analysis revealed a Cronbach's alpha of .86. All psychometric
analyses were repeated for data from each country revealing results
that are comparable to the results found in the total sample. Given
these results, a total score (mean of SANS items) is appropriate. Further
analyses revealed that dropping specific items would not result in
reduced internal consistency. Therefore based on the pilot the SANS
questionnaire was revised so that SANS_2 focuses on 5 Likert scale
items. Questions regarding demographic details and previous exposure
to sustainability sessions were also included. The items of SANS_2 can
be found in Box 1.
A 7-point Likert scale with the end-points “1 = strongly disagree”
and “7 = strongly agree”was used for each of the 5 items on the ques-
tionnaire. Likert scales of this format are widely used in social and
nursing research with many studies showing that this form of assess-
ment may yield reliable and valid information on target constructs
(Burns and Burns, 2008). For this current study, the questionnaire was
revised (based on the pilot phase results) and translated into German,
Spanish and French. Translations were carried out by native speakers.
These translations were translated back to English by other native
speakers and modifications were made where necessary to ensure the
final versions of the translated SANS_2 represent adequate translations
of the English original.
Box 1
Items of the scale to assess nurses' attitudes on sustainability.
1) Climate change is an important issue for nursing.
2) Issues about climate change should be included in the nursing
curriculum
3) Sustainability is an important issue for nursing.
4) Sustainability should be included in the nursing curriculum.
5) I apply sustainability principles in my nursing practice.
3J. Richardson et al. / Nurse Education Today xxx (2015) xxx–xxx
Please cite this article as: Richardson, J., et al., Including sustainability issues in nurse education: A comparative studyof first year student nurses'
attitudes in four European c..., Nurse Educ. Today (2015), http://dx.doi.org/10.1016/j.nedt.2015.11.005

Data Collection
Data were collected in a cross-sectional design by giving the
questionnaire to undergraduate student nurses at the start of their
first academic year. Students were invited to complete the SANS_2
questionnaire during class and return it to their tutor. Efforts were
made to hand out the questionnaire at the start of the academic term
before students had any exposure to sustainability teaching in their
host university. Data collection took place in September and October
2014.
Ethical approval for the study was granted by Plymouth University
Faculty of Health and Human Sciences Research Ethics Committee;
local ethical permissions and procedures were applied at data collection
sites. Student details were not recorded on the questionnaire and
teachers were not aware of specific student responses. Guidelines for
computer-assisted data processing were followed.
Statistical Analyses
Analyses were based on standard psychometric and statistical
procedures. To determine factorial structure, a factor analysis (Principal
Component Analysis) using the Scree Test was used. For internal consis-
tency, Cronbach's alpha was used. Pearson product–moment correla-
tions were computed to assess linear dependence of items. Group
comparisons were performed by ANOVA and chi-square test according
to the assumed level of measurement. Psychometric analyses are
reported for the whole sample and, for the individual countries. Analy-
ses were performed using IBM SPSS Statistics 20.0.
Results
Psychometric Analysis of SANS_2
Correlational analysis reveals that all five items of SANS_2 show
positive and highly significant (p b.001) Pearson correlations. As can
be expected,item 5 which relates to personal sustainability-related atti-
tudes shows lower intercorrelations with the other items (Table 1).
A principle components analysis revealed only one component with
an Eigenvalue larger than 1 (2.92). This component explains 58.4% of
total variance. Thus, both according to the Scree Test andthe Eigenvalue
criterion, a one-factor solution was chosen. Item-total correlations were
all high and positive (Item 1: .75; Item 2: .83; Item 3: .83; Item 4: .84;
Item 5: .52). Internal consistency of the scale was good (Cronbach's
alpha = .82).
Psychometric results for SANS_2 in each country revealed compara-
ble results with the exception that internal consistency was lower in the
German sample (.73) than in the other countries (alpha N.83). This
result might be due to smaller correlations between items pertaining
to climate change in nursing versus sustainability in nurse education.
Table 2 shows means and standard deviations of total scale and
individual items across countries as well as 95% Confidence Intervals
of mean scores. ANOVA (Analysis of variance) for SANS_2 total score in-
dicates that there is at least one significant difference between two
countries. Significant differences between countries are also found for
Items 2, 3, 4 and 5 with no significant difference for item 1 (climate
change is an important issue for nursing). Post hoc tests were per-
formed using the Tamhane T-2 statistic. This is appropriate given the
assumption that variances are not equal across countries. Results indi-
cate that for SANS_2 total score, German nursing students score higher
than students from the UK and Spain.
Item 2 (Issues about climate change should be included in the
nursing curriculum) indicates that German students rate this item
significantly higher than students from the UK, while Item 3 (Sustain-
ability is an important issue for nursing) showed that German nursing
students scored higher than students from all other countries, students
from Switzerland scored higher than students from Spain. Results for
item 4 (Sustainability should be included in the nursing curriculum)
paralleled those for item 3. In contrast, with regard to Item 5, Spanish
students were more likely to report applying sustainability principles
in nursing practice than students from all other countries.
Discussion
The main aims of the current paper were to (i) to compare student
nurses' attitudes across fourEuropean countries and (ii) assess psycho-
metric data of a questionnaire to assess student nurses' attitudes on
including sustainability in the curriculum. Based on analyses from a
pre-test with 363 nursing students from three European countries, a
revised scale (SANS_2) consisting of five items was employed in this
study. Psychometric analyses revealed good psychometric characteris-
tics of the scale (internal consistency, factor structure, item-total corre-
lations) both for the total sample and for separate analyses in students
from the respective countries. These psychometric analyses indicate
that it is possible to form a total score. Interestingly, internal consistency
was lower in the German sample than in the sample from the other
countries.
The results pertaining to differences in attitudes between countries
show an interestingpattern with German students voicing the strongest
need to include sustainability in the curriculum. Again, this might be
explained by the high level of sustainability awareness in current
German politics. However, contrary to this speculation, German
students report significantly lower levels of adherence to sustainability
principles in their private life. Sustainability awareness and the applica-
tion of sustainability principles may becontext dependant. For example
German students may be more aware of the fact that they should be
doing more, because they are more aware of the problem. These are
clearly results that raise further questions that require more detailed
exploration.
Nurses need to be able to work in changing environments —this will
require an understanding of the implications of climate change and
natural resource depletion for clinical practice. Nurses' attitudes
towards sustainability will inevitably impact on their use of resources,
so it is important that scales are available to measure attitudes and as-
sess any changes in attitudes that follow interventions. The SANS_2 is
an appropriate instrument to assess sustainability-related attitudes in
nursing students and can be used in further studies: such studies
could investigate whether including sustainability-related content in
nursing curricula is associated with an increase in SANS_2 score. Further
studies could evaluate which teaching and learning approaches are
more helpful in changing nurses' sustainability-related attitudes than
others. In this current study we are at the hypothesis generation stage,
it will be important to follow up students with SANS_2 including
some measure of indirect and direct change assessment and possible
qualitative interviews to gain an understanding of any differences
between countries.
In clinical practice nurses have some degree of control over the
use and disposal of resources, SANS_2, or similar approaches could
be used to determine attitudes towards climate change and sustainabil-
ity before and following initiatives designed to change behaviour.
Taking into account Fishbein and Ajzen's (1975) model of changing
Table 1
Item intercorrelations (all p b0.001).
Item 1 2345
1 .67 .48 .37 .28
2 .51 .61 .32
3 .77 .31
4 .32
* 1 = Climate change is an important issue for nursing; 2 = Issues about climate change
should be included in the nursing curriculum; 3 = Sustainability is an important issue
for nursing; 4 = Sustainability should be included in the nursing curriculum; 5 = I
apply sustainability principles in my nursing practice.
4J. Richardson et al. / Nurse Education Today xxx (2015) xxx–xxx
Please cite this article as: Richardson, J., et al., Including sustainability issues in nurse education: A comparative studyof first year student nurses'
attitudes in four European c..., Nurse Educ. Today (2015), http://dx.doi.org/10.1016/j.nedt.2015.11.005

behavioural intent, interventions should also incorporate elements to
change perceived norms; SANS_2 results could be communicated to
nursing students to evaluate peer attitudes and perceptions. A promis-
ing perspective in this context is Social Norms Theory (Berkowitz,
2003): the basic assumption of this approach is that individual
behaviour is determined –among a number of other factors –by the
perception of peers' behaviour. For example, studies on alcohol abuse
among college populations show that heavy drinkers typically overesti-
mate the amount of alcohol intake in their respective social group. Social
Norms interventions provide feedback and show/demonstrate a
reduction in alcohol consumption in heavy drinking students (Perkins,
2002).
While this study shows good psychometricproperties of the SANS_2
and significant differences in nurse students' attitudes between
EU countries, it has a number of limitations: first, since all items are
formulated in a positive sense, the high inter-correlation might be due
to method effects. In a similar vein, social desirability may play a role
in shaping participants' answers. Finally, samples were derived in a
non-random way which might account for sampling error. These limita-
tions should be taken into account in any further research.
Conclusions
These data indicate that there are significant differences in sustain-
ability awareness of students of different European countries. The
scale described in this paper is a reliable and valid instrument to assess
nursing students' attitudes towards sustainability and should be used in
further research. Limitations of the study include possible method
effects, confounding of country and training status and non-random
sampling.
Relevance to Clinical Practice
Greater knowledge about the attitudes of nurses towards sustain-
ability and including this topic in nursing curricula can support the
development and testing of sustainability-focused teaching and learn-
ing materials. Education for sustainable development will be central to
equipping nurses to practice healthcare in the context of an environ-
ment challenges by climate change and increasing scarcity of natural
resources.
What Does This Paper Contribute to the Wider Global Clinical
Community?
•The paper draws attention to sustainability and climate change as a
global challenge in healthcare and the need to embed these topics
into nursing curricula.
•The paper compares student nurses attitudes towards climate
change and sustainability in nursing curricula across four European
Countries.
•The SANS questionnaire has been translated into a number of
languages, tested for psychometric properties, and can be used to
measure changes in attitudes following educational interventions.
Permissions
The revised version of the SANS (in English, Spanish, German, Dutch
and French)is freely available for use from the senior author.
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Table 2
Comparison of sustainability-related attitudes between countries (M = Mean, SD = Standard Deviation; CL95 = 95%Confidence Interval;non-overlapping confidence intervals indicate
significant differences between countries).
SANS_2 item UK Germany Spain Switzerland ANOVA
Total SANS_2 (M, SD) [CI95] 4.52 (1.03)
[4.43–4.62]
4.93 (0.94)
[4.80–5.06]
4.54 (1.14)
[4.34–4.75]
4.65 (1.12)
[4.46–4.83]
F (3.911) = 7.45 p b0.001
Climate change is an important issue for nursing 4.41 (1.31)
[4.29–4.53]
4.64 (1.42)
[4.44–4.84]
4.70 (1.48)
[4.43–4.96]
4.51 (1.39)
[4.26–4.74]
F (3.909) = 2.16 ns
Issues about climate change should be included in the nursing curriculum 3.86 (1.36)
[3.73–3.98]
4.26 (1.45)
[4.06–4.47]
3.88 (1.53)
[3.61–4.15]
4.04 (1.55)
[3.79–4.30]
F (3.310) = 3.87 p b0.01
Sustainability is an important issue for nursing 5.02 (1.29)
[4.90–5.14]
5.65 (1.25)
[5.47–5.84]
4.65 (1.42)
[4.44–4.91]
5.14 (1.35)
[4.92–5.36]
F (3.911) = 16.69 p b0.001
Sustainability should be included in the nursing curriculum 4.63 (1.37)
[4.50–4.76]
5.27 (1.34)
[5.08–5.46]
4.10 (1.54)
[3.83–4.38]
4.61 (1.45)
[4.38–4.85]
F (3.907) = 18.69 p b0.001
I apply sustainability principles in my nursing practice 4.69 (1.27)
[4.58–4.81]
4.83 (1.30)
[4.65–5.01]
5.38 (1.26)
[5.16–5.61]
4.93 (1.31)
[4.77–4.94]
F (3.908) = 9.51 p b0.001
5J. Richardson et al. / Nurse Education Today xxx (2015) xxx–xxx
Please cite this article as: Richardson, J., et al., Including sustainability issues in nurse education: A comparative studyof first year student nurses'
attitudes in four European c..., Nurse Educ. Today (2015), http://dx.doi.org/10.1016/j.nedt.2015.11.005

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attitudes in four European c..., Nurse Educ. Today (2015), http://dx.doi.org/10.1016/j.nedt.2015.11.005