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

Including sustainability issues in nurse education: A comparative study of
rst year student nurses' attitudes in four European countries
Janet Richardson
, Fabienne Fasseur
, Jane Grose
Norma Huss
, Isabel M. López-Medina
, Angélick Schweizer
Faculty of Health and Human Sciences, Plymouth University, 8 Portland Villas, Drake Circus, Plymouth PL4 8AA, UK
Faculty of Social Work, Health Care and Nursing Sciences, Hochschule Esslingen University of Applied Sciences, Flandernstr. 101, 73732 Esslingen, Germany
Department of Nursing,Faculty of Health Sciences Institution, University of Jaén, Edif. B3, Dep. 243, Campus Las Lagunillas, s/n, 23071 Jaén, Spain
Institute of Psychology, Research Center in Health Psychology (CerPsa), Faculty of Social and Political Sciences, University of Lausanne, Geopolis 4530 Dorigny, 1015 Lausanne, Switzerland
Universiteit Maastricht, Minderbroedersberg 46, 616, 6200 MD Maastricht, The Netherlands
Department of Nursing, Faculty of Health Sciences Institution, University of Jaén, Building B3, Dep. 265, Campus Las Lagunillas, s/n, 23071 Jaen, Spain
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
Nurse education
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
Design: A comparative survey design using the Sustainability Attitudes in Nursing Survey (SANS_2) question-
Settings:Nursing classes of Universities and Nursing Schools infour European countries were investigatedusing a
questionnaire consisting of ve 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 veitems loaded on a single factor which
explained 58% of variance. ANOVA of the SANS_2 total score showed signicant 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 signicant
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) xxxxxx
Corresponding author at: School of Nursing andMidwifery,Plymouth University, Drake Circus, Plymouth PL4 8AA, UK. Tel.: +44 1752 586535.
E-mail addresses: (J. Richardson), (T. Heidenreich), (C. Álvarez-Nieto), (F. Fasseur), (J. Grose), (N. Huss), (M. Huynen), (I.M. López-Medina), (A. Schweizer).
Tel.: +49 711 397 45 86.
Tel.: +31 43 388 4840.
YNEDT-03112; No of Pages 6
0260-6917/© 2015 Elsevier Ltd. All rights reserved.
Contents lists available at ScienceDirect
Nurse Education Today
journal homepage:
Please cite this article as: Richardson, J., et al., Including sustainability issues in nurse education: A comparative studyof rst year student nurses'
attitudes in four European c..., Nurse Educ. Today (2015),
Sustainable development is a concept vital to healthcare: due to its
relatively large CO
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
emissions, the equivalent of the
region's international aviation and shipping industries combined
(KPMG, 2012). Hence, reductions in energy use and improvements in
resource efciency 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 rst. 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 ve 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.
High CO
producingsectors across the EU are responding to the need
to take a lead on sustainability. For example, the German Government
reafrmed 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 ofcial data on the
Spanish GHG emissions Inventory data for 19902005, 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 scal policy (Sustainable Development
In the UK, the National Health Service (NHS) produces approximate-
ly 19.7 million tonnes of CO
equivalent (NHS Sustainable Development
Unit, 2012); signicant work needs to be done in order for the NHS to
meet its CO
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
(20052014). 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 specic
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 specic
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 prole 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 agoodthingbut their
positive response did not correlate with their degree of familiarity
2J. Richardson et al. / Nurse Education Today xxx (2015) xxxxxx
Please cite this article as: Richardson, J., et al., Including sustainability issues in nurse education: A comparative studyof rst year student nurses'
attitudes in four European c..., Nurse Educ. Today (2015),
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 specicstudies,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
efciency. 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 efcacy
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.
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 rst-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
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 inuence 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 productmoment 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 signicant 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 rst 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 specic 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 agreewas 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 modications were made where necessary to ensure the
nal 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
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) xxxxxx
Please cite this article as: Richardson, J., et al., Including sustainability issues in nurse education: A comparative studyof rst year student nurses'
attitudes in four European c..., Nurse Educ. Today (2015),
Data Collection
Data were collected in a cross-sectional design by giving the
questionnaire to undergraduate student nurses at the start of their
rst 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
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 specic 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 productmoment 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.
Psychometric Analysis of SANS_2
Correlational analysis reveals that all ve items of SANS_2 show
positive and highly signicant (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% Condence Intervals
of mean scores. ANOVA (Analysis of variance) for SANS_2 total score in-
dicates that there is at least one signicant difference between two
countries. Signicant differences between countries are also found for
Items 2, 3, 4 and 5 with no signicant 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
signicantly 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.
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 ve 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
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 signicantly 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
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) xxxxxx
Please cite this article as: Richardson, J., et al., Including sustainability issues in nurse education: A comparative studyof rst year student nurses'
attitudes in four European c..., Nurse Educ. Today (2015),
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,
While this study shows good psychometricproperties of the SANS_2
and signicant differences in nurse students' attitudes between
EU countries, it has a number of limitations: rst, 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.
These data indicate that there are signicant 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
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
What Does This Paper Contribute to the Wider Global Clinical
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
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.
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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Sustainability into the Engineering Curriculum. Department of Mechanical and
Table 2
Comparison of sustainability-related attitudes between countries (M = Mean, SD = Standard Deviation; CL95 = 95%Condence Interval;non-overlapping condence intervals indicate
signicant differences between countries).
SANS_2 item UK Germany Spain Switzerland ANOVA
Total SANS_2 (M, SD) [CI95] 4.52 (1.03)
4.93 (0.94)
4.54 (1.14)
4.65 (1.12)
F (3.911) = 7.45 p b0.001
Climate change is an important issue for nursing 4.41 (1.31)
4.64 (1.42)
4.70 (1.48)
4.51 (1.39)
F (3.909) = 2.16 ns
Issues about climate change should be included in the nursing curriculum 3.86 (1.36)
4.26 (1.45)
3.88 (1.53)
4.04 (1.55)
F (3.310) = 3.87 p b0.01
Sustainability is an important issue for nursing 5.02 (1.29)
5.65 (1.25)
4.65 (1.42)
5.14 (1.35)
F (3.911) = 16.69 p b0.001
Sustainability should be included in the nursing curriculum 4.63 (1.37)
5.27 (1.34)
4.10 (1.54)
4.61 (1.45)
F (3.907) = 18.69 p b0.001
I apply sustainability principles in my nursing practice 4.69 (1.27)
4.83 (1.30)
5.38 (1.26)
4.93 (1.31)
F (3.908) = 9.51 p b0.001
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attitudes in four European c..., Nurse Educ. Today (2015),
... Although there is a consistent increase in the number of nursing publications addressing the SDGs nowadays, new studies are needed to increase efforts and add to the evidence base documenting progress and challenges in meeting the SDGs (Osingada and Porta, 2020;WHO, 2017). Sustainable development training is a goal recognized by many countries and a vital concept in health (Richardson et al., 2016). In some studies, the importance of including the SDGs in the nursing education curriculum has been emphasized and the current deficiencies have been mentioned (Osingada and Porta, 2020;Sullivan et al., 2019). ...
... The universities have been recommended to make necessary efforts to integrate the three vital aspects of sustainability (social, economic and environmental) into their educators' training, workshops or related activities and policies that will facilitate an equivalent awareness of sustainability dimensions (Moganadas et al., 2020). In a study conducted in England, nursing students were found not to be ready to understand the relationship between resources, climate change, sustainability and health (Richardson et al., 2016). However, it is stated that future health professionals will face two important challenges that will affect their ability to provide care: Climate change (malnutrition/hunger, deaths due to floods, mass migration and changes in disease patterns due to weather change, etc.) and geopolitical events (resource scarcity, natural disasters and disruption of the supply of essential health supplies) (Richardson et al., 2014a,b). ...
... The role of higher education has been emphasized to be indispensable in sustainability practices and it can develop students, from all disciplines (medicine, nursing, educational sciences, etc.), with skills that support sustainable development. It is becoming increasingly important to include appropriate materials on sustainable development in the training programs of many professions (Richardson et al., 2016;Wright et al., 2022). The way higher education institutions address sustainable development is manifested in many leading agreements, statutes and partnerships. ...
Aim To determine the sustainable development awareness and related factors in nursing students. Background Sustainable Development Goals have an important place in nursing education. While the Sustainable Development Goals set out the determinants of health, they also provide guidance to nurses for their interventions. In this respect, it is important to determine the awareness of nursing students and to address this issue in nursing education. Design Correlational descriptive study. Methods A total of 199 Turkish nursing students were included in the study. Data were collected online through Google Forms between March and June 2021 by the demographic characteristics form and “Sustainable Development Awareness Scale”. Results The mean age of the nursing students in the study was 20.18 (± 1.27) years. Students' mean score from the scale was 164.41 (± 15.13) points. While 63.8% of the participants stated not hearing of the sustainable development concept before and 77.4% of them did not know about Sustainable Development Goals. The social sustainability, environmental sustainability and total scale scores were determined to show significant differences between the genders and female participants got higher scores compared with males. Participants over the age of twenty were found to score significantly higher in the environmental sustainability sub-dimension. According to the status of thinking that there is a relationship between sustainable development and nursing, the environmental sustainability scores of the students were found to differ statistically. According to the status of wanting to get more information about Sustainable Development Goals, the economic sustainability, environmental sustainability and total scale scores of the students were found to show a statistically significant difference (p < 0.05). Conclusions The sustainable development awareness levels of nursing students were found to be higher than the average. While more than half of the participants stated not hearing of the sustainable development concept before and three quarters of them did not know about Sustainable Development Goals. In this study, the scale total or sub-dimension scores were found to show significant differences according to gender, age, the status of thinking that there is a relationship between sustainable development and nursing and the status of wanting to get more information about Sustainable Development Goals. To mobilize future nurses, it can be suggested that SDGs be added to the curriculum, considering their knowledge and willingness.
... The education in sustainability and its awareness among nurses have been described as pillars to mitigate the negative impact of pollution on people's health (Leffers et al., 2017), being entangled in all 17 Sustainable Development Goals (Anåker & Elf, 2014;Kearns & Kearns, 2021;Kitt-Lewis et al., 2020). Therefore, nurses are engines of change in the current health system regarding environmental sustainability through research, and projects are integrated to achieve it (Lilienfeld et al., 2018;Richardson et al., 2016). Recent research indicated a scarcity of research focused on nurses and environmentally sustainable health systems (Osingada & Porta, 2020). ...
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Objective: To analyze the current scientific knowledge and research lines focused on environmentally sustainable health systems, including the role of nurses. Background: There seem to be differences between creating interventions focused on environmentally sustainable health systems, including nurses, and the scarcity of research on this topic, framed on the Sustainable Development Goals. Methods: A bibliometric analysis was carried out, via three databases (Web of Science, Scopus, and Pubmed), and the guideline recommendations were followed to select bibliometric data. Results: The search resulted in 159 publications, significantly increasing the trends from 2017 to 2021 (p=0.028). The most relevant countries in this area were the United States of America, the United Kingdom, and Sweden. Also, the top articles were from relevant journals, indexed in Journal Citation Report, and the first and the second quartile linked to the nursing field and citations (p<0.001). Conclusion: Education is key to achieving environmentally sustainable health systems via institutions and policies. Implications for nursing management: There is a lack of experimental data and policies on achieving or maintaining environmentally sustainable health care systems, indicating that nurses have an important role and should be consulted and included in decision-making policies regarding sustainability in the healthcare systems.
... Content validity was again determined through discussions with nursing education and sustainability experts, and they rated content to assess the desired construct [19]. Level of attitudes were categorized in: Excellent (scores > 90%), Very good (scores 70-89%), Good (scores 50-69%), Not enough (scores 30-49%) and Poor (scores < 29%) [20]. ...
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Background Mainstreaming sustainable healthcare into the curricula of health professions is a key action to raise awareness and change attitudes. Therefore, the present study aimed to assess the contribution of scenario-based learning and augmented reality to the environmental awareness and attitudes toward climate change and sustainability among undergraduate nursing students. Methods This study was designed as a time-series analysis. Undergraduate nursing students in their 3 years were introduced to sustainability and climate change in the context of healthcare through scenario-based learning sessions. Questionnaires were used to collect data on participants’ attitudes towards sustainability and climate change, the usefulness of the educational sessions and the extent to which students changed their clinical practice. A data summary, related sample Friedman and Wilcoxon signed-rank tests were used to test for differences in survey scores. Results Attitudes and environmental awareness toward climate change and sustainability increased significantly as students received the learning sessions over the 3 years. After their first clinical training period, students already showed a high awareness of unsustainable practices in their working environment; however, they still struggled to apply sustainability and address unsustainable practices in healthcare settings. Most students felt that the scenarios helped them to make links between climate change, resources, and health. Conclusions The scenario-based learning and augmented reality increase environmental awareness and attitudes toward climate change and sustainability among nursing students. Students are very aware of unsustainable practices in their work environment, but more work needs to be done on the application of sustainability principles to nursing practice.
... Thus, educating nursing students about these topics is required to empower nurses to take leadership for change. There is evidence of varying attitudes toward including sustainability and climate change in nursing curricula in different countries (Richardson et al., 2016), and teaching materials and approaches need to be context and culturally specific. ...
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Background: Delivering health care negatively influences the environment and contributes to climate change. This study examined how nursing students in England and Sweden can make changes in clinical practice to enhance environmental sustainability. Method: Third-year undergraduate nursing students at English and Swedish universities responded to open-ended questions on the Sustainability Attitudes in Nursing Survey. Data were analyzed using inductive content analysis. Results: Students in both countries identified lack of confidence as the main barrier to challenging unsustainable practice, followed by a resistance to change in practice. English students predominantly changed their own behavior or influenced the practice of others. Swedish students either changed their own behavior or their own attitudes to sustainability. Conclusion: There is a need to ensure students have confidence to act as change agents to enhance sustainable practice in the clinical environment. [J Nurs Educ. 2022;61(7):390-393.].
... Es central vincular los conceptos de salud, el ambiente y las condiciones económicas y sociales de las poblaciones para dar respuesta real desde la atención médica y de enfermería ante el cambio climático y el desarrollo sostenible (Richardson, Heidenreich, et al., 2016;Shea et al., 2020), el orientar estrategias que solo se enfoquen a las habilidades biomédicas desarrollara en lo que menciona (Goodman, 2011) generara a futuro unos eco-analfabetas. ...
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Hospitals are institutions that operate permanently, requiring the consumption of resources and inputs, which permanently generate waste, atmospheric emissions and discharges that will generate major impacts on society and ecosystems. Health personnel is a fundamental actor to mitigate these impacts from the actions in each of the health care services. For this reason, we intend to design a training program in environmental sustainability focused on education for the development of business practices and sustainable communities for the health personnel of the 199 health institutions linked to the Global Network of Green and Healthy Hospitals (Global Network) in Colombia. For its development, a research process was carried out in three phases: the first phase identified the linkage of environmental issues in the training programs of health sciences and the advances in the environmental management of the hospitals linked to the Global Network. For the second phase, a rigorous review of the scope of the scientific literature was carried out, which was analyzed together with the results of the interviews conducted with those responsible for environmental management linked to the Global Network in hospitals in Nariño, Valle del Cauca, Cundinamarca and Bogotá D.C. as evidence-based knowledge for the design of the training program. In the third phase, the business environment was assessed for the design of the business and environmental management system of the Growing Up Foundation organization for the execution of the training program, evaluating its financial feasibility for its development. Among the results, there is evidence of the lack of training of sanitary personnel in environmental issues, and there are important commitments to waste management, chemical substances and leadership. On the other hand, the literature reports the weakness of health professionals who have the tools to contribute to mitigate environmental impacts. A training program with five (5) training levels is proposed. For the third phase, a business and environmental management system is designed for the Growing Up Foundation organization, having the possibility of its execution since the proposal presents operational and financial feasibility.
Aim: This study aimed to investigate the Integrating Sustainability Development Education Program in Nursing to Challenge Practice Among Nursing Interns in Health Care. Background: The combination of sustainable development and climate change in health care delivery benefits from the apparent environmental changes. Subjects and methods: The quasi-experimental, cross-sectional, comparative study included 160 nursing interns who completed the intervention. Both genders were assigned to Saudi (N=80) and Egyptian nursing interns (N=80). Data were collected through a self-administered questionnaire, including The Sustainability Consciousness Questionnaire and the Sustainability Attitudes in Nursing Survey. Results: A statistically significant difference was found between student nurses' knowledge, attitude, and behavior during pre intervention and post intervention, as well as in student nurses' sustainability development dimension effectiveness after than before program implementation. Conclusion: The program had a significant effect on all sustainability development domains and a large effect on total sustainability development during post intervention. This study recommended that educational programs can upgrade sustainability development and challenge practice levels. Implications for nursing management: Sustainable development is the future of management and is the next phase of management innovation. Sustainability, in the context of healthcare, is about progress in high-quality patient care delivery for all by promoting the three elements of sustainable development: environmental, social, and financial. Nurses play a significant leadership role in addressing environmental sustainability and climate change.
Aim: The aim of this research study was to investigate the perceptions of climate change and sustainability of faculty teaching in associate and baccalaureate degree nursing programs in South Carolina and their attitudes toward inclusion of relevant content into the nursing curriculum. Background: Climate change is a topic that receives limited discussion in most nursing education curricula. Method: This cross-sectional, descriptive study gathered data from 21 schools of nursing via an online survey consisting of demographic questions, the New Ecological Paradigm Scale, and the Sustainability Attitudes in Nursing Survey 2 and two questions regarding the current inclusion of content. Results: Eighty-one percent of respondents did not include health implications of climate change in their teaching content; 67% did not include health implications of sustainability. Conclusion: Results provide preliminary evidence of gaps and areas of need for curricular content related to climate change and sustainability.
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Aim This review identifies and synthesizes literature related to the awareness of and attitudes towards sustainability and climate change from the perspective of nursing students and educators. Design A systematic integrative review. Methods The review will follow the five stages outlined by Whittemore and Knafl: problem identification, literature search, data evaluation, data analysis and presentation. The data analysis will be based on inductive content analysis developed by Elo and Kyngäs. Principles of the Cochrane Collaboration and Preferred Reporting Items for Systematic Reviews and Meta Analyses (PRISMA) will also inform the review process. Results This review will offer insights about sustainability and climate change in relation to an important target population: the future nursing workforce and those educating its members. Findings might inform curriculum development, potentially contributing to a nursing profession that looks after the health of the planet and the health of the population inhabiting it.
Health professionals have key roles in addressing the health consequences of climate change. Climate change is the leading public health concern of the 21st century and has implications for population health globally. Our changing climate is exacerbating health conditions with both acute consequences as well as chronic health conditions including nutrition and food security; food- and water-related challenges; vector-borne illnesses; and extreme weather outcomes that include social disruption, physical displacement, injuries and death, and mental health consequences. Greenhouse gas emissions (GGEs) are responsible for the impact on climate and health. Expanding an understanding of the impact of climate and associated deleterious health consequences is critical in health professions education and within an interprofessional framework. A scoping review methodology was conducted of peer-reviewed academic and grey literature via bibliographic databases that included MEDLINE via PubMed, CINAHL Complete via Ebscohost, ERIC via Ebscohost, and Google Scholar. A total of 111 articles were included in our review with 74 papers yielded that were discussion papers, 24 quantitative studies, 4 qualitative studies, 1 mixed methods paper, 1 systematic review, 3 scoping reviews,1 integrative review, 1 toolkit and 2 posters/abstracts. Thematic analysis yielded five themes: curriculum (with subthemes of environmental sustainability, climate change and health, and planetary health); knowledge, attitudes, and skills; interprofessional education; educational strategies; and content. The results of this scoping review suggest that most literature was published in the disciplines of medicine and nursing and that few papers focused on the importance of interprofessional engagement among health professionals related to climate change and associated health consequences.
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Aim To evaluate attitudes towards embedding sustainability and climate change in nursing curricula among nursing students, some of whom had participated in a sustainability and health skills session, and determine whether the session could improve knowledge of sustainability. Methods Three months after the sustainability session, students who had participated along with a sample of students who had not, completed a Sustainability Attitudes in Nursing Survey questionnaire. This investigated attitudes towards climate change and sustainability in nursing curricula and the costs of clinical and domestic waste disposal. Results Nursing students were positive about sustainability and climate change and its inclusion in the curriculum, irrespective of their participation in the sustainability scenario session. Participants in the sustainability session were more likely to identify correctly the cost of clinical waste disposal in the NHS. Conclusion The sustainability and health skills session has the potential to improve nursing students' knowledge of the cost of clinical waste disposal.
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The aim of this study was to explore nurses' perceptions of climate and environmental issues and examine how nurses perceive their role in contributing to the process of sustainable development. Climate change and its implications for human health represent an increasingly important issue for the healthcare sector. According to the International Council of Nurses Code of Ethics, nurses have a responsibility to be involved and support climate change mitigation and adaptation to protect human health. This is a descriptive, explorative qualitative study. Nurses (n = 18) were recruited from hospitals, primary care and emergency medical services; eight participated in semi-structured, in-depth individual interviews and 10 participated in two focus groups. Data were collected from April-October 2013 in Sweden; interviews were transcribed verbatim and analysed using content analysis. Two main themes were identified from the interviews: (i) an incongruence between climate and environmental issues and nurses' daily work; and (ii) public health work is regarded as a health co-benefit of climate change mitigation. While being green is not the primary task in a lifesaving, hectic and economically challenging context, nurses' perceived their profession as entailing responsibility, opportunities and a sense of individual commitment to influence the environment in a positive direction. This study argues there is a need for increased awareness of issues and methods that are crucial for the healthcare sector to respond to climate change. Efforts to develop interventions should explore how nurses should be able to contribute to the healthcare sector's preparedness for and contributions to sustainable development. © 2015 The Authors. Journal of Advanced Nursing published by John Wiley & Sons Ltd.
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Research dealing with various aspects of* the theory of planned behavior (Ajzen, 1985, 1987) is reviewed, and some unresolved issues are discussed. In broad terms, the theory is found to be well supported by empirical evidence. Intentions to perform behaviors of different kinds can be predicted with high accuracy from attitudes toward the behavior, subjective norms, and perceived behavioral control; and these intentions, together with perceptions of behavioral control, account for considerable variance in actual behavior. Attitudes, subjective norms, and perceived behavioral control are shown to be related to appropriate sets of salient behavioral, normative, and control beliefs about the behavior, but the exact nature of these relations is still uncertain. Expectancy— value formulations are found to be only partly successful in dealing with these relations. Optimal rescaling of expectancy and value measures is offered as a means of dealing with measurement limitations. Finally, inclusion of past behavior in the prediction equation is shown to provide a means of testing the theory*s sufficiency, another issue that remains unresolved. The limited available evidence concerning this question shows that the theory is predicting behavior quite well in comparison to the ceiling imposed by behavioral reliability.
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The aim of this study was to describe, explore and explain the concept of sustainability in nursing. Although researchers in nursing and medicine have emphasised the issue of sustainability and health, the concept of sustainability in nursing is undefined and poorly researched. A need exists for theoretical and empirical studies of sustainability in nursing. Concept analysis as developed by Walker and Avant. Data were derived from dictionaries, international healthcare organisations and literature searches in the CINAHL and MEDLINE databases. Inclusive years for the search ranged from 1990 to 2012. A total of fourteen articles were found that referred to sustainability in nursing. Sustainability in nursing involves six defining attributes: ecology, environment, future, globalism, holism and maintenance. Antecedents of sustainability require climate change, environmental impact and awareness, confidence in the future, responsibility and a willingness to change. Consequences of sustainability in nursing include education in the areas of ecology, environment and sustainable development as well as sustainability as a part of nursing academic programs and in the description of the academic subject of nursing. Sustainability should also be part of national and international healthcare organisations. The concept was clarified herein by giving it a definition. Sustainability in nursing was explored and found to contribute to sustainable development, with the ultimate goal of maintaining an environment that does not harm current and future generations' opportunities for good health. This concept analysis provides recommendations for the healthcare sector to incorporate sustainability and provides recommendations for future research.