Introduction
Climate change is a pressing global issue that demands urgent attention and action from individuals, communities, governments, and businesses around the world [1]. Its importance cannot be overstated, as it poses significant threats to the environment, biodiversity, and socioeconomic stability [2].
According to the World Health Organization [3], the Earth has warmed every decade due to the increasing concentration of greenhouse gases, resulting in more extreme meteorological events (sea level rise, tropical storms, cyclones, and hurricanes). There is widespread scientific consensus that the world’s climate is changing [4].
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Global documents on climate change, for example, Global Climate 2011–2020: A Decade of Acceleration, 2023; Special Report on Climate Change and Land, 2019; State of Climate Services, 2023; Yearbook of Global Climate Action, 2023: Marrakech Partnership for Global Change Action, 2023 [2, 5‐7] emphasize the urgent need for action to mitigate its impacts and adapt to changing environmental conditions. Similarly, they emphasize the scientific consensus on human-induced climate change and its harmful effects on ecosystems, economies, and societies, particularly those affecting vulnerable populations. These documents set targets to reduce greenhouse gas emissions, move to renewable energy, increase resilience to climate disasters, and encourage sustainable development. They underscore the need for global cooperation, financial aid to developing countries, and the participation of governments, businesses, and civil society.
Concerning human health, climate change affects the environment, natural systems, and societal conditions, including health systems. It exacerbates risks, potentially reversing progress in public health [3]. Climate changes have the potential to negatively impact population health worldwide, while the effects vary between geographic regions and populations [4, 8, 9]. Based on an overview of systematic reviews [18] meteorological factors such as temperature, precipitation, and humidity are associated with diverse vector-borne, food-borne, and water-borne infectious diseases, mortality, cardiovascular, respiratory, and neurological outcomes, mental health issues, pregnancy and birth outcomes, nutritional outcomes, skin diseases and allergies, and, finally, occupational health outcomes and injuries. Extreme water events (e.g. flooding) have been linked to an increased risk of infectious diseases, mortality, mental health issues, pregnancy and birth outcomes, and nutritional outcomes. Air quality factors (e.g. exposure to air pollution or wildfire smoke) were reported to lead to respiratory-specific mortality, cardiovascular, respiratory, and neurological outcomes, and pregnancy and birth outcomes. Furthermore, climate change undermines the health workforce and infrastructure, reducing the capacity for universal health coverage [10]. Delaying action on climate change escalates health risks, undermines global health progress, and violates our commitment to universal health rights [3, 10].
Climate changes underscore the need for emergency preparedness for climate-related disasters, sustainable health systems that can withstand these challenges, and a broader understanding of the links between climate and health. Health professionals must perceive environmental health as an integral part of human health and must strive to influence it at the individual, collective, and political levels [8].
Currently, nursing is beginning its journey toward addressing climate change. Nursing is one of the most trusted professions in the world, and the number of nurses is approximately 60% of all health professionals worldwide [11]. Therefore, nurses can be crucial in achieving the goals of sustainable development, environmental sustainability, and human well-being [12].
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Generally, it is essential to talk about the important role of nurses as front-line workers in the fight against climate change. Their role can be important directly in the disaster area or, for example, in providing care to the increased number of emergency department visits due to climate-related incidents and events [13]. At the same time, nurses should lobby for public health planning to address the anticipated health consequences of climate change and measures to slow climate change [14]. However, nurses overwhelmingly feel that they are still underprepared to take action on climate change, which appears to represent a moral imperative for the health of the planet within their profession. However, to address this issue, nurses must be confident that they can participate in coordinated and cooperative pathways within their nursing practice [15]. Inclusion in nursing education could support the response of the nursing profession to this new and important aspect of healthcare [16].
By proactively addressing climate-related health risks, nurses can improve patient care, promote public health, and strengthen healthcare systems. They should address the impact of climate change on health outcomes, as it directly affects patient well-being and community health. However, there are literature gaps in nursing perspectives on the health consequences of climate change. Currently, there are several reviews in the literature focusing on health impacts in general [17, 18] or from the perspective of other healthcare professionals than nursing [19]. Nurses may not be aware of the potential of a positive impact on climate change, and if they are, the relationship with nursing care is only slightly uncovered [20]. Therefore, perception, attitudes, and nurses’ awareness about climate change in relation to nursing care can lead to better care and better patient outcomes. Thus, this systematic review aimed to investigate the effects of climate change on patient outcomes from nurses’ perceptions of how climate change might impact nursing care. Improving patient outcomes is the main goal of the nurse’s work, which should be visible and measurable. Therefore, we do not only assess the patient’s outcome but also consider the nurses´ perspective on climate change, as their views play a crucial role in shaping the health outcome. Consequently, the objective of the review is twofold – the primary outcome is focusing on patient health outcomes directly associated with climate change, such as the emergence of new diseases, increased mortality, and the burden placed on the healthcare system. The secondary outcome is considering the nurses’ perspectives on climate change, including their awareness, attitudes, and perceived responsibilities in mitigating climate-related health impacts. Understanding these perspectives is essential, as they influence how climate-related patient health outcomes are managed in practice.
Aim
The mixed-method systematic review aimed to synthesize existing empirical evidence on the association between climate change and patient health outcomes. A specific review question was formulated: What is the impact of climate change, as perceived by nurses, on specific health outcomes for patients?
Methods
Design
A mixed-methods systematic review with a data-based convergent design was chosen [21], with the inclusion criterion that the reviewed studies focus mainly on climate change and its association with patient health outcomes.
The data-based convergent design is a mixed-methods approach that is particularly valuable in systematic reviews, allowing for the integration of both qualitative and quantitative evidence to provide a comprehensive synthesis of the literature. This design is characterized by the simultaneous but independent analysis of different types of data, followed by their integration at the synthesis stage. This mixed-methods systematic review followed the modified level of integration where data were combined to provide a comprehensive understanding of the research question [21].
Search methods
This review adhered to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) [22]. The SPIDER tool, which stands for Sample, Phenomenon of Interest, Design, Evaluation, and Research type, was employed to structure the research question. This tool is particularly suited for qualitative and mixed-methods research, ensuring that all key elements of the study were systematically addressed (Table 1) [23].
Table 1
SPIDER tool terms
Criteria | Inclusion | Exclusion |
|---|---|---|
Sample | Nursing professionals (e.g., nurses, nursing students, nurse aids, nurse managers…) | Other healthcare professionals (e.g., physicians, midwifery…) |
Phenomenon of interest | Association between climate change and patient health outcomes | No association between climate change and patient health outcomes |
Design | All designs | None |
Evaluation | Questionnaires, surveys, interviews, focus groups, etc. | None |
Research type | Empirical research (quantitative, qualitative, mixed method) | Reviews, discussion articles, study protocols, editorials, commentaries, case studies, conference abstracts |
Time frame | From the earliest published study up to January 2024 | After January 2024 |
Language | English | Languages other than English |
The search was carried out in January 2024 in six scientific databases, including CINAHL, PubMed, Scopus, ProQuest, Web of Science, and OVID Nursing. The search was carried out using both Boolean operators (AND, OR) and different combinations of keywords that referred to climate change and patient health outcomes (Additional File 3). The search was limited to language (English); however, no time limits were determined.
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Inclusion and exclusion criteria
Inclusion and exclusion criteria were stated, following the SPIDER tool. The study was included if it: (a) was an empirical study (quantitative, qualitative, mixed-method); (b) was published in a peer-reviewed journal; (c) was published in the English language; (d) was focused on the topic of interest (climate change and patient health outcomes); (e) reflected nursing perspective (e.g., nurses, nursing students, nursing assistants, nursing aids). On the contrary, the study was not included if it: (a) involved other than a nursing perspective (e.g., physician, midwifery); (b) was a review study, discussion article, case study, conference abstract, study protocol, editorial, or commentary.
Study retrieval
Based on predefined criteria, the data were systematically retrieved by two independent researchers (AS, DK) within two retrieval phases. Any discrepancies were resolved through consensus discussions, and when necessary, a third reviewer (JT) was consulted to make the final decision. This process ensured that the study selection was conducted in a fair and unbiased manner. The search and retrieval processes were reflected in the PRISMA flow diagram (Fig. 1) [22]. The Rayyan QCRI® program [24] was used to retrieve studies effectively in both retrieval phases. The search produced 1,257 studies (CINAHL = 103, PubMed = 62, ProQuest = 528, Scopus = 90, Web of Science = 418, OVID Nursing = 56). After removing duplicates (n = 345), 912 studies were analyzed by title and abstract and examined against inclusion and exclusion criteria. In this phase, 893 studies were excluded because they did not directly relate to the stated objective of the study and because they did not meet the predefined inclusion criteria. In the second retrieval phase, 19 studies were examined by reading full texts. The second phase resulted in 18 studies included in further analysis. One study was excluded from the final analysis based on the evaluation that it did not relate to the nursing perspective.
Fig. 1
PRISMA flow diagram
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Quality appraisal of the studies
For the evaluation of the methodological quality of 18 retrieved studies, the specific Mixed Method Appraisal Tool (MMAT) was used in our review [25], which is designed for quantitative (n = 9), qualitative (n = 6), and mixed-method study (n = 3) assessments. The evaluation of the methodological quality of the studies was carried out by two independent researchers (DK, JT), with any differences resolved through discussion until consensus was achieved. Our assessment revealed that most of the quantitative studies did not employ adequate sampling strategies, which raises concerns about the representativeness of their samples. Additionally, none of the studies provided sufficient evidence to demonstrate a low risk of non-response bias, which may impact the generalizability of their findings. Despite these limitations, nearly all studies utilized precise measurements and conducted statistical analyses that were appropriate for answering the research questions. All six qualitative studies were assessed as adequately fulfilling all the criteria specified by MMAT, that is a clear congruity between the research objectives and the methodological approach, as represented by the data collection method, the data analysis procedure, and the interpretation appropriately grounded in the data. The mixed-method studies failed to fulfill one [26], two [27], and, respectively, four [28] of a total of five criteria evaluated. A significant terminological ambiguity was identified, e.g. study title indicated a different research design from what the authors conducted and what the study reported. Based on the MMAT, none of the studies was excluded from the review due to low methodological quality. The comprehensive results are shown in Additional File 1.
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Data extraction
Data extraction of studies included in the systematic review was performed by two independent researchers (JT, DK). The data extraction process was conducted using a standardized Microsoft Excel spreadsheet. The spreadsheet was preformatted with specific columns for each relevant data element, including authors, year of publication, country, methodology (design, sampling methods, sample size including targeted respondents, data collection, data analysis), and perspective (nurses, nursing students). To ensure consistency in data extraction, each column was accompanied by specific instructions, detailing the information to be extracted and providing examples where necessary. This standardization, along with a comprehensive coding manual, helped to ensure uniformity and reduce the potential for extraction errors across different researchers.
Study risk of bias assessment
To mitigate potential bias, the study employed the following strategies: (a) all researchers actively participated in the refining of the study protocol; (b) the literature search was conducted independently by two researchers (DK, AS); (c) two researchers independently performed data extraction (JT, DK) under the supervision of the senior researcher (TS); (d) two researchers independently evaluated the methodological quality of the studies (DK, JT); and (e) collective decision-making accompanied each stage, with a meeting held to determine progress to the next stage.
Data synthesis
Data were analyzed using a convergent integrated approach, which combines qualitative and quantitative data for comprehensive analysis. The data-based convergent synthesis design is a widely used mixed-methods approach where both qualitative and quantitative data are collected simultaneously, analyzed separately, and integrated during the interpretation phase. This method is particularly valuable for corroborating and complementing findings from different data types to develop a more complete understanding of the research question.
In this systematic mixed-methods review, a modified level of integration was applied, as outlined by Hong et al. [21]. The integration process involved three key stages:
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Data synthesis, where all evidence was analyzed using a single, uniform synthesis method.
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Results of synthesis, which involved comparing or merging the outcomes from synthesizing both qualitative and quantitative evidence.
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Interpretation, where findings from the synthesis were discussed and integrated across both qualitative and quantitative evidence.
This design allowed us to address a single review question and involve data transformation to enable uniform analysis (quantitative data, such as mean values or percentages were transformed into themes). More specifically, quantitative data and qualitative evidence were integrated using thematic synthesis. This involved line-by-line coding, the development of descriptive themes, and generation of analytical themes to report a comprehensive summary of the study results [21]. Each article was reviewed for expressions and statements reflecting the association between climate change and patient health outcomes. These statements were thematically synthetized into subthemes and further thematically organized into overarching themes based on their content.
The language and expressions used by study participants and authors were preserved in the analysis to minimize interpretation bias. Joint display methods, such as visual or narrative representations, were utilized to present the combined findings from qualitative and quantitative analyses. Throughout the analysis process, the research team discussed, condensed, and charted data, double-checking the precision of 10% of the material to ensure accuracy.
This integration of methods provides a holistic understanding of the research question, ensuring that both qualitative insights and quantitative evidence contribute to a richer, more nuanced interpretation of the findings.
Results
Given the rather broad scope of this review, the included studies were conducted in various settings of nursing practice and education, employed a wide range of designs, and aimed to address various research objectives (Additional File 2). In general, various methodological approaches were included and they varied in terms of location and samples, highlighting the complexity of the issue addressed. The review included quantitative studies (n = 9), qualitative studies (n = 6), and mixed-method studies (n = 3). Most of the studies were conducted in the United States (n = 6), followed by Spain (n = 2), Turkey (n = 2) and China (n = 2), and one study each in the United Kingdom, Canada, the Republic of Korea, and Peru. Two studies analyzed data from more than 1 country [29, 30]. Regarding the sample, most of the studies included practicing nurses (n = 8) and nursing students (n = 6). The sample size in all studies ranged from 20 to 733 respondents. The method most frequently used in data collection was a questionnaire (n = 9), followed by interviews or focus groups (n = 4). The sample size of quantitative studies (n = 9) ranged from 90 to 489 respondents with a total n = 2025 (two separate studies used the same sample with different analyses). All samples were non-representative and used descriptive, cross-sectional design (n = 9), with only descriptive statistics used (n = 2) [31, 41], descriptive and inferential statistics used (n = 5) [29, 32, 34, 39, 40]; and psychometric statistics used (n = 2) [34, 37]. Five studies used advanced statistical procedures (multiple linear regression, logistic regression, GLM, CFA, and IRT; [32, 37, 39, 40].
Review findings
The findings were extracted and synthesized into three themes that were further specified by seven subthemes (Fig. 2). In studies in which the sample comprised of nurses and other healthcare professionals [27, 31, 32] or members of the public [33], only the results from the nursing perspective were included in the analysis and synthesis.
Fig. 2
Main themes and subthemes reflecting the association between climate change and patient health outcomes
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Theme 1: climate healthcare interplay
The first theme is related to the interrelation of the environment and healthcare and represents the context, in which healthcare is provided. The findings suggest that nurses are aware of this context – climate change poses a significant risk to human health, and on the other hand, the healthcare industry contributes through its energy and resources requirements, greenhouse gas emissions, and waste production to this critical state. This theme was synthesized from two subthemes (The environment as a factor of health; Healthcare as an unsustainable industry), as described below.
Subtheme 1: the environment as a factor of health
The first subtheme included three codes (Nurses are aware that the environment is an important determinant of health; Climate change poses new healthcare needs; The health impacts of climate change are geographically dependent). Quantitative and qualitative findings were integrated to underscore the awareness among nurses and nursing students that climate change poses significant health risks. While quantitative data provided measurable trends, qualitative data enriched the findings by illustrating the personal experiences and concerns of nurses and students regarding climate change health impacts.
As was evident in several studies [30‐32, 34, 35], the environment appeared to be an important determinant of health, as reported by practicing nurses, nursing students, as well as faculty. Furthermore, they understand the risks to human health in relation to climate change [31, 32, 34, 35] and are concerned about the health impacts of climate change (e.g. 94.6.% of the student sample [32]). Given the traditional emphasis of nursing on addressing social inequalities, nurses recognize that communities are disproportionately affected, resulting in climate injustice – groups of people who have the least power in society (e.g., Indigenous people, and people with low income) are more vulnerable to climate change impacts, which was evident from focus group data [30]. Furthermore, based on the studies analyzed, we identified that nurses understand that climate change poses new healthcare needs [26, 27, 34, 36]. Students [26, 36] and nurses [27, 34] recognize the health impacts of climate change through newly emerging diseases and infections, such as respiratory diseases, cardiovascular diseases, infectious diseases, mental health issues, cancer, fetal malformations, premature births, increased incidence of chronic diseases in children, and new healthcare needs (e.g., epidemics related to seasonal changes) that arise due to extreme weather conditions and place a burden on the health system. These conditions may include heat or cold waves, temperature changes, natural disasters, and drought. In this context, various regions of the world face various health impacts of changing climate that were explored in four mainly quantitative studies included in this review [26, 27, 34, 37]. For example, in the United States, some symptoms associated with climate change were rated by nurses themselves, their families, and patients as experienced frequently (respiratory diseases and mental health issues), and some were indirectly experienced by reading or hearing (vector-borne diseases, heat illness, and trauma) [34]. Similarly, Turkish students listed their own experience with respiratory diseases, while water-borne diseases, and deaths due to malnutrition as impacts of climate change were experienced indirectly [26]. On the other hand, heat illness and vector-borne diseases in China were reported as local health impacts of climate change [27, 37].
Subtheme 2: healthcare as an unsustainable industry
The second subtheme included three codes (Nursing as a profession must address the climate change topic; The healthcare sector is a significant contributor to climate change; Years of practice may raise awareness and action). Both quantitative and qualitative findings reflected the significant contribution of the healthcare sector to climate change. While quantitative data provided valid evidence, qualitative insights provided context by illustrating how nurses felt responsible for addressing the issue within their practice but were often constrained by institutional barriers.
The review findings highlighted the need to address the topic of climate change from the nursing perspective [30‐32]. Nurses believe that they have a professional obligation to address this issue within their practice. This professional obligation is related to the holistic perspective of nursing – the interviewees emphasized that if the health of individuals is to be preserved, the environment as a crucial determinant of health should be protected [30].
In this context, nurses raised another important issue of the healthcare system being a significant contributor to climate change, as suggests data from interviews [35], focus groups [30], and open-ended questionnaire items [32, 36, 38]. Generally, nurses surveyed acknowledged that the healthcare sector generates excessive waste and has a considerable environmental footprint [30, 35]. Nurses recognize that the healthcare sector contributes significantly to climate change through its energy consumption and waste production, particularly due to the overuse of single-use materials [30, 35, 38]. Quantitative data further showed that once students enter clinical practice, they find out how much waste is produced, how healthcare material is overused, and how waste is or is not managed, recycled, and disposed of. They become concerned about the excessive use of healthcare equipment and proper disposal of materials and understand the need to balance overuse and patient health [32, 36, 38]. However, quantitative findings indicated their scores of awareness, concern, motivation, and change behavior at home and work are lower than those of practicing nurses and faculty [34]. Qualitative data provided an interpretation, as students reported a lack of knowledge and experience in sustainable practice [34, 36]. Nurses with more years of clinical practice rated their tendency to adopt appropriate environmental practices (e.g. energy use and waste management) slightly higher than those less experienced [39].
It can be concluded that the primary outcomes of Theme 1 highlighted the emergence of new health conditions linked to climate change, the worsening of patient health outcomes, and a significant burden placed on healthcare systems. The secondary outcomes revealed that nurses were keenly aware of their responsibility to address these issues, and they recognized healthcare’s contribution to climate change.
Theme 2: future nurses as agents of change
The second theme outlines key areas related to environmental education in nursing in terms of student awareness, the effect of sustainability education, and challenges related to curriculum integration. It highlights how nursing students are aware of the impacts of climate change and advocate for more education on environmental health. Additionally, it discusses the effectiveness of sustainability education in improving students’ knowledge and behavior, as well as the challenges in integrating climate change topics into the curriculum. This theme was synthesized from three subthemes (Readiness to address climate change; Sustainability education; Curriculum integration of climate change topics), as described below.
Subtheme 1: readiness to address climate change
The first subtheme included two codes (Aware generation; Students are ready to address the climate change issues). Quantitative and qualitative findings were integrated to emphasize that although climate change and health topics are not included in current curricula across the surveyed institutions, students’ awareness of these issues is high as is their demand to learn about them. Quantitative data indicated a high proportion of students were aware, while qualitative data explored their concerns and ideas regarding education on the health impacts of climate change. The findings of this review suggested that although many students did not receive formal education on environmental issues, they know about climate change and are aware of its impacts on many aspects of their private and future professional lives, primarily due to media exposure. Quantitative data revealed that 87.7% of the students recognized the main cause of climate change, and 94.2% believed that climate change affects daily life [26]. Additionally, nurse educators can build on students’ awareness [26, 31, 32, 40]. In this context, the review findings also highlighted that nursing students enter the profession with the expectation that nursing as a profession has the responsibility and influence needed to address the topic of climate change. Students believe that modern nursing roles include being a researcher, educator, and leader in climate change actions [26]. Both quantitative and qualitative data showed that they believed environmental awareness needed to be increased [36, 38] and called for more education on the influence of the environment on health and the environmental impact of healthcare [26, 32, 36]. Overall, 72% of nursing students believed these issues should be covered in the classroom and reinforced in the clinical setting [32].
Subtheme 2: sustainability education
The second subtheme included two codes (Sustainability education may raise knowledge and behavior; Extracurricular activities count). Both quantitative and qualitative findings supported the effectiveness of various forms of sustainability education. Quantitative data indicated improved scores in students’ awareness, knowledge, attitudes, and behavior, while qualitative data provided insight into how this education contributes to their sense of competence and readiness to address climate change in their practice.
In three studies [29, 36, 38], the emphasis was placed on sustainability education. It can support students to challenge unsustainable practices and implement change, e.g. waste management and use of resources [38], has improved the competencies of nursing students and increased their awareness of sustainable care [36] and has improved students’ knowledge, attitude, and behavior regarding sustainability development, as measured by questionnaires administered before and after the intervention [29]. As quantitative data suggested, awareness of global climate change was related to environmental literacy and significantly higher in students who have previously participated in meetings on environmental problems [40], or environmental voluntary activities and watched environmental documentaries [26].
Subtheme 3: curriculum integration of climate change topics
The third subtheme included two codes (The curriculum needs to address climate change topics; Curriculum integration of climate change topics is difficult). Quantitative and qualitative findings were integrated to highlight the need to address climate change topics in education of future nurses and challenges it poses to nursing programs. While quantitative data indicated high emphasis on this issue, qualitative data enriched the findings by illustrating the perspective of nursing educators.
Three studies specifically addressed the topic of climate change and its integration into the nursing curriculum [26, 31, 41]. However, this topic was not generally included in the nursing curriculum in the analyzed studies conducted in the USA or Turkey. Additionally, other studies analyzed did not reflect the topic of curriculum integration of climate change. Nurse practitioner program directors, faculty, and nursing students believe that there should be greater emphasis on environmental health in their programs. Nevertheless, the integration of the topic of climate change into the nursing curriculum is difficult, mainly due to serious barriers related to overcrowded curricula, with dense content that it already needs to cover, lack of faculty expertise in the area (e.g. 76% of faculty reported feeling not at all or only a little prepared to teach climate change and health concepts [31]), and lack of access to information resources related to environmental health [31, 41].
The primary outcome of Theme 2 highlighted that sustainable healthcare practices were essential for mitigating climate change’s impact on patient health and that patient health outcomes depended on well-prepared healthcare providers. The secondary outcomes revealed a gap between nursing students’ awareness and readiness to address these challenges and their feeling of being unprepared to do so due to a lack of formal education. This gap highlighted the need for curriculum reform to ensure future nurses can effectively manage climate change’s health impacts [31, 32, 36], as sustainability education improved nursing students’ confidence in addressing environmental issues and could enhance the healthcare sector’s ability to deliver patient care with a reduced environmental footprint [29, 36, 38].
Theme 3: navigating sustainability challenges in nursing
The third and last theme explores challenges that hinder sustainable nursing practices, focusing on patient-centered care and lack of support. Nurses prioritize patient needs over environmental concerns due to busy clinical settings, which leads to minimal attention to environmental issues. Additionally, the lack of organizational support and barriers faced by students contribute to the challenge. The narrative highlights the importance of education, awareness, and leadership in promoting sustainable practices and advocating for environmental stewardship within the nursing profession. This theme was synthesized from two subthemes (Patient-centered care; Lack of support), as described below.
Subtheme 1: patient-centered care
The first subtheme included two codes (Patient care is a priority; Some issues are more relevant to nursing, and some are less). Both quantitative and qualitative findings highlighted the environmental awareness of nurses; however, qualitative data uniquely explored the patient-centered perspective, revealing that nurses prioritized patient outcomes over environmental concerns, which made sustainable practices difficult to implement.
Based on mostly qualitative findings, the environmental aspect of healthcare is understood and present in the way nurses think about climatic change and nursing, but in busy clinical settings, it is less likely to impact the quality of care. When deciding between the needs of the patients and the environmental perspective, the patient is the priority. Nurses must deal with competing priorities and prioritize patient care/safety over the environment, as was evident from interviews and observation data [42]. Questionnaire self-ratings [34] indicate that although nurses scored high on the awareness scale, awareness alone did not lead to behavior change, because nurses feel overwhelmed, as qualitative data validated [42]. The interviews with nursing and non-nursing leaders of environmental stewardship explored various nurse-sensitive environmental indicators and suggested that nurses strongly believe that their actions can significantly impact the area of waste management. The impact in the areas of sustainable food, chemical reduction, and sustainable transportation is moderate, and the impact in the areas of energy and water use is minimal [35]. Another qualitative study suggested patients may benefit from meteorological information utilization, e.g. warnings regarding heat waves. However, the narrative emphasized it is not the primary patient care issue – it would be difficult to provide additional information beyond that indispensable in busy healthcare settings. Patients must receive and remember essential information on check-ups and medication, and too much information can cause overwhelming at discharge [33].
Subtheme 2: lack of support
The second subtheme included three codes (Workplace culture and organizational policy do not support environmentally responsible practices; Future nurses face even more barriers; Education, awareness, and leadership are crucial for success). Quantitative and qualitative findings were integrated to provide an understanding of the context within which nurses tried to balance the demands of high-quality nursing care and environmentally responsible practice. Quantitative data showed that nurses could behave sustainably at home, but not at work, while qualitative data explained why – interview and observation data shed light on the everyday challenges nurses faced in a working environment that did not support sustainable practices. The review findings highlighted that hospitals prioritized patient safety and budget. As data from interviews suggested, nurses perceived a lack of organizational support, they believed that the management should implement the change, not individuals (e.g., recycle bins, use of single-use vs. reusable products, more plant-based options in food services, low-emission transportation) [42]. Nurses reported more sustainable behavior at home than at work, because at home they have more control over the context and do not need to follow regulations and guidelines [34]. Insufficient support was perceived by nurses who participate in environmental activism, too. The focus group data showed that nurses who feel a professional duty to address climate change experience strong emotions such as anger, fear, and sadness. They are frustrated by the lack of recognition of environmental care in nursing and may feel isolated and overwhelmed. Environmental activism adds emotional labor beyond patient care. US nurses feel more supported in activism than UK nurses [30]. In addition, nursing students perceived several barriers to providing sustainable care to patients during their clinical placements, as reported in two studies [36, 38]. These barriers reported in open-ended questions included a lack of confidence due to an imbalance of power and lack of knowledge, resistance to change in practice, lack of time, and lack of facilities [38]. What students may perceive as a lack of environmental awareness on the part of the healthcare staff with whom they work during their clinical placements [36], may be the result of competing priorities in busy clinical settings, prioritizing patient needs and safe care, and lack of organizational support that prevents nurses from acting sustainable [42]. The lack of support was also evident regarding insufficient education about environmental stewardship, as reported by nurses in two studies [26, 35]. Although the interview participants were not asked directly about leadership, most of them identified the need for support of nurses to address environmental stewardship [35]. Nurses believe that once educated, they can have an impact on public health – educate patients, families, and communities about environmental health. Furthermore, continuing education for practicing nurses is needed, especially in developing countries [39] and for emergencies related to extreme weather events, e.g., heat illness [37].
The primary outcome of Theme 3 suggested that patient care often took precedence over sustainability efforts, leading to a short-term focus that can negatively impact healthcare’s environmental footprint. Lack of systemic support for sustainability in healthcare directly affected patient outcomes by exacerbating the environmental impacts of healthcare delivery. The secondary outcomes revealed that while nurses were aware of this conflict, they felt that time constraints, competing priorities, and a lack of institutional leadership limited their ability to implement sustainable practices. Addressing this tension is crucial for promoting both patient health and environmental sustainability [34, 35, 42].
Discussion
The systematic review aimed to synthesize the existing evidence on the links between climate change and patient health outcomes from a nursing perspective. The findings were synthesized into three main themes.
The findings of the first theme, “Climate Healthcare Interplay”, shed light on the intricate relationship between the environment and healthcare delivery. Nurses, as frontline healthcare providers, recognize the significant impact of climate change on human health firsthand, either through personal experiences or indirectly through patient care. The health impacts of climate change and the emergence of new diseases were the main nursing outcomes on this theme. Furthermore, nurses in the analyzed studies recognized that the environment is an important determinant of health and health outcomes [31, 32, 34, 35].
Climate-related shocks such as temperature fluctuations, precipitation changes, and rising sea levels degrade environmental and social factors that influence health [3, 43]. All aspects of health, from air and water quality to food systems, are impacted [3].
According to the WHO, climate change may be responsible for 250,000 additional deaths per year between 2030 and 2050 [44]. The impact of climate change is increasing the severity and frequency, and health problems that did not exist before arise [45]. More specifically, climate change introduces new healthcare needs, with emerging diseases and infections becoming more prevalent due to extreme weather conditions, such as heat waves, floods, and storm intensity [46, 47], or they can result from subsequent changes in environmental conditions that lead to an increase in waterborne diseases [48], foodborne diseases [49, 50], vector-borne diseases [51], and nutritional insecurity [52].
Mental health can also be affected by the impacts of climate change [46, 47]. Problems related to climate anxiety, ecological anxiety, climate sadness, and solastalgia are also described as the health consequences of climate change [53]. Posttraumatic stress disorder is a direct consequence of acute weather events [54], and traumatic exposure to major storms is a predictor of multiple mental health outcomes, including substance use and addiction [55], especially among people who already belong to marginalized groups [56]. It is people from marginalized communities and groups who are much more vulnerable to climate change [30]. At the same time, they have less potential to respond to the effects of climate change or to adapt to them. Therefore, it is necessary to pay attention to the equality of services provided for disadvantaged regions, vulnerable individuals, and communities [57].
The findings of this systematic review also showed that with climate change and the emergence of new diseases, new healthcare needs arise [26, 27, 34, 36]. This was recognized not only by nurses [27, 34] but also by nursing students [26, 36].
The findings of this systematic review highlighted the important role and responsibility of nurses in managing climate change and its impact on patient care, health, and patient outcomes. Furthermore, nurses represent the largest global healthcare resource to contribute to disaster preparedness efforts for climate change-related water disasters and work to mitigate environmental toxins that can threaten human health [58]. The role of nurses is also to minimize the effects of climate change on mental health among vulnerable population groups through evaluation, preventive education, and care [59].
In particular, advanced practice nurses (APNs) are pivotal in tackling climate change’s health challenges. They educate on climate-related risks, offer preventive care, manage acute and chronic conditions exacerbated by climate change, and advocate for sustainable policies [13, 14]. APNs play a vital role in promoting resilience and protecting public health from climate-related threats. Their specific competencies should include identifying people with increased vulnerability – young, old, people with chronic health conditions and marginalized groups living in poverty, with lack of health care coverage, immigration status, language barriers, homelessness, or mental illness – and providing advanced education about these risks together with identifying available community health services [13, 14]. Despite the indisputable advantages and importance of advanced practice, the tasks and roles of these nurses have not been clearly defined, which significantly limits their implementation in the current healthcare system, especially when addressing climate change impacts [60]. Similarly to APNs, community nurses and public health nurses are considered key stakeholders when it comes to addressing climate change. They are defined as professionals who are supposed to lead as influencers of climate action and strengthen communities, for the active involvement of all individuals in achieving socio-political change [61].
In the context of addressing climate change, the nursing perspective is essential, especially in terms of the healthcare sector, as discussed in all included studies in this review [30, 32, 34‐36, 38]. More specifically, nursing professionals recognize the healthcare sector as a significant contributor to climate change, primarily due to excessive waste production and energy consumption [30‐32, 35]. When providing health care, policymakers in several countries recommend the use of disposable medical devices, which increases waste in the health sector. A recent example is the excessive use of medical gloves and masks due to the outbreak of the COVID-19 pandemic, which has significantly worsened this problem [62]. Medical waste also includes syringes, scalpels, linen contaminated with biological material and body parts [63], and hazardous toxic and radioactive materials [64]. Improper healthcare waste management practices can exacerbate the problem in developing countries, which can negatively affect the sustainability of the environment and public health [65].
The link between the increase in waste in the healthcare delivery system also exists in connection with the global increase in population and the aging population [66], with the occurrence of chronic diseases and comorbidities [67], and with the increase in infectious diseases [68].
Overall, the entire healthcare sector needs to address its carbon footprint, which means that healthcare professionals, managers, and nursing leaders must be involved in addressing increased energy costs, stressed health services [13], increased plastic waste, and personal protective equipment as one of the environmental side effects of the recent COVID-19 pandemic [69]. The issue of increased medical waste was also highlighted in the analyzed studies from the perspective of nursing students and their education, while emphasis was placed on the topic of correct understanding of the use of medical equipment [32, 36, 38] and support of motivation to change behavior with greater responsibility towards the environment. Better preparation is already required during the education of nurses, as many nursing students are not sufficiently prepared for the health impacts of climate change and the response of the nursing profession [16].
The findings of the second theme, “Future Nurses as Agents of Change”, highlight the role of nursing students in environmental education, their awareness of climate change impacts, the effectiveness of sustainability education, and challenges in curriculum integration.
Education appears to be important in knowing and understanding the relationships between climate change and patient health outcomes. Nursing students enter the profession with the expectation that nursing as a profession has a responsibility in influencing climate change with the need to continuously raise awareness of this topic [36, 38]. The findings of our systematic review suggested that students received limited education about environmental and climate change issues in their formal university education. Although students are informed about these topics primarily through the media (including social networks), they would request more education, especially on environmental impact on health, as well as environmental impact and waste generation within the provision of healthcare [26, 32, 36]. Nurses’ awareness that their work also impacts the development of climate change could influence their behavior and care delivery procedures. However, current findings indicate that awareness of the impact of nurses’ work on climate change is low [20].
As part of achieving the 2030 Sustainable Development Goals, specifically Goal 13, and Goal 3: “Improving environmental education and awareness”, education must equip nursing students with the knowledge and skills they need to sustainably promote the health and well-being of current and future generations [70]. A necessary step to achieve transformational change is the inclusion of planetary health education in the curriculum [71] and the explanation of nurses’ competencies to strengthen the sustainability of the support of people’s health and well-being, as well as the health of the planet [72]. There is evidence of the impact of education on the sustainability of environmental resources, on promoting the competencies of nursing students, and on increasing their awareness of this topic [29, 36, 38].
Among the extracurricular activities that appeared to be useful in raising awareness of global climate change, the discussions about environmental problems [40], environmental voluntary activities, and watching environmental documentaries [26] were crucial and discussed across the analyzed studies. These activities not only help increase knowledge about climate change but also foster environmentally sensitive and positive behavior in nursing students in the fight against climate change and its effects [26].
Efforts to integrate climate change topics into the curriculum in nursing education were also discussed [26, 31, 41]. Environmental topics are currently absent in the curriculum, and some barriers limit its integration. This is mainly a consequence of the overcrowded and demanding curriculum and a lack of professional competence in environmental health [31, 41]. First, overcoming the barrier of an overcrowded curriculum should be easier because the current generation of students, both in general and in nursing, are open to climate change topics and strongly advocate for their integration into nursing education [26, 73]. Second, overcoming the professional competence barrier should be supported by the rapidly growing body of research in this field across a wide range of countries [26, 73], including systematic reviews. Strategies for integrating climate change into nursing education already exist [73], such as using advanced teaching methods like scenario-based learning, interactive online forums, and case studies. These methods help students gain a deeper understanding of the complex dynamics between climate change and health outcomes. The findings of the third and last theme, “Navigating Sustainability Challenges in Nursing” shed light on the obstacles to sustainable nursing practices, focusing on patient-centered care and the lack of organizational support. Areas that hinder sustainable nursing practices have been identified. These calls are mainly directed at management and policymakers. When providing nursing care in terms of quality and safety, nurses prioritize the needs of the patient. When deciding between patient needs and environmental needs, the patient is the priority [42]. On the other hand, it should be emphasized that nurses are aware that their actions can significantly affect waste areas and impact the environment [35]. However, prioritizing unnecessary patient care over environmental concerns can affect the sustainability of healthcare systems [74]. The healthcare system is a significant source of greenhouse gases, air pollution, and waste. One principle of reducing the environmental impact of care is to decrease the need and demand for health services. Another principle is to ensure adequate care while avoiding unnecessary procedures, such as invasive testing and excessive laboratory tests.
Nursing students already perceived several obstacles in providing sustainable care to patients within clinical education [36, 38, 42]. They felt that their lecturers during clinical education did not address awareness of environmental aspects [36] not only because they prioritized the needs of patients in terms of quality and safety, but also due to demands and rush in providing care in the clinical environment, and due to insufficient management support [42]. On the other hand, rather low nursing competence to support sustainable practice is a result of insufficient education in this area [26, 35, 37, 39].
The important challenge here arises: How can nurses deal with climate change within the healthcare sector? The solution can be found in education and training that addresses the impact of climate change on health, as well as strategies to mitigate or adapt to these impacts [75]. The way to secure sustainable practices should be supported by hospital management [42]. An important area is the integration of sustainability practices, which involves encouraging healthcare facilities to adopt practices such as reducing energy, minimizing energy consumption and waste generation, and using environmentally friendly products [76]. It is essential to incorporate sustainability practices from the procurement stage through to service provision. Involving nurses in decisions about procuring more ecological materials will contribute to more sustainable development [77].
Nurses must advocate for policies and initiatives that promote environmental sustainability in healthcare delivery at the local, national, and international levels [78]. An example of this is involving nurses in decision-making about procuring more ecological consumables [77]. Furthermore, nurses could adopt a green advocacy role in addition to changing nursing practices for sustainable care [79]. For instance, the Royal College of Nursing and the Center for Sustainable Healthcare in the UK have collaborated on a campaign to raise awareness about the environmental impact of glove use [80].
Policy support is particularly associated with providing evidence from best practices for nurses to address climate change issues, with research and development of evidence-based interventions as essential activities [81]. There are also useful approaches, such as the Sustainability in Quality Improvement framework (SusQI), which provides a holistic method for encompassing environmental, social, and economic costs and impacts [82]. Collaboration and networking among nurses and other healthcare professionals, environmental organizations, and community groups are of great importance in promoting environmental sustainability in healthcare [83]. Nurses feel their professional duty to support environmental care, as well as the need for greater environmental activism to achieve change [30]. All these actions can help nurses play a key role in mitigating the impacts of climate change on patient outcomes and promoting sustainability in healthcare.
Implications for the international audience
The present review has highlighted several methodological weaknesses in the reviewed studies. One of the most significant challenges was related to sampling. Most studies employed convenience sampling in specific regions or only one institution with rather small sample sizes which were not diverse enough, and with limited response rates, which may raise questions about the representativeness of the sample and generalizability of the findings. With current technological possibilities for global research integration, comparative studies may seem a promising direction, with special regard to communities more vulnerable to experiencing impacts of climate change due to their health status or geographical, demographic, and social characteristics. However, it is important to continue to address specific research objectives through qualitative or mixed–method studies, which provide useful perspectives to explore the lived experience of all actors who participate in the interplay of climate change and nursing. As the review findings suggest, students seem to be ready to implement sustainable practices in clinical settings, but organizational policy and workplace culture often do not support their motivation. It is crucial to explore the settings where the change was successfully implemented and to verify the factors that facilitate it. Lastly, it is essential to look for ways to raise environmental awareness of practicing nurses, especially in developing countries, and explore how to empower them to adopt sustainable practices that will not represent another burden on their already busy work pace but will integrate quality patient care with low environmental impact. There is a growing body of evidence suggesting that various forms of sustainability education and integrating the issue of climate change and health in the curriculum may increase the levels of knowledge, awareness, and motivation to act sustainably in students. The challenges we identified need to be addressed – competing curricular priorities and lack of expertise and resources on the part of faculty. Once educators have enough support, they can start to perceive these issues as clinically relevant and find a way to integrate them into the curriculum.
Limitations
Only studies published in English were included possibly resulting in omitting relevant research published in non-English studies. The authors come from different backgrounds and there was some discrepancy in evaluations of the methodological quality of the studies at the beginning, however, several discussions took place until the agreement in the team was achieved.
Conclusion
The purpose of the present systematic review was to critically examine empirical studies on the impact of climate change on patient health outcomes from the nursing perspective and to synthesize the evidence reported in quantitative, qualitative, and mixed-method studies available through all relevant databases searches. If a shift to sustainable healthcare and introducing climate change-related topics into the curriculum is to be made, it is crucial to understand the nursing perspective, the most numerous and most influential and trusted healthcare workforce, who is expected to implement changes in practice. Although the reviewed studies have some methodological limitations, provide promising findings on nursing education and practice. Nurses, who work hard to find the balance between quality patient care and low environmental impact healthcare, are faced with barriers related to organizational policy and workplace culture. Sustainability education seems to improve the environmental awareness of nursing students; however, the curriculum is already too extensive, and the same barriers present in clinical settings prevent students from implementing the changes. In conclusion, competing priorities in both educational and clinical settings, although they seem legitimate, need to be solved to effectively address the challenge of climate change and nursing.
Acknowledgements
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