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 [30, 31, 33, 34].
Climate-related shocks such as temperature fluctuations, precipitation changes, and rising sea levels degrade environmental and social factors that influence health [3, 42]. 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 [43]. The impact of climate change is increasing the severity and frequency, and health problems that did not exist before arise [44]. 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 [45, 46], or they can result from subsequent changes in environmental conditions that lead to an increase in waterborne diseases [47], foodborne diseases [48, 49], vector-borne diseases [50], and nutritional insecurity [51]. Mental health can also be affected by the impacts of climate change [45, 46]. Problems related to climate anxiety, ecological anxiety, climate sadness, and solastalgia are also described as the health consequences of climate change [52]. Posttraumatic stress disorder is a direct consequence of acute weather events [53], and traumatic exposure to major storms is a predictor of multiple mental health outcomes, including substance use and addiction [54], especially among people who already belong to marginalized groups [55]. This was also reflected in our systematic review, while findings highlighted that with climate change and the emergence of new diseases, new healthcare needs arise [25, 26, 33, 35], which were recognized not only by nurses [26, 33] but also by nursing students [25, 35].
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 [56]. 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 [57]. 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[58]. 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 [59].
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 [29, 31, 33–35, 37]. More specifically, nursing professionals recognize the healthcare sector as a significant contributor to climate change, primarily due to excessive waste production and energy consumption [29–31, 34]. 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 [60]. Medical waste also includes syringes, scalpels, linen contaminated with biological material and body parts [61], and hazardous toxic and radioactive materials [62]. Improper healthcare waste management practices can exacerbate the problem in developing countries, which can negatively affect the sustainability of the environment and public health [63]. 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 [64], with the occurrence of chronic diseases and comorbidities [65], and with the increase in infectious diseases [66]. 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 [67]. 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 [31, 35, 37] 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 [35, 37]. 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 [25, 31, 35]. 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 [68]. A necessary step to achieve transformational change is the inclusion of planetary health education in the curriculum [69] 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 [70]. Furthermore, 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 [28, 35, 37]. Among the extracurricular activities that appeared to be useful in raising awareness of global climate change, the discussions about environmental problems [39], environmental voluntary activities, and watching environmental documentaries [25] were crucial and discussed across the analyzed studies. Efforts to integrate climate change topics into the curriculum in nursing education were also discussed [25, 30, 40]. 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 [30, 40].
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 [41]. On the other hand, it should be emphasized that nurses are aware that their actions can significantly affect waste areas and impact the environment [34]. The main reason for their actions is the lack of support from hospital management [41]. The findings of this review highlighted that hospitals prioritize patient safety and budget. Nursing students already perceived several obstacles in providing sustainable care to patients within clinical education [35, 37, 41]. They felt that their lecturers during clinical education did not address awareness of environmental aspects [35] 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 [41]. On the other hand, rather low nursing competence to support sustainable practice is a result of insufficient education in this area [25, 34, 36, 38]. 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 [71]. Another 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 [72]. Nurses must advocate for policies and initiatives that promote environmental sustainability in healthcare delivery at the local, national, and international levels [73]. 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 [74]. Collaboration and networking among nurses and other healthcare professionals, environmental organizations, and community groups are of great importance in promoting environmental sustainability in healthcare [75]. Nurses feel their professional duty to support environmental care, as well as the need for greater environmental activism to achieve change [29]. 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.