Art & science professional issues
Effect of climate change and resource scarcity on health care Richardson J et al (2014) Effect of climate change and resource scarcity on health care. Nursing Standard. 28, 45, 44-49. Date of submission: October 7 2013; date of acceptance: February 6 2014.
Abstract Climate change and resource scarcity pose significant threats to healthcare delivery. Nurses should develop the skills to cope with these challenges in the future. Skills sessions using sustainability scenarios can help nursing students to understand the effect climate change and resource scarcity will have on health care. Involving design students in clinical skills sessions can encourage multidisciplinary working and help to find solutions to promote healthcare sustainability.
Authors Janet Richardson Professor of Health Service Research, Faculty of Health and Human Sciences, Plymouth University, Plymouth, Devon. Jane Grose Research Fellow, Sustainability and Health, Faculty of Health and Human Sciences, Plymouth University. Bethany Jackson and Jamie-Lee Gill Nursing students, School of Nursing and Midwifery, Plymouth University. Hannah Becky Sadeghian and Johannes Hertel Design students, School of Architecture, Design and Environment, Plymouth University. Janet Kelsey Senior Lecturer, Health Studies (Child Health), Faculty of Health and Human Sciences, Plymouth University. Correspondence to: [email protected]
Keywords Climate change, multidisciplinary team, nursing students, resource management, sustainability
Review All articles are subject to external double-blind peer review and checked for plagiarism using automated software.
Online Guidelines on writing for publication are available at www.nursing-standard.co.uk. For related articles visit the archive and search using the keywords above.
FUTURE HEALTHCARE PRACTITIONERS will be faced with two major challenges that will affect their ability to deliver care. First, climate change will have significant effects on health, resulting in changing patterns of disease because of changing weather and mass migration; malnutrition and starvation; and deaths from flooding. Climate change has been defined as the biggest global health threat of the twenty-first century (Costello et al 2009). It will put pressure on resources and compromise our ability to deliver health care. Costello et al (2013) present a compelling argument for healthcare professionals to become involved in mitigating and adapting to climate change; informing the public of risks; working towards sustainable development goals and protecting vulnerable populations; adopting more sustainable lifestyles; and advocating for an increase in recycling and sustainable energy solutions. Although the consequences of climate change for health are well documented, the implementation of strategies to reduce the effects of healthcare delivery on carbon dioxide emissions are less evident (Nichols et al 2009). However, some notable examples of good practice in energy saving and recycling initiatives can be found in the NHS (Naylor and Appleby 2012). The second major challenge of the future will result from resource scarcity, natural disasters and geopolitical events that disrupt the supply of essential healthcare items (Grose and Richardson 2013). For example, a medical device alert was issued in July 2012 about haemofiltration machine consumables from Baxter Healthcare Limited following earthquakes in northern Italy in May of that year (Medicines and Healthcare products Regulatory Agency 2012). A total of 104 hospitals in the UK rely on Baxter supplies for haemofiltration units for their intensive care units (ICUs), representing 50% of ICU capacity in the NHS. On July 19 2012 the forecast suggested that there was less than six weeks’ supply left before all stock was used (Faculty of Intensive Care Medicine et al 2012).
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This particular problem was resolved by moving production to another location. However, it demonstrates how supply chains for essential healthcare items can be threatened by natural disasters, with potentially profound effects on the ability to deliver care. The NHS supply chain relies on products manufactured from potentially scarce resources, such as rare metals used in the manufacture of electronic devices and lithium used in batteries. Many items are made from plastics and cotton. Scarcity, drought, flooding, natural disasters and climate change can cause price fluctuations, affect availability, and threaten the sustainability of supplies. David Pencheon, director of the NHS Sustainable Development Unit (SDU), has written: ‘Sustainability means more than merely lasting or surviving; it means designing and delivering health care that uses resources in ways that don’t prejudice future health and wellbeing’ (Pencheon 2011). It is too easy to assume that the problems of sustainability in the NHS will be dealt with by policy makers and managers, as with the Department of Health’s Supply Resilience Analysis and Assessment Project (Grose and Richardson 2014), which develops previous research. The project aims to identify critical medical devices and consumable products, and to assess these against a number of risk factors with the aim of identifying a ‘shortlist’ of products where the risks to continuity of supply are greatest. This should result in recommendations and actions that limit the potentially serious consequences to supply of a major interruption such as that experienced following the Italian earthquake in 2012. In the context of climate change mitigation, the SDU suggests actions that can be taken by NHS trusts to reduce carbon emissions, providing examples of how some trusts have made progress towards the NHS carbon reduction strategy (NHS SDU 2014). Centrally planned initiatives are to be welcomed. However, each individual has a role to play, and nurses can work imaginatively alongside other professionals to create sustainability solutions. Nurses can have a significant effect on how resources are used and disposed of in health care, and there is potential for the nursing profession to reduce both the financial costs and the carbon emissions associated with the delivery of health care. There is little guidance from the Nursing and Midwifery Council (NMC) or case studies in the nursing literature on the role of nurses in mitigating and adapting to climate change and promoting sustainability in health and in health care (Goodman and Richardson 2010, Richardson and Wade 2010, Goodman 2011). A few authors
have suggested ways in which nurses can become engaged in promoting sustainability, for example by more effective waste segregation procedures (Barna et al 2012, Goodman and East 2013, Richardson et al 2013). While there is nothing explicit about sustainability in The Code, the standard of ‘ensuring that nurses promote the health and wellbeing of people in our care, their families and the wider community’, and the principle that we ‘manage risk’, are clearly relevant (NMC 2008). As nurses and nurse educators, our responsibility is to ensure that we develop skills that are both fit for purpose and fit for the future – a future likely to require skills that support practice in a changing climate where healthcare resources are challenged. This article reports how academics involved nursing students in discussions about sustainability. It also illustrates how students from the university’s design school worked alongside nursing students in developing ideas to tackle potential sustainability problems of the future. This collaboration yielded new ideas and a novel approach to student learning, and it is now embedded in the nursing and design curricula at Plymouth University.
Process In our view, the best way to raise awareness about sustainability in health care is to demonstrate its relevance to practice. At Plymouth University, we teach sustainability to nursing students and midwives in the context of clinical skills sessions, using a station featuring health and sustainability scenarios that have been evaluated positively by students (Richardson et al 2013). This approach has been achieved by building on our own sustainability research (Grose and Richardson 2012) and by developing evidence-based scenarios that require nurses to think about items they use in clinical practice and the effect on patient care if these items were no longer available. The purpose of the scenario session is to raise awareness about sustainability and the resources nurses use in everyday practice, what they are made from, how and why supply might be interrupted and the effect of waste segregation on the environment.
Description of sustainability and health skills session: nursing students
Learning outcomes By the end of the session the student will be able to: Describe where plastic comes from. Assess the effect of loss of crucially important items on service delivery. Allocate items to the appropriate waste facilities.
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Art & science professional issues Materials available To assist students during the session, the following are available: Computer. Plastic materials, such as intravenous (IV) giving sets and syringes. Yellow and black rubbish bags. Tape to make a line on the floor, distinguishing between items that have a high impact or low impact on patient experience and service delivery. File of background information. Step 1. Scenario information Students are provided with a scenario to read; a file of background information and a computer are available for further research. The aim of the scenario is to engage the nurse in discussions about risk and sustainable procurement and dealing with future limited availability of resources important for patient care. The uninterrupted supply of essential items for patient care is crucial for healthcare organisations. Most products central to health care are derived from natural resources such as oil and cotton, and with increased global demand, some resources are becoming depleted. Initially this will affect the cost of acquiring resources, adding a further burden to NHS expenditure. Also of concern is the possibility that some essential resources may become unavailable. The scenario was prepared by identifying an item that might present a risk to the delivery of health care should its supply be restricted or removed. The scenario describes a situation where the global availability of raw materials required for critical products consumed by the NHS has been affected. The scenario is based on factual information; however, the situation described is fictional. The nurse is asked to follow the questions and prompts suggested by the scenario and take notes so he or she can report back following discussion. It is estimated that globally, more than 100 million tonnes of plastic are manufactured each year. The use of plastics in health care is widespread. On a typical day in one hospital, several hundred patients receive medication bottles and IV catheters and undergo surgical procedures involving plastic, single-use products. Because many of these items have contact with body fluids, none of the components are usually recycled. The price of plastic increases and the hospital becomes concerned about how many plastic items it can afford. Step 2. Facilitated discussion This is based on the scenario and on further reading or computer research. The discussion covers: Where does plastic – the main raw material – come from?
Why is the cost of plastic increasing? Why might it not be available? What are the implications for practice? What do you think can be done? Step 3. Assessment The group discusses the effect on patient care and service delivery if plastic items used in clinical practice are no longer available. A line on the floor is marked with ‘no impact on patient experience or service delivery’ at one end and ‘significant impact on patient experience and service delivery’ at the other. Students are asked to take a plastic item, such as a syringe, bag of IV fluid or medicine pot, from the resources available and place it on the line at the point illustrating the degree to which its loss would affect patient experience and service delivery. They explain the reasons for their decision; the group then discusses the rationale for the decision and what alternative items or materials might be used. Step 4. Appropriate waste disposal When all the items have been placed on the line, the students are given a brief hypothetical scenario for each of the items indicating for example potential for contamination, and asked to put their item in whichever waste bag or bin, black or yellow, they think is appropriate. They explain the reasons for their choice. When all the items have been placed into a waste bag or bin, students are asked if they know the average costs of disposal of a 5kg clinical waste bag and a 5kg domestic waste bag. When they have all provided an answer, the bags are turned over and the cost is shown to be printed on the underside. Step 5. Relevance to practice A facilitated discussion then takes place on the actions that nurses can take in practice to reduce the effect of health care on the environment.
Clinical skills sessions
We also try to reduce the waste used in our clinical skills sessions. We do this by bringing design students from the university into the skills sessions to observe the clinical skills being learned and to participate in the sustainability scenarios. The design students then develop sustainable solutions to be tested and evaluated by the nursing students. Not only does this process provide solutions and products that can be developed further, but it is also an opportunity for interdisciplinary teaching and learning. As a consequence of the process, some of our design and nursing students were shortlisted for a university Vice-Chancellor’s Enterprise Award and have presented their work at conferences. We implemented and evaluated the approach for the first time in 2012/13 with our second-year child
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health programme, and it is now a feature of our curriculum for nursing and design cohorts.
Description of sustainability and health skills session: design students
Design students who have completed a module on sustainable design and are expected to develop a product are invited to take part in the sustainability and healthcare skills session. They are given a brief overview of some of the issues related to sustainability in health care, with a specific focus on the products and packaging used in clinical care and nurse training. Step 1. Observation of the sustainability and health skills session The design students observe the nursing students during the skills session outlined in the previous section. In particular, they are asked to observe the discussion about how important the items are for patient care and/or service delivery and what the effect might be if the item was no longer available. Using their knowledge of raw materials, they are able to consider what alternative, more sustainable products might be used. Step 2. Observation of clinical skills The design students then observe other clinical skills stations not included in the sustainability session, for example those undertaking aseptic technique or other clinical procedures. They are asked to consider how resources used in the procedures might be reduced, re-used or recycled. Step 3. Questions and clarifications At the end of the observations, the design students are encouraged to ask the nursing students, and lecturers, questions about how the resources are used and disposed of, and other questions arising from their observations. Step 4. Product design Design students have an opportunity to design a product or solution, and nursing students and lecturers are invited to the design studio, where ideas are discussed. Step 5. Prototype development Design students who have developed a prototype ask nursing students and lecturers to test and comment on the design and potential use of the prototype in training or practice.
Gaining acceptance
Establishing our approach to embedding sustainability in the nursing curriculum has been a challenge. Many of our nursing academic colleagues were sceptical initially – for example, they were not convinced of the relevance of climate change to nursing practice. What really engaged them and developed their enthusiasm was their participation in the sustainability and health scenario sessions. Similarly, some students were
surprised to find a sustainability and health station and design students participating in the clinical skills session.
Nursing students’ experience (Bethany and Jamie-Lee)
‘When we first walked into the clinical skills session and saw the station [that had been] prepared for us on sustainability, many of us were confused as to the relation of this to practice. However, as the session progressed it became thought provoking – clearly an issue that is bound to affect every one of us. It really made us think about where the equipment and products we use readily in placement come from and what would happen if they were no longer available, and to think of ways we can help, as nurses, to reduce the waste. ‘As students, spending half our degree in placement, we can be seen as a gateway to the education of other staff nurses and doctors on the issue of sustainability. [We] found that the most common change to be made was the disposal of waste and distinguishing between contaminated and general waste. ‘After the initial session, we were keen to see this process develop and to meet again with the design students to see whether their ideas were feasible and beneficial to our training. I was amazed at what they came up with and how simple changes can dramatically reduce the waste from our clinical skills training stations. It was important that we were involved in the process to ensure their ideas and creations [were relevant to practice]. ‘Being involved in the project has been a rare opportunity to work together with design students and get to generate new ideas and designs that are practical for the clinical setting. [We] feel privileged to have been part of the process and encourage any other students to do so in the future.’
Design students’ experience (Hannah and Johannes)
‘As product design students we were able to implement an “empathic design process”. This involved observation of users and user environments to stimulate insights; idea generation, development and prototyping in 3D; and collaborative discussion with users to evaluate and then refine concept propositions. ‘Having the opportunity for primary observation of users and user environments (the clinical skills training sessions) was powerful in stimulating the insights from which to generate relevant ideas. It enabled us to identify a focus for each of our projects. For Hannah the focus was reducing waste through the development of
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Art & science professional issues a training pack to improve learning experiences for nursing students. For Johannes the focus was extending the life of sample packs used in skills training by re-sealing them.’
Learning points
The students involved in this collaborative session on sustainability and health found it innovative, exciting and challenging. They are using some of the ideas they developed in their final-year projects. For the academics involved, the most significant learning points were that: Sustainability solutions in health care require an interdisciplinary approach and this should begin with the student population. Climate change and resource depletion will be considered only as theoretical challenges, unless the relevance to practice is experienced by healthcare practitioners and students. The sustainability and health session outlined in this article has been delivered to a number of healthcare practitioners and nursing and midwifery students. All have completed evaluation forms demonstrating an increase in knowledge and a high level of engagement with the material (Richardson et al 2013).
Discussion Nurses require skills and awareness of sustainability issues to deliver care in a changing environment and influence policy and practice. Nursing students training today will encounter significant challenges in a future where climate change affects health care and resources may be compromised. Skills sessions provide a clinically relevant approach to developing an awareness of sustainability issues. They enable students to develop some critical thinking about how resources are used and disposed of, and to consider and discuss possible alternatives. The sessions help draw attention to actions nurses can take in their clinical practice to develop sustainable solutions (Box 1). Working with other disciplines highlights opportunities to find alternative solutions. It enables nurses to ‘think outside the box’ and demonstrates how other professionals can help them work towards finding sustainable solutions. Furthermore, our interdisciplinary approach to education provides nurses with the confidence to engage with other disciplines. The approach also provides design students with experience of real-world challenges which will help them to take their design careers forward. Staff also benefit from this approach and are beginning to work with other disciplines as a consequence.
BOX 1 Actions that nurses can take to develop sustainability in health care Waste reduction: Nurses have significant control over the resources they use and through their awareness they can have a direct effect on waste reduction. Nurses should: Only open packages of items necessary for the procedure. Think about appropriate waste segregation – is the item contaminated; does it really need to go in clinical waste? Consider how non-contaminated items could be re-used – for example, in procedures that do not require sterile items, for play or for demonstration. If the only available option in a clinical area is a clinical waste bag, ask why this is the case and suggest a domestic waste bag is made available for non-clinical waste. Ensure patient areas are not overstocked, which can result in unnecessary disposal of items to comply with infection control policies. Use re-usable resources rather than those for single-patient use where possible, for example washable slide sheets. Education: Nurses can educate others, for example colleagues, students and patients, by modelling good practice, challenging poor practice and using a sound evidence base on which to focus discussion. Nurses should: Inform colleagues and students about the relative costs of clinical and domestic waste. Ask colleagues if they are aware of any issues that might have an effect on the continuous supply of items used in health care, for example products made from plastics, cotton and paper. Discover who in the clinical area orders supplies; discuss the potential for putting the cost of items on the shelves where they are stored.
This approach goes some way to addressing the call by Costello et al (2013) for healthcare professionals to address climate change, in particular mitigation of the effect of excessive NHS waste on the environment and advocating for an increase in recycling and sustainable energy solutions. We plan to use this collaboration to investigate other issues that might benefit from shared knowledge about climate change and sustainability, drawing on the skills different disciplines can bring to these challenges. One of the outputs of the collaborative approach to teaching sustainability is the development of a prototype ‘e-version’ of the sustainability and health scenario skills sessions. This project includes a range of scenarios, together with a training manual, and is being developed by third-year
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design students and tested by second and third-year nursing students. The intention is to make it more widely available to educators, nurses and other healthcare practitioners.
practice. Solutions to climate change and resource scarcity in healthcare require knowledge and input from different disciplines, and such an interdisciplinary approach should begin in nursing training NS
Conclusion
Acknowledgements
Climate change and resource scarcity will increasingly affect health care, and nurses will need to be able to manage this through careful use and re-use of resources. Working through scenarios in nursing education is one way to highlight the potential effects on everyday
We would like to thank Maggie Doman, lecturer in child health, Plymouth University, and Mike Woods, lecturer in 3D design, Plymouth University, for their support and engagement in this initiative and their ongoing work with student projects.
References Barna S, Goodman B, Mortimer F (2012) The health effects of climate change: what does a nurse need to know? Nurse Education Today. 32, 7, 765-771. Costello A, Abbas M, Allen A et al (2009) Managing the health effects of climate change. The Lancet. 373, 9676, 1693-1733. Costello A, Montgomery H, Watts N (2013) Climate change: the challenge for healthcare professionals. British Medical Journal. 347, f6060. Faculty of Intensive Care Medicine, Intensive Care Society, British Renal Association (2012) Joint Recommendations Concerning the Supply Problem Affecting Baxter Aquarius and BM25 CVVH Machines. Update on a Rapidly Evolving Situation. Communication 1. tinyurl.com/q46mgvp (Last accessed: June 18 2014.) Goodman B (2011) The need for a ‘sustainability curriculum’ in nurse
education. Nurse Education Today. 31, 8, 733-737. Goodman B, East L (2014) The ‘sustainability lens’: a framework for nurse education that is ‘fit for the future’. Nurse Education Today. 34, 1, 100-103. Goodman B, Richardson J (2010) Climate change, sustainability and health in UK higher education: the challenges for nursing. In Jones P, Selby D, Sterling S (Eds) Sustainability Education: Perspectives and Practice Across Higher Education. Earthscan, London, 109-131. Grose J, Richardson J (2012) Raw Materials Risk in Healthcare Supply Chains. tiny.cc/materials_risk (Last accessed: June 18 2014.) Grose J, Richardson J (2013) Managing a sustainable, low carbon supply chain in the English National Health Service: The views of senior managers. Journal of Health Services Research & Policy. 18, 2, 83-89. Grose J, Richardson J (2014)
Strategies to identify future shortages due to interruptions in the healthcare procurement supply chain and their impact on health services: a method from the English National Health Service. Journal of Health Services Research & Policy. 19, 1, 19-26. Medicines and Healthcare products Regulatory Agency (2012) Medical Device Alert: Aquarius Haemofiltration Machine Consumables Supplied by Baxter Healthcare Ltd (MDA/2012/045). tinyurl.com/ m93a3tm (Last accessed: June 18 2014.) Naylor C, Appleby J (2012) Sustainable Health and Social Care. The King’s Fund, London. NHS Sustainable Development Unit (2014) Route Map. tinyurl. com/kyc9t8j (Last accessed: June 18 2014.) Nichols A, Maynard V, Goodman B, Richardson J (2009) Health, climate change and sustainability:
a systematic review and thematic analysis of the literature. Environmental Health Insights. 3, 63-88. Nursing and Midwifery Council (2008) The Code: Standards of Conduct, Performance and Ethics for Nurses and Midwives. NMC, London. Pencheon D (2011) Wellbeing. Does sustainability have a future. Health Service Journal. 121, 6271, 28-29. Richardson J, Grose J, Doman M, Kelsey J (2013) The use of evidence-informed sustainability scenarios in the nursing curriculum: development and evaluation of teaching methods. Nurse Education Today. 34, 4, 490-493. Richardson J, Wade M (2010) Public health threats in a changing climate. In Kagawa F, Selby D (Eds) Education and Climate Change: Living and Learning in Interesting Times. Routledge, Oxford, 197-214.
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Effect of climate change and resource scarcity on health care Richardson J et al (2014) Effect of climate change and resource scarcity on health care. Nursing Standard. 28, 45, 44-49. Date of submission: October 7 2013; date of acceptance: February 6 2014.
Abstract Climate change and resource scarcity pose significant threats to healthcare delivery. Nurses should develop the skills to cope with these challenges in the future. Skills sessions using sustainability scenarios can help nursing students to understand the effect climate change and resource scarcity will have on health care. Involving design students in clinical skills sessions can encourage multidisciplinary working and help to find solutions to promote healthcare sustainability.
Authors Janet Richardson Professor of Health Service Research, Faculty of Health and Human Sciences, Plymouth University, Plymouth, Devon. Jane Grose Research Fellow, Sustainability and Health, Faculty of Health and Human Sciences, Plymouth University. Bethany Jackson and Jamie-Lee Gill Nursing students, School of Nursing and Midwifery, Plymouth University. Hannah Becky Sadeghian and Johannes Hertel Design students, School of Architecture, Design and Environment, Plymouth University. Janet Kelsey Senior Lecturer, Health Studies (Child Health), Faculty of Health and Human Sciences, Plymouth University. Correspondence to: [email protected]
Keywords Climate change, multidisciplinary team, nursing students, resource management, sustainability
Review All articles are subject to external double-blind peer review and checked for plagiarism using automated software.
Online Guidelines on writing for publication are available at www.nursing-standard.co.uk. For related articles visit the archive and search using the keywords above.
FUTURE HEALTHCARE PRACTITIONERS will be faced with two major challenges that will affect their ability to deliver care. First, climate change will have significant effects on health, resulting in changing patterns of disease because of changing weather and mass migration; malnutrition and starvation; and deaths from flooding. Climate change has been defined as the biggest global health threat of the twenty-first century (Costello et al 2009). It will put pressure on resources and compromise our ability to deliver health care. Costello et al (2013) present a compelling argument for healthcare professionals to become involved in mitigating and adapting to climate change; informing the public of risks; working towards sustainable development goals and protecting vulnerable populations; adopting more sustainable lifestyles; and advocating for an increase in recycling and sustainable energy solutions. Although the consequences of climate change for health are well documented, the implementation of strategies to reduce the effects of healthcare delivery on carbon dioxide emissions are less evident (Nichols et al 2009). However, some notable examples of good practice in energy saving and recycling initiatives can be found in the NHS (Naylor and Appleby 2012). The second major challenge of the future will result from resource scarcity, natural disasters and geopolitical events that disrupt the supply of essential healthcare items (Grose and Richardson 2013). For example, a medical device alert was issued in July 2012 about haemofiltration machine consumables from Baxter Healthcare Limited following earthquakes in northern Italy in May of that year (Medicines and Healthcare products Regulatory Agency 2012). A total of 104 hospitals in the UK rely on Baxter supplies for haemofiltration units for their intensive care units (ICUs), representing 50% of ICU capacity in the NHS. On July 19 2012 the forecast suggested that there was less than six weeks’ supply left before all stock was used (Faculty of Intensive Care Medicine et al 2012).
44 july 9 :: vol 28 noRCNi.com 45 :: 2014 NURSING STANDARD / RCN Downloaded from by ${individualUser.displayName} on Nov 23, 2015.©For personal use only. No other usesPUBLISHING without permission. Copyright © 2015 RCNi Ltd. All rights reserved.
This particular problem was resolved by moving production to another location. However, it demonstrates how supply chains for essential healthcare items can be threatened by natural disasters, with potentially profound effects on the ability to deliver care. The NHS supply chain relies on products manufactured from potentially scarce resources, such as rare metals used in the manufacture of electronic devices and lithium used in batteries. Many items are made from plastics and cotton. Scarcity, drought, flooding, natural disasters and climate change can cause price fluctuations, affect availability, and threaten the sustainability of supplies. David Pencheon, director of the NHS Sustainable Development Unit (SDU), has written: ‘Sustainability means more than merely lasting or surviving; it means designing and delivering health care that uses resources in ways that don’t prejudice future health and wellbeing’ (Pencheon 2011). It is too easy to assume that the problems of sustainability in the NHS will be dealt with by policy makers and managers, as with the Department of Health’s Supply Resilience Analysis and Assessment Project (Grose and Richardson 2014), which develops previous research. The project aims to identify critical medical devices and consumable products, and to assess these against a number of risk factors with the aim of identifying a ‘shortlist’ of products where the risks to continuity of supply are greatest. This should result in recommendations and actions that limit the potentially serious consequences to supply of a major interruption such as that experienced following the Italian earthquake in 2012. In the context of climate change mitigation, the SDU suggests actions that can be taken by NHS trusts to reduce carbon emissions, providing examples of how some trusts have made progress towards the NHS carbon reduction strategy (NHS SDU 2014). Centrally planned initiatives are to be welcomed. However, each individual has a role to play, and nurses can work imaginatively alongside other professionals to create sustainability solutions. Nurses can have a significant effect on how resources are used and disposed of in health care, and there is potential for the nursing profession to reduce both the financial costs and the carbon emissions associated with the delivery of health care. There is little guidance from the Nursing and Midwifery Council (NMC) or case studies in the nursing literature on the role of nurses in mitigating and adapting to climate change and promoting sustainability in health and in health care (Goodman and Richardson 2010, Richardson and Wade 2010, Goodman 2011). A few authors
have suggested ways in which nurses can become engaged in promoting sustainability, for example by more effective waste segregation procedures (Barna et al 2012, Goodman and East 2013, Richardson et al 2013). While there is nothing explicit about sustainability in The Code, the standard of ‘ensuring that nurses promote the health and wellbeing of people in our care, their families and the wider community’, and the principle that we ‘manage risk’, are clearly relevant (NMC 2008). As nurses and nurse educators, our responsibility is to ensure that we develop skills that are both fit for purpose and fit for the future – a future likely to require skills that support practice in a changing climate where healthcare resources are challenged. This article reports how academics involved nursing students in discussions about sustainability. It also illustrates how students from the university’s design school worked alongside nursing students in developing ideas to tackle potential sustainability problems of the future. This collaboration yielded new ideas and a novel approach to student learning, and it is now embedded in the nursing and design curricula at Plymouth University.
Process In our view, the best way to raise awareness about sustainability in health care is to demonstrate its relevance to practice. At Plymouth University, we teach sustainability to nursing students and midwives in the context of clinical skills sessions, using a station featuring health and sustainability scenarios that have been evaluated positively by students (Richardson et al 2013). This approach has been achieved by building on our own sustainability research (Grose and Richardson 2012) and by developing evidence-based scenarios that require nurses to think about items they use in clinical practice and the effect on patient care if these items were no longer available. The purpose of the scenario session is to raise awareness about sustainability and the resources nurses use in everyday practice, what they are made from, how and why supply might be interrupted and the effect of waste segregation on the environment.
Description of sustainability and health skills session: nursing students
Learning outcomes By the end of the session the student will be able to: Describe where plastic comes from. Assess the effect of loss of crucially important items on service delivery. Allocate items to the appropriate waste facilities.
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Art & science professional issues Materials available To assist students during the session, the following are available: Computer. Plastic materials, such as intravenous (IV) giving sets and syringes. Yellow and black rubbish bags. Tape to make a line on the floor, distinguishing between items that have a high impact or low impact on patient experience and service delivery. File of background information. Step 1. Scenario information Students are provided with a scenario to read; a file of background information and a computer are available for further research. The aim of the scenario is to engage the nurse in discussions about risk and sustainable procurement and dealing with future limited availability of resources important for patient care. The uninterrupted supply of essential items for patient care is crucial for healthcare organisations. Most products central to health care are derived from natural resources such as oil and cotton, and with increased global demand, some resources are becoming depleted. Initially this will affect the cost of acquiring resources, adding a further burden to NHS expenditure. Also of concern is the possibility that some essential resources may become unavailable. The scenario was prepared by identifying an item that might present a risk to the delivery of health care should its supply be restricted or removed. The scenario describes a situation where the global availability of raw materials required for critical products consumed by the NHS has been affected. The scenario is based on factual information; however, the situation described is fictional. The nurse is asked to follow the questions and prompts suggested by the scenario and take notes so he or she can report back following discussion. It is estimated that globally, more than 100 million tonnes of plastic are manufactured each year. The use of plastics in health care is widespread. On a typical day in one hospital, several hundred patients receive medication bottles and IV catheters and undergo surgical procedures involving plastic, single-use products. Because many of these items have contact with body fluids, none of the components are usually recycled. The price of plastic increases and the hospital becomes concerned about how many plastic items it can afford. Step 2. Facilitated discussion This is based on the scenario and on further reading or computer research. The discussion covers: Where does plastic – the main raw material – come from?
Why is the cost of plastic increasing? Why might it not be available? What are the implications for practice? What do you think can be done? Step 3. Assessment The group discusses the effect on patient care and service delivery if plastic items used in clinical practice are no longer available. A line on the floor is marked with ‘no impact on patient experience or service delivery’ at one end and ‘significant impact on patient experience and service delivery’ at the other. Students are asked to take a plastic item, such as a syringe, bag of IV fluid or medicine pot, from the resources available and place it on the line at the point illustrating the degree to which its loss would affect patient experience and service delivery. They explain the reasons for their decision; the group then discusses the rationale for the decision and what alternative items or materials might be used. Step 4. Appropriate waste disposal When all the items have been placed on the line, the students are given a brief hypothetical scenario for each of the items indicating for example potential for contamination, and asked to put their item in whichever waste bag or bin, black or yellow, they think is appropriate. They explain the reasons for their choice. When all the items have been placed into a waste bag or bin, students are asked if they know the average costs of disposal of a 5kg clinical waste bag and a 5kg domestic waste bag. When they have all provided an answer, the bags are turned over and the cost is shown to be printed on the underside. Step 5. Relevance to practice A facilitated discussion then takes place on the actions that nurses can take in practice to reduce the effect of health care on the environment.
Clinical skills sessions
We also try to reduce the waste used in our clinical skills sessions. We do this by bringing design students from the university into the skills sessions to observe the clinical skills being learned and to participate in the sustainability scenarios. The design students then develop sustainable solutions to be tested and evaluated by the nursing students. Not only does this process provide solutions and products that can be developed further, but it is also an opportunity for interdisciplinary teaching and learning. As a consequence of the process, some of our design and nursing students were shortlisted for a university Vice-Chancellor’s Enterprise Award and have presented their work at conferences. We implemented and evaluated the approach for the first time in 2012/13 with our second-year child
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health programme, and it is now a feature of our curriculum for nursing and design cohorts.
Description of sustainability and health skills session: design students
Design students who have completed a module on sustainable design and are expected to develop a product are invited to take part in the sustainability and healthcare skills session. They are given a brief overview of some of the issues related to sustainability in health care, with a specific focus on the products and packaging used in clinical care and nurse training. Step 1. Observation of the sustainability and health skills session The design students observe the nursing students during the skills session outlined in the previous section. In particular, they are asked to observe the discussion about how important the items are for patient care and/or service delivery and what the effect might be if the item was no longer available. Using their knowledge of raw materials, they are able to consider what alternative, more sustainable products might be used. Step 2. Observation of clinical skills The design students then observe other clinical skills stations not included in the sustainability session, for example those undertaking aseptic technique or other clinical procedures. They are asked to consider how resources used in the procedures might be reduced, re-used or recycled. Step 3. Questions and clarifications At the end of the observations, the design students are encouraged to ask the nursing students, and lecturers, questions about how the resources are used and disposed of, and other questions arising from their observations. Step 4. Product design Design students have an opportunity to design a product or solution, and nursing students and lecturers are invited to the design studio, where ideas are discussed. Step 5. Prototype development Design students who have developed a prototype ask nursing students and lecturers to test and comment on the design and potential use of the prototype in training or practice.
Gaining acceptance
Establishing our approach to embedding sustainability in the nursing curriculum has been a challenge. Many of our nursing academic colleagues were sceptical initially – for example, they were not convinced of the relevance of climate change to nursing practice. What really engaged them and developed their enthusiasm was their participation in the sustainability and health scenario sessions. Similarly, some students were
surprised to find a sustainability and health station and design students participating in the clinical skills session.
Nursing students’ experience (Bethany and Jamie-Lee)
‘When we first walked into the clinical skills session and saw the station [that had been] prepared for us on sustainability, many of us were confused as to the relation of this to practice. However, as the session progressed it became thought provoking – clearly an issue that is bound to affect every one of us. It really made us think about where the equipment and products we use readily in placement come from and what would happen if they were no longer available, and to think of ways we can help, as nurses, to reduce the waste. ‘As students, spending half our degree in placement, we can be seen as a gateway to the education of other staff nurses and doctors on the issue of sustainability. [We] found that the most common change to be made was the disposal of waste and distinguishing between contaminated and general waste. ‘After the initial session, we were keen to see this process develop and to meet again with the design students to see whether their ideas were feasible and beneficial to our training. I was amazed at what they came up with and how simple changes can dramatically reduce the waste from our clinical skills training stations. It was important that we were involved in the process to ensure their ideas and creations [were relevant to practice]. ‘Being involved in the project has been a rare opportunity to work together with design students and get to generate new ideas and designs that are practical for the clinical setting. [We] feel privileged to have been part of the process and encourage any other students to do so in the future.’
Design students’ experience (Hannah and Johannes)
‘As product design students we were able to implement an “empathic design process”. This involved observation of users and user environments to stimulate insights; idea generation, development and prototyping in 3D; and collaborative discussion with users to evaluate and then refine concept propositions. ‘Having the opportunity for primary observation of users and user environments (the clinical skills training sessions) was powerful in stimulating the insights from which to generate relevant ideas. It enabled us to identify a focus for each of our projects. For Hannah the focus was reducing waste through the development of
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Art & science professional issues a training pack to improve learning experiences for nursing students. For Johannes the focus was extending the life of sample packs used in skills training by re-sealing them.’
Learning points
The students involved in this collaborative session on sustainability and health found it innovative, exciting and challenging. They are using some of the ideas they developed in their final-year projects. For the academics involved, the most significant learning points were that: Sustainability solutions in health care require an interdisciplinary approach and this should begin with the student population. Climate change and resource depletion will be considered only as theoretical challenges, unless the relevance to practice is experienced by healthcare practitioners and students. The sustainability and health session outlined in this article has been delivered to a number of healthcare practitioners and nursing and midwifery students. All have completed evaluation forms demonstrating an increase in knowledge and a high level of engagement with the material (Richardson et al 2013).
Discussion Nurses require skills and awareness of sustainability issues to deliver care in a changing environment and influence policy and practice. Nursing students training today will encounter significant challenges in a future where climate change affects health care and resources may be compromised. Skills sessions provide a clinically relevant approach to developing an awareness of sustainability issues. They enable students to develop some critical thinking about how resources are used and disposed of, and to consider and discuss possible alternatives. The sessions help draw attention to actions nurses can take in their clinical practice to develop sustainable solutions (Box 1). Working with other disciplines highlights opportunities to find alternative solutions. It enables nurses to ‘think outside the box’ and demonstrates how other professionals can help them work towards finding sustainable solutions. Furthermore, our interdisciplinary approach to education provides nurses with the confidence to engage with other disciplines. The approach also provides design students with experience of real-world challenges which will help them to take their design careers forward. Staff also benefit from this approach and are beginning to work with other disciplines as a consequence.
BOX 1 Actions that nurses can take to develop sustainability in health care Waste reduction: Nurses have significant control over the resources they use and through their awareness they can have a direct effect on waste reduction. Nurses should: Only open packages of items necessary for the procedure. Think about appropriate waste segregation – is the item contaminated; does it really need to go in clinical waste? Consider how non-contaminated items could be re-used – for example, in procedures that do not require sterile items, for play or for demonstration. If the only available option in a clinical area is a clinical waste bag, ask why this is the case and suggest a domestic waste bag is made available for non-clinical waste. Ensure patient areas are not overstocked, which can result in unnecessary disposal of items to comply with infection control policies. Use re-usable resources rather than those for single-patient use where possible, for example washable slide sheets. Education: Nurses can educate others, for example colleagues, students and patients, by modelling good practice, challenging poor practice and using a sound evidence base on which to focus discussion. Nurses should: Inform colleagues and students about the relative costs of clinical and domestic waste. Ask colleagues if they are aware of any issues that might have an effect on the continuous supply of items used in health care, for example products made from plastics, cotton and paper. Discover who in the clinical area orders supplies; discuss the potential for putting the cost of items on the shelves where they are stored.
This approach goes some way to addressing the call by Costello et al (2013) for healthcare professionals to address climate change, in particular mitigation of the effect of excessive NHS waste on the environment and advocating for an increase in recycling and sustainable energy solutions. We plan to use this collaboration to investigate other issues that might benefit from shared knowledge about climate change and sustainability, drawing on the skills different disciplines can bring to these challenges. One of the outputs of the collaborative approach to teaching sustainability is the development of a prototype ‘e-version’ of the sustainability and health scenario skills sessions. This project includes a range of scenarios, together with a training manual, and is being developed by third-year
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design students and tested by second and third-year nursing students. The intention is to make it more widely available to educators, nurses and other healthcare practitioners.
practice. Solutions to climate change and resource scarcity in healthcare require knowledge and input from different disciplines, and such an interdisciplinary approach should begin in nursing training NS
Conclusion
Acknowledgements
Climate change and resource scarcity will increasingly affect health care, and nurses will need to be able to manage this through careful use and re-use of resources. Working through scenarios in nursing education is one way to highlight the potential effects on everyday
We would like to thank Maggie Doman, lecturer in child health, Plymouth University, and Mike Woods, lecturer in 3D design, Plymouth University, for their support and engagement in this initiative and their ongoing work with student projects.
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