Art & science research
Nursing students’ attitudes towards sustainability and health care Richardson J et al (2015) Nursing students’ attitudes towards sustainability and health care. Nursing Standard. 29, 42, 36-41. Date of submission: October 16 2014; date of acceptance: December 5 2014.
Abstract Aim To evaluate attitudes towards embedding sustainability and climate change in nursing curricula among nursing students, some of whom had participated in a sustainability and health skills session, and determine whether the session could improve knowledge of sustainability. Methods Three months after the sustainability session, students who had participated along with a sample of students who had not, completed a Sustainability Attitudes in Nursing Survey questionnaire. This investigated attitudes towards climate change and sustainability in nursing curricula and the costs of clinical and domestic waste disposal. Results Nursing students were positive about sustainability and climate change and its inclusion in the curriculum, irrespective of their participation in the sustainability scenario session. Participants in the sustainability session were more likely to identify correctly the cost of clinical waste disposal in the NHS. Conclusion The sustainability and health skills session has the potential to improve nursing students’ knowledge of the cost of clinical waste disposal.
Authors Janet Richardson Professor of Health Service Research, School of Nursing and Midwifery Jane Grose Senior research fellow, Health and Sustainability, School of Nursing and Midwifery Anita O’Connor Research officer, School of Nursing and Midwifery Martyn Bradbury Lecturer, School of Nursing and Midwifery Janet Kelsey Senior lecturer, School of Nursing and Midwifery Maggie Doman Lecturer, School of Nursing and Midwifery All at Plymouth University, Plymouth, England. Correspondence to: [email protected]. @nursus.eu
Keywords Attitudes, climate change, clinical waste disposal, cost, health care, nursing, nursing education, nursing students, sustainability
Review All articles are subject to external double-blind peer review and checked for plagiarism using automated software.
Online For related articles visit the archive and search using the keywords above. Guidelines on writing for publication are available at: journals.rcni.com/r/author-guidelines
CLIMATE CHANGE IS likely to affect health in the future and, increasingly, health and social care will need to be delivered in ways that are both environmentally and financially sustainable (Naylor and Appleby 2012). Although greenhouse gases are naturally present in the atmosphere, since the industrial revolution excessive emissions due to burning fossil fuels have contributed to climate change (United States Environmental Protection Agency 2015). While gases such as methane contribute to global warming, it is thought that the contribution of carbon dioxide has the most significant impact. Carbon dioxide equivalent (CO2e) is a measure of the global warming potential of emissions caused by various greenhouse gases. The carbon footprint of the NHS in England in 2010 was approximately 20 million tonnes CO2e (NHS Sustainable Development Unit (SDU) 2012a). The procurement of goods and services and managing waste accounted for 65% of CO2e emissions for the NHS in England in 2010 (NHS SDU 2012b). The NHS produces 5.5kg of waste per patient per day (Tudor et al 2008a), and much of this is inappropriately segregated to the clinical waste stream (Manzi et al 2014). The process of raising awareness among healthcare staff of climate change and its potential to increase resource or supply vulnerability is gathering momentum (Richardson et al 2014a, 2014b). Promoting sustainability as a means of managing resources now to protect future generations is increasingly being viewed as a way of responding to potential interruptions in the supply chain. The document Saving Carbon, Improving Health: NHS Carbon Reduction Strategy for England (NHS SDU 2009) was published to provide a framework for developing a more sustainable NHS. It has been suggested that a 10% CO2e emissions reduction by 2015 was necessary to meet targets for 2020, that 90% of senior NHS leaders agreed sustainability was important and 60% believed it was essential for the running of their organisations (NHS SDU 2012a). Despite the widely acknowledged importance of both education for sustainable development (ESD)
36 june 17 :: vol 29 42 :: 2015 STANDARD Downloaded fromnoRCNi.com by ${individualUser.displayName} on Jul 03, 2016. For personal use only. No NURSING other uses without permission. Copyright © 2016 RCNi Ltd. All rights reserved.
(Sterling 2012) and a more sustainable healthcare sector, there is limited literature on nursing and climate change and/or sustainability. Nursing students are poorly prepared to understand the connections between resources, climate change, sustainability and health (Goodman and Richardson 2010). However, the potential effect of increasingly intense weather events and the need to understand how to manage resources sustainably can be embedded in the healthcare curriculum through a range of learning opportunities, such as in the context of public health and health inequalities, poverty, food security and infectious diseases (Richardson and Wade 2010). It has been suggested that nursing programmes should embed learning about sustainability in a broader context that links health and the natural environment (Barna et al 2012). Arguably, because climate change and fossil fuel dependency pose serious threats to future health care, we have an obligation to prepare students for the consequences, so that they are able to deal with the associated healthcare planning and resource issues. Nurses are agents of change and have a remit to promote health and control the use of health resources. Nurse educators have a responsibility to embed this learning using practical vocational examples. A nurse who cannot make links between clinical waste, resource use, carbon reduction and health inequalities will not be able to devise solutions for future healthcare challenges associated with climate change and sustainable development (Goodman 2011). A survey of university students found that more than eight in ten believed that sustainable development should be actively incorporated and promoted by universities, more than two-thirds believed that sustainable development should be covered in university courses, and more than 60% wanted to learn more about sustainable development (Drayson et al 2013). Goodman and Richardson (2010) and Barna et al (2012) suggest that there is an absence of sustainability education in UK nursing curricula. By contrast, a range of priority learning outcomes for sustainability have been developed for medical students by the Sustainable Healthcare Education Network (Barna et al 2012). There is, therefore, limited knowledge about nurses’ attitudes towards climate change and sustainability. Further, where sustainability issues are explored, only limited studies include evidence of formal evaluation of nursing students (Richardson et al 2014a, 2014b). Richardson et al (2014b) also found that a sustainability and health skills scenario session increased awareness among nurses about sustainability. With the exception of
the work of Richardson and colleagues, there is no evidence on nursing students’ attitudes towards including climate change and sustainability in the nursing curriculum. In addition, limited data are available regarding nurses’ general attitudes towards sustainability-related issues.
Aim The aim of this evaluation was to measure attitudes towards embedding sustainability and climate change in nursing curricula among nursing students who had participated in a sustainability and health skills session, and to compare these attitudes with those of nursing students who had not participated in the session. The evaluation also aimed to determine whether the session could improve knowledge of sustainability.
Methods A sustainability and health skills session using evidence-based scenarios was completed by second-year child health nursing students. The aim of the session was to raise awareness about the potential effects of climate change on the natural resources needed to produce items that are used every day in nursing practice. Links were made to factors that might affect their availability, such as natural disasters and severe weather events. The session was based on research examining the potential for natural resource scarcity to affect patient care, and research on healthcare waste management (Grose and Richardson 2014). Students were required to identify where plastic comes from, consider why plastic might become expensive or scarce, and discuss the potential effects on patient care should plastic no longer be available to make items such as syringes, intravenous administration sets and fluid bags. Students placed the items on an ‘impact line’, ranging from ‘low impact on patient experience and service delivery’ to ‘high impact on patient experience and service delivery’ (youtu.be/zIFT2Dbg08o). At the end of the session students were presented with a brief hypothetical scenario for each of the items and asked to identify the waste stream into which they would dispose of the item. In addition, they were asked what they thought was the average cost of disposing of a 5kg bag of clinical waste and a 5kg bag of domestic waste. This sustainability session was evaluated positively by nursing students, who appeared to engage fully with the material (Richardson et al 2014b). Three months after the sustainability scenario session, the child health nursing students were asked
NURSING STANDARD juneNo 17other :: voluses 29 without no 42 ::permission. 2015 37 Downloaded from RCNi.com by ${individualUser.displayName} on Jul 03, 2016. For personal use only. Copyright © 2016 RCNi Ltd. All rights reserved.
Art & science research to complete a questionnaire to determine their attitudes towards climate change and sustainability in nursing and the nursing curriculum. Responses to the Sustainability Attitudes in Nursing Survey (SANS) were measured on a numbered seven-point Likert scale, with 1 representing ‘Strongly disagree’ and 7 representing ‘Strongly agree’ (Box 1). Development of the questionnaire was based on input from experts in nursing education and sustainability through group discussions. Preliminary versions of the items were discussed with nursing students. Experts rated the internal validity of the questionnaire in assessing the desired construct. The questionnaire asked students to estimate the average cost to the NHS of disposing of a 5kg bag of domestic waste and a 5kg bag of clinical waste. They were asked to circle one of six options. Correct and incorrect answers were treated as categorical data for analysis. The same questionnaire was given to second-year adult nursing students who had not participated in the sustainability session. Questionnaires were handed to students by their course tutors. Responses to the questionnaire were anonymous, so confidentiality was assured
BOX 1 Statements assessed in the Sustainability Attitudes in Nursing Survey Sustainability should be included in the nursing curriculum. Sustainability is an important issue for nursing. I apply sustainability principles at home. I apply sustainability principles in my nursing practice. Climate change is an important issue for nursing. Issues about climate change should be included in the nursing curriculum.
and students were not under any pressure to take part. The university research ethics committee was approached and, in line with procedures for evaluating new course materials, ethical approval was not required for this evaluation.
Results All nursing students who were asked to complete the questionnaire responded: 29 child health nursing students who had participated in the sustainability session and 28 adult nursing students who had not participated.
Responses to Likert scale statements The data from the responses to the Likert scale statements were plotted as histograms. The Kolmogorov-Smirnov test was used to compare the results with a standard normal distribution. The two-sample Kolmogorov-Smirnov test is a general non-parametric method for comparing two samples. Examination of histograms and Kolmogorov-Smirnov tests of normality suggested that the data deviated from normality – P 0.05). Only eight out of 29 students (27.6%) who had participated in the sustainability session and eight out of 28 students (28.6%) who did not participate in the session answered this question accurately. For estimating the disposal cost for clinical waste in the NHS, there was a highly significant association between participation in the sustainability session and responses (P = 0.001), indicating that participants in the sustainability session were more likely to answer this question correctly. Accurate estimates of the cost of disposal of clinical waste were provided by 20
6 4 2 0
1
2
3 4 5 Seven-point Likert scale
Adult nursing students
6
7
Child health nursing students
1 represents ‘Strongly disagree’ and 7 represents ‘Strongly agree’
NURSING STANDARD juneNo 17other :: voluses 29 no 42 ::permission. 2015 39 Downloaded from RCNi.com by ${individualUser.displayName} on Jul 03, 2016. For personal use only. without Copyright © 2016 RCNi Ltd. All rights reserved.
Art & science research inclusion of sustainability and climate change in the curriculum. However, the sample was small and the study may not have had sufficient power to detect statistically significant differences between the two groups. It is interesting to note that, although the students were more likely to apply sustainability principles at home, this did not necessarily translate into nursing practice. This might be because the nature of the clinical environment is not conducive to, for example, managing waste sustainably. A number of interventions have been shown to successfully reduce waste, including compulsory training for staff, colour-coded bins (Almuneef and Memish 2003), reducing the size of clinical waste bins and providing extra bins for recycling plastic, cardboard and paper (Tudor et al 2008a). Such interventions encourage waste reduction by changing the way staff behave. Other strategies for reducing clinical waste include developing systems for measuring ‘per capita waste’, improved classification of clinical waste, active healthcare staff involvement, involvement of motivated and committed individuals or groups,
and the support of senior managers (Lee et al 2004, Tudor 2007, Tudor et al 2008b). The significant association between participation in the sustainability and health skills training session and accurate estimation of the cost of disposing of clinical waste may suggest that the session increased learning and awareness. This learning may have translated into different behaviour towards waste management in the clinical environment, and research into this should be explored further. The results suggest that the students in this sample were inclined to consider sustainability and climate change important for nursing. However, the study is limited by the small sample size, lack of baseline data and lack of randomisation to the training session. As such, the results require cautious interpretation. Further research should assess nurses’ attitudes towards sustainability as well as the potential for educational interventions to change attitudes and knowledge. Any research would need to address the limitations of the current evaluation, and include the use of qualitative methodologies to gain a deeper
References Almuneef M, Memish ZA (2003) Effective medical waste management: it can be done. American Journal of Infection Control. 31, 3, 188-192. 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. Drayson R, Bone E, Agombar J, Kemp S (2013) Student Attitudes Towards and Skills for Sustainable Development. Higher Education Academy, York.
Goodman B (2011) The need for a ‘sustainability curriculum’ in nurse education. Nurse Education Today. 31, 8, 733-737. 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, Abingdon, 109-132. Grose J, Richardson J (2014) Strategies to identify future shortages due to interruptions in the health care
procurement supply chain and their impact on health services: a method from the English National Health Service. Journal of Health Services Research and Policy. 19, 1, 19-26.
of England. Journal of Health Services Research and Policy. 19, 4, 231-235. Naylor C, Appleby J (2012) Sustainable Health and Social Care. The King’s Fund, London.
Lee BK, Ellenbecker MJ, Moure-Ersaso R (2004) Alternatives for treatment and disposal cost reduction of regulated medical wastes. Waste Management. 24, 2, 143-151.
NHS Sustainable Development Unit (2009) Saving Carbon, Improving Health: NHS Carbon Reduction Strategy for England. NHS SDU, Cambridge.
Manzi S, Nichols A, Richardson J (2014) A systematic observational study of health and social care waste disposal behaviour in the South West
NHS Sustainable Development Unit (2012a) Sustainability in the NHS: Health Check 2012. NHS SDU, Cambridge.
40 june 17 :: vol from 29 no 42 :: 2015 STANDARD Downloaded RCNi.com by ${individualUser.displayName} on Jul 03, 2016. For personal use only. No NURSING other uses without permission. Copyright © 2016 RCNi Ltd. All rights reserved.
understanding of what factors influence nurses’ attitudes towards sustainability. The SANS questionnaire, which was recently developed as part of a large research study, requires further testing with a larger number of students to assess the psychometric properties of the scale and evaluate its ability to detect differences between groups. The questionnaire was recently used with whole cohorts of first-year nurses in five European countries, and results are currently being analysed.
Sustainability sessions for undergraduate nursing students have improved their knowledge regarding the cost of disposal of clinical waste. The same was not found for assessment of the cost of domestic waste, since correct responses to this question were not significantly different between students who participated in the sessions and those who did not. However, this evaluation is based on a small sample and further research with a larger student sample is necessary. Sustainability education is considered increasingly valuable for nursing students, who face
Richardson J, Grose J, Jackson B, Sadeghian BH, Hertel J, Kelsey J (2014a) Effect of climate change and resource scarcity on health care. Nursing Standard. 28, 45, 44-49. Richardson J, Grose J, Doman M, Kelsey J (2014b) The use of evidence-informed sustainability scenarios in the nursing curriculum: development and evaluation of
Acknowledgement The authors are grateful to all the nursing students who took part in this project and offered their insightful comments as part of the evaluation.
IMPLICATIONS FOR PRACTICE
Conclusion
NHS Sustainable Development Unit (2012b) NHS England Carbon Footprint. NHS SDU, Cambridge.
the prospect of delivering care with fewer resources in the future. The more nurses can consider how to adapt current practice or use alternative materials, the more they will be prepared for potential changes in the materials supply chain NS
Nursing students appear to have positive attitudes towards the inclusion of climate change and sustainability in nursing education and practice. Education on climate change and sustainability has the potential to reduce the financial and environmental cost of health care. Delivering a sustainability session has the potential to improve nursing students’ knowledge about the cost of clinical waste disposal. Key messages about the sustainable use of healthcare resources could lead to more sustainable healthcare practices.
teaching methods. Nurse Education Today. 34, 4, 490-493.
in HE. The Higher Education Academy, York.
Richardson J, Wade M (2010) Public health threats in a changing climate; meeting the challenges through sustainable health education. In Kagawa F, Selby D (Eds) Education and Climate Change: Living and Learning in Interesting Times. Routledge, Oxford, 197-214.
Tudor TL (2007) Towards the development of a standardised measurement unit for healthcare waste generation. Resources, Conservation and Recycling. 50, 3, 319-333.
Sterling S (2012) The Future Fit Framework: An Introductory Guide to Teaching and Learning for Sustainability
Tudor TL, Marsh CL, Butler S, Van Horn JA, Jenkin LE (2008a) Realising resource efficiency in the management of healthcare waste from the Cornwall National Health Service (NHS) in the UK. Waste Management. 28, 7, 1209-1218.
Tudor TL, Bannister S, Butler S et al (2008b) Can corporate social responsibility and environmental citizenship be employed in the effective management of waste? Case studies from the National Health Service (NHS) in England and Wales. Resources, Conservation and Recycling. 52, 5, 764-774. United States Environmental Protection Agency (2015) Overview of Greenhouse Gases. tinyurl.com/cwneb4u (Last accessed: May 18 2015.)
NURSING STANDARD juneNo 17other :: voluses 29 without no 42 ::permission. 2015 41 Downloaded from RCNi.com by ${individualUser.displayName} on Jul 03, 2016. For personal use only. Copyright © 2016 RCNi Ltd. All rights reserved.
Nursing students’ attitudes towards sustainability and health care Richardson J et al (2015) Nursing students’ attitudes towards sustainability and health care. Nursing Standard. 29, 42, 36-41. Date of submission: October 16 2014; date of acceptance: December 5 2014.
Abstract Aim To evaluate attitudes towards embedding sustainability and climate change in nursing curricula among nursing students, some of whom had participated in a sustainability and health skills session, and determine whether the session could improve knowledge of sustainability. Methods Three months after the sustainability session, students who had participated along with a sample of students who had not, completed a Sustainability Attitudes in Nursing Survey questionnaire. This investigated attitudes towards climate change and sustainability in nursing curricula and the costs of clinical and domestic waste disposal. Results Nursing students were positive about sustainability and climate change and its inclusion in the curriculum, irrespective of their participation in the sustainability scenario session. Participants in the sustainability session were more likely to identify correctly the cost of clinical waste disposal in the NHS. Conclusion The sustainability and health skills session has the potential to improve nursing students’ knowledge of the cost of clinical waste disposal.
Authors Janet Richardson Professor of Health Service Research, School of Nursing and Midwifery Jane Grose Senior research fellow, Health and Sustainability, School of Nursing and Midwifery Anita O’Connor Research officer, School of Nursing and Midwifery Martyn Bradbury Lecturer, School of Nursing and Midwifery Janet Kelsey Senior lecturer, School of Nursing and Midwifery Maggie Doman Lecturer, School of Nursing and Midwifery All at Plymouth University, Plymouth, England. Correspondence to: [email protected]. @nursus.eu
Keywords Attitudes, climate change, clinical waste disposal, cost, health care, nursing, nursing education, nursing students, sustainability
Review All articles are subject to external double-blind peer review and checked for plagiarism using automated software.
Online For related articles visit the archive and search using the keywords above. Guidelines on writing for publication are available at: journals.rcni.com/r/author-guidelines
CLIMATE CHANGE IS likely to affect health in the future and, increasingly, health and social care will need to be delivered in ways that are both environmentally and financially sustainable (Naylor and Appleby 2012). Although greenhouse gases are naturally present in the atmosphere, since the industrial revolution excessive emissions due to burning fossil fuels have contributed to climate change (United States Environmental Protection Agency 2015). While gases such as methane contribute to global warming, it is thought that the contribution of carbon dioxide has the most significant impact. Carbon dioxide equivalent (CO2e) is a measure of the global warming potential of emissions caused by various greenhouse gases. The carbon footprint of the NHS in England in 2010 was approximately 20 million tonnes CO2e (NHS Sustainable Development Unit (SDU) 2012a). The procurement of goods and services and managing waste accounted for 65% of CO2e emissions for the NHS in England in 2010 (NHS SDU 2012b). The NHS produces 5.5kg of waste per patient per day (Tudor et al 2008a), and much of this is inappropriately segregated to the clinical waste stream (Manzi et al 2014). The process of raising awareness among healthcare staff of climate change and its potential to increase resource or supply vulnerability is gathering momentum (Richardson et al 2014a, 2014b). Promoting sustainability as a means of managing resources now to protect future generations is increasingly being viewed as a way of responding to potential interruptions in the supply chain. The document Saving Carbon, Improving Health: NHS Carbon Reduction Strategy for England (NHS SDU 2009) was published to provide a framework for developing a more sustainable NHS. It has been suggested that a 10% CO2e emissions reduction by 2015 was necessary to meet targets for 2020, that 90% of senior NHS leaders agreed sustainability was important and 60% believed it was essential for the running of their organisations (NHS SDU 2012a). Despite the widely acknowledged importance of both education for sustainable development (ESD)
36 june 17 :: vol 29 42 :: 2015 STANDARD Downloaded fromnoRCNi.com by ${individualUser.displayName} on Jul 03, 2016. For personal use only. No NURSING other uses without permission. Copyright © 2016 RCNi Ltd. All rights reserved.
(Sterling 2012) and a more sustainable healthcare sector, there is limited literature on nursing and climate change and/or sustainability. Nursing students are poorly prepared to understand the connections between resources, climate change, sustainability and health (Goodman and Richardson 2010). However, the potential effect of increasingly intense weather events and the need to understand how to manage resources sustainably can be embedded in the healthcare curriculum through a range of learning opportunities, such as in the context of public health and health inequalities, poverty, food security and infectious diseases (Richardson and Wade 2010). It has been suggested that nursing programmes should embed learning about sustainability in a broader context that links health and the natural environment (Barna et al 2012). Arguably, because climate change and fossil fuel dependency pose serious threats to future health care, we have an obligation to prepare students for the consequences, so that they are able to deal with the associated healthcare planning and resource issues. Nurses are agents of change and have a remit to promote health and control the use of health resources. Nurse educators have a responsibility to embed this learning using practical vocational examples. A nurse who cannot make links between clinical waste, resource use, carbon reduction and health inequalities will not be able to devise solutions for future healthcare challenges associated with climate change and sustainable development (Goodman 2011). A survey of university students found that more than eight in ten believed that sustainable development should be actively incorporated and promoted by universities, more than two-thirds believed that sustainable development should be covered in university courses, and more than 60% wanted to learn more about sustainable development (Drayson et al 2013). Goodman and Richardson (2010) and Barna et al (2012) suggest that there is an absence of sustainability education in UK nursing curricula. By contrast, a range of priority learning outcomes for sustainability have been developed for medical students by the Sustainable Healthcare Education Network (Barna et al 2012). There is, therefore, limited knowledge about nurses’ attitudes towards climate change and sustainability. Further, where sustainability issues are explored, only limited studies include evidence of formal evaluation of nursing students (Richardson et al 2014a, 2014b). Richardson et al (2014b) also found that a sustainability and health skills scenario session increased awareness among nurses about sustainability. With the exception of
the work of Richardson and colleagues, there is no evidence on nursing students’ attitudes towards including climate change and sustainability in the nursing curriculum. In addition, limited data are available regarding nurses’ general attitudes towards sustainability-related issues.
Aim The aim of this evaluation was to measure attitudes towards embedding sustainability and climate change in nursing curricula among nursing students who had participated in a sustainability and health skills session, and to compare these attitudes with those of nursing students who had not participated in the session. The evaluation also aimed to determine whether the session could improve knowledge of sustainability.
Methods A sustainability and health skills session using evidence-based scenarios was completed by second-year child health nursing students. The aim of the session was to raise awareness about the potential effects of climate change on the natural resources needed to produce items that are used every day in nursing practice. Links were made to factors that might affect their availability, such as natural disasters and severe weather events. The session was based on research examining the potential for natural resource scarcity to affect patient care, and research on healthcare waste management (Grose and Richardson 2014). Students were required to identify where plastic comes from, consider why plastic might become expensive or scarce, and discuss the potential effects on patient care should plastic no longer be available to make items such as syringes, intravenous administration sets and fluid bags. Students placed the items on an ‘impact line’, ranging from ‘low impact on patient experience and service delivery’ to ‘high impact on patient experience and service delivery’ (youtu.be/zIFT2Dbg08o). At the end of the session students were presented with a brief hypothetical scenario for each of the items and asked to identify the waste stream into which they would dispose of the item. In addition, they were asked what they thought was the average cost of disposing of a 5kg bag of clinical waste and a 5kg bag of domestic waste. This sustainability session was evaluated positively by nursing students, who appeared to engage fully with the material (Richardson et al 2014b). Three months after the sustainability scenario session, the child health nursing students were asked
NURSING STANDARD juneNo 17other :: voluses 29 without no 42 ::permission. 2015 37 Downloaded from RCNi.com by ${individualUser.displayName} on Jul 03, 2016. For personal use only. Copyright © 2016 RCNi Ltd. All rights reserved.
Art & science research to complete a questionnaire to determine their attitudes towards climate change and sustainability in nursing and the nursing curriculum. Responses to the Sustainability Attitudes in Nursing Survey (SANS) were measured on a numbered seven-point Likert scale, with 1 representing ‘Strongly disagree’ and 7 representing ‘Strongly agree’ (Box 1). Development of the questionnaire was based on input from experts in nursing education and sustainability through group discussions. Preliminary versions of the items were discussed with nursing students. Experts rated the internal validity of the questionnaire in assessing the desired construct. The questionnaire asked students to estimate the average cost to the NHS of disposing of a 5kg bag of domestic waste and a 5kg bag of clinical waste. They were asked to circle one of six options. Correct and incorrect answers were treated as categorical data for analysis. The same questionnaire was given to second-year adult nursing students who had not participated in the sustainability session. Questionnaires were handed to students by their course tutors. Responses to the questionnaire were anonymous, so confidentiality was assured
BOX 1 Statements assessed in the Sustainability Attitudes in Nursing Survey Sustainability should be included in the nursing curriculum. Sustainability is an important issue for nursing. I apply sustainability principles at home. I apply sustainability principles in my nursing practice. Climate change is an important issue for nursing. Issues about climate change should be included in the nursing curriculum.
and students were not under any pressure to take part. The university research ethics committee was approached and, in line with procedures for evaluating new course materials, ethical approval was not required for this evaluation.
Results All nursing students who were asked to complete the questionnaire responded: 29 child health nursing students who had participated in the sustainability session and 28 adult nursing students who had not participated.
Responses to Likert scale statements The data from the responses to the Likert scale statements were plotted as histograms. The Kolmogorov-Smirnov test was used to compare the results with a standard normal distribution. The two-sample Kolmogorov-Smirnov test is a general non-parametric method for comparing two samples. Examination of histograms and Kolmogorov-Smirnov tests of normality suggested that the data deviated from normality – P 0.05). Only eight out of 29 students (27.6%) who had participated in the sustainability session and eight out of 28 students (28.6%) who did not participate in the session answered this question accurately. For estimating the disposal cost for clinical waste in the NHS, there was a highly significant association between participation in the sustainability session and responses (P = 0.001), indicating that participants in the sustainability session were more likely to answer this question correctly. Accurate estimates of the cost of disposal of clinical waste were provided by 20
6 4 2 0
1
2
3 4 5 Seven-point Likert scale
Adult nursing students
6
7
Child health nursing students
1 represents ‘Strongly disagree’ and 7 represents ‘Strongly agree’
NURSING STANDARD juneNo 17other :: voluses 29 no 42 ::permission. 2015 39 Downloaded from RCNi.com by ${individualUser.displayName} on Jul 03, 2016. For personal use only. without Copyright © 2016 RCNi Ltd. All rights reserved.
Art & science research inclusion of sustainability and climate change in the curriculum. However, the sample was small and the study may not have had sufficient power to detect statistically significant differences between the two groups. It is interesting to note that, although the students were more likely to apply sustainability principles at home, this did not necessarily translate into nursing practice. This might be because the nature of the clinical environment is not conducive to, for example, managing waste sustainably. A number of interventions have been shown to successfully reduce waste, including compulsory training for staff, colour-coded bins (Almuneef and Memish 2003), reducing the size of clinical waste bins and providing extra bins for recycling plastic, cardboard and paper (Tudor et al 2008a). Such interventions encourage waste reduction by changing the way staff behave. Other strategies for reducing clinical waste include developing systems for measuring ‘per capita waste’, improved classification of clinical waste, active healthcare staff involvement, involvement of motivated and committed individuals or groups,
and the support of senior managers (Lee et al 2004, Tudor 2007, Tudor et al 2008b). The significant association between participation in the sustainability and health skills training session and accurate estimation of the cost of disposing of clinical waste may suggest that the session increased learning and awareness. This learning may have translated into different behaviour towards waste management in the clinical environment, and research into this should be explored further. The results suggest that the students in this sample were inclined to consider sustainability and climate change important for nursing. However, the study is limited by the small sample size, lack of baseline data and lack of randomisation to the training session. As such, the results require cautious interpretation. Further research should assess nurses’ attitudes towards sustainability as well as the potential for educational interventions to change attitudes and knowledge. Any research would need to address the limitations of the current evaluation, and include the use of qualitative methodologies to gain a deeper
References Almuneef M, Memish ZA (2003) Effective medical waste management: it can be done. American Journal of Infection Control. 31, 3, 188-192. 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. Drayson R, Bone E, Agombar J, Kemp S (2013) Student Attitudes Towards and Skills for Sustainable Development. Higher Education Academy, York.
Goodman B (2011) The need for a ‘sustainability curriculum’ in nurse education. Nurse Education Today. 31, 8, 733-737. 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, Abingdon, 109-132. Grose J, Richardson J (2014) Strategies to identify future shortages due to interruptions in the health care
procurement supply chain and their impact on health services: a method from the English National Health Service. Journal of Health Services Research and Policy. 19, 1, 19-26.
of England. Journal of Health Services Research and Policy. 19, 4, 231-235. Naylor C, Appleby J (2012) Sustainable Health and Social Care. The King’s Fund, London.
Lee BK, Ellenbecker MJ, Moure-Ersaso R (2004) Alternatives for treatment and disposal cost reduction of regulated medical wastes. Waste Management. 24, 2, 143-151.
NHS Sustainable Development Unit (2009) Saving Carbon, Improving Health: NHS Carbon Reduction Strategy for England. NHS SDU, Cambridge.
Manzi S, Nichols A, Richardson J (2014) A systematic observational study of health and social care waste disposal behaviour in the South West
NHS Sustainable Development Unit (2012a) Sustainability in the NHS: Health Check 2012. NHS SDU, Cambridge.
40 june 17 :: vol from 29 no 42 :: 2015 STANDARD Downloaded RCNi.com by ${individualUser.displayName} on Jul 03, 2016. For personal use only. No NURSING other uses without permission. Copyright © 2016 RCNi Ltd. All rights reserved.
understanding of what factors influence nurses’ attitudes towards sustainability. The SANS questionnaire, which was recently developed as part of a large research study, requires further testing with a larger number of students to assess the psychometric properties of the scale and evaluate its ability to detect differences between groups. The questionnaire was recently used with whole cohorts of first-year nurses in five European countries, and results are currently being analysed.
Sustainability sessions for undergraduate nursing students have improved their knowledge regarding the cost of disposal of clinical waste. The same was not found for assessment of the cost of domestic waste, since correct responses to this question were not significantly different between students who participated in the sessions and those who did not. However, this evaluation is based on a small sample and further research with a larger student sample is necessary. Sustainability education is considered increasingly valuable for nursing students, who face
Richardson J, Grose J, Jackson B, Sadeghian BH, Hertel J, Kelsey J (2014a) Effect of climate change and resource scarcity on health care. Nursing Standard. 28, 45, 44-49. Richardson J, Grose J, Doman M, Kelsey J (2014b) The use of evidence-informed sustainability scenarios in the nursing curriculum: development and evaluation of
Acknowledgement The authors are grateful to all the nursing students who took part in this project and offered their insightful comments as part of the evaluation.
IMPLICATIONS FOR PRACTICE
Conclusion
NHS Sustainable Development Unit (2012b) NHS England Carbon Footprint. NHS SDU, Cambridge.
the prospect of delivering care with fewer resources in the future. The more nurses can consider how to adapt current practice or use alternative materials, the more they will be prepared for potential changes in the materials supply chain NS
Nursing students appear to have positive attitudes towards the inclusion of climate change and sustainability in nursing education and practice. Education on climate change and sustainability has the potential to reduce the financial and environmental cost of health care. Delivering a sustainability session has the potential to improve nursing students’ knowledge about the cost of clinical waste disposal. Key messages about the sustainable use of healthcare resources could lead to more sustainable healthcare practices.
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