Sage Journals: Discover world-class research

Abstract

Background and Purpose

The consequences of climate change on individuals’ and communities’ health are numerous. Nurses are among the healthcare professionals most confronted with the climate crisis, and have great potential to limit its impact on vulnerable populations. However, our knowledge of educational options for preparing nurses to address climate change remains limited. The aim of this scoping review was to examine how climate change is integrated into the academic curricula or continuing education of nurses.

Methods and Procedures

Arksey and O’Malley's (2005) framework was used to conduct this scoping review. Documentary search strategies were developed and tested in four databases, and a search of the grey literature was carried out. A two-stage selection process was implemented. Data from 16 scientific articles were extracted and 11 grey literature references were included in the analyses. A narrative summary allowed to synthesize the findings.

Results

Academic and healthcare organizations are increasingly implementing innovative and participatory educational initiatives to raise nurses’ awareness of climate change's health impacts and encourage students and nurses to act in their daily lives and clinical practice. Challenges include a dense curriculum, the absence of a climate competency framework, and theoretical content being presented in an unstimulating manner.

Conclusions

The use of innovative, interactive teaching methods, reference to a theoretical model centered on planetary health, and climate change content distributed throughout the curriculum are some ways to stimulate students’ interest in climate issues. Collaborative efforts involving academia and organizations are needed to foster nurses’ awareness and encourage a variety of climate-oriented actions with planetary reach.

Keywords

Education nursing continuing education climate change scoping review

Background and Purpose

Climate change represents the greatest threat to human health of the twenty-first century (Costello et al., 2009; IPCC, 2023; Romanello et al., 2023; Yang et al., 2019). The concentration of greenhouse gases (GHGs) in the atmosphere is now at an all-time high, causing global warming and ocean acidification (Intergovernmental Panel on Climate Change [IPCC], 2023). On a planetary scale, it is estimated that the healthcare systems of all countries collectively constitute the fifth largest emitter of GHGs in the world (Health Care Climate Council, 2020). The Canadian healthcare system is responsible for 4.6% of national CO2 emissions (Eckelman et al., 2018). It is therefore urgent that the healthcare system itself contributes to reducing its GHGs emissions.

The scientific consensus indicates that a global temperature rise of 1.5°C above pre-industrial levels will lead to irreversible health impacts and biodiversity loss (International Panel on Climate Change, 2023). The United States Environmental Protection Agency (US EPA, 2023) states that climate change is contributing to an increase in the frequency and intensity of extreme weather events, such as heatwaves, forest fires, floods and storms. The consequences for human health of these climatic transformations are numerous. Heatstroke-induced heart attacks are on the rise (Gosselin et al., 2021; Liu et al., 2022). Globally, a loss of almost ten percent of food crops occurred between 1964 and 2007 due to heatwaves or other extreme weather events (Lesk et al., 2016). An increase of several thousand deaths annually attributable to higher carbon concentrations in the air is anticipated (Silva et al., 2017). High temperatures combined with increased rainfall or flooding in certain regions favour the transmission of vector-borne diseases such as malaria (Parham & Michael, 2010). Climate change increases physical and psychological health risks, amplifying the demand for care and straining healthcare systems (Or & Seppänen, 2024). As a result of climate change, some 250,000 additional deaths per year will be attributable to malnutrition, heatwaves, malaria and diarrhea between 2030 and 2050 (WHO, 2023).

Certain populations are more affected by the impacts of environmental change. These include children, pregnant women, the elderly, migrants, members of indigenous or remote communities, and people with chronic illnesses, including those with mental disorders (Watts et al., 2015). Urgent measures, such as integrating climate change into health policies, strengthening medical infrastructure, and training healthcare professionals, are essential to protect vulnerable populations and ensure system resilience (Freifeld et al., 2023). It is necessary both to strengthen efforts to educate nurses on the impacts of climate change on these populations and to promote research demonstrating the relationships between the environment and health (Valentine-Maher et al., 2018).

Yang et al. (2019) argue that healthcare professionals contribute significantly to the wellbeing of individuals affected by climate change. As front-line medical staff, nurses have an important role to play in protecting people from the effects of climate change. Québec, Canadian and international nursing associations and professional orders have expressed growing concern about the impact of pollution and climate change issues on human and global health, stressing the importance of educating nurses about these factors (American Nurses Association [ANA], 2007; American Nurses for Healthy Environments [ANHE], 2011; Canadian Federation of Nurses Union [CFNU], 2019; International Council of Nurses [ICN], 2018; Ordre des infirmières et infirmiers du Québec [OIIQ], 2019). Nurses have the opportunity to make a significant contribution to the fight against climate change because of their numbers and the high level of trust placed in nurses by the public (Leffers & Butterfield, 2018; Milton, 2018; Valentine-Maher et al., 2018). Nursing's commitment to health equality places nurses in a privileged position to speak up on behalf of the population, to promote the latter's interests and improve their living conditions (Nicholas & Breakey, 2017). Not only do nurses work closely with vulnerable populations (Butterfield et al., 2021; Polivka et al., 2012), they also can work jointly with individuals and community groups to limit the health impacts of climate change or, at a minimum, to facilitate adaptation to the adverse consequences of climate change (ICN, 2018). By remaining alert to these realities, nurses can reflect on how nursing practice can be adapted to reduce social inequities and climate injustices (Lilienfeld et al., 2018).

Nurses need to be prepared to cope with these environmental issues and to address them in collaboration with vulnerable populations. However, an overview of the literature revealed a number of challenges associated with the integration of climate change content into nursing education: a lack of uniformity in the provision of climate change content in academic programs, a limited number of teachers adequately trained in the subject, university or faculty resistance due to already dense curricula, a lack of time or opportunities for training in clinical settings, and a lack of interest in the subject of climate change (Barna et al., 2012; Cruz et al., 2018; Leffers et al., 2017; McDermott-Levy et al., 2019; Neal-Boylan et al., 2019). Lopez-Medina et al. (2019) carried out a systematic review of environmental health competencies and pedagogical approaches used to educate nurses about sustainability issues. These authors pointed out that a systemic and interdisciplinary approach to embedding environmental issues in curricula was still lacking. Although their synthesis highlighted content elements to be integrated into nursing education, the authors’ main focus was on how a transformation leading to sustainable clinical nursing practices would reduce the impact of healthcare on climate change. Dalapati et al. (2023), for their part, published a scoping review indicating that educational interventions focused on climate change generally increase students’ awareness of climate change-related health issues. However, their study focused on interdisciplinary programs and excluded educational initiatives developed specifically in nursing schools, for example, or for continuing education.

The main aim of this literature review was to examine how climate change is integrated into the academic curricula or continuing education of nurses. The term academic refers to training provided in a school setting, regardless of level, and leading to a diploma or a professional license to practice. The term continuing education refers to training offered to practicing registered nurses through clinical networks. To our knowledge, this is the first literature review to focus specifically on this subject. Some studies have been carried out in the past, but they considered healthcare professionals in general and did not present results specific to nursing education, or they addressed sustainability issues in a global manner, without examining issues associated with climate change and health. Numerous articles have pointed to the relevance of educating nurses about climate change, but this observation has been based mainly on studies of nurses’ perceptions of climate change (Anåker et al., 2015, 2021; Aronsson et al., 2024; Chen & Price, 2020; Cruz et al., 2018; Kalogirou et al., 2020). Such studies examined nurses’ or students’ attitudes toward integrating climate change into curricula but did not explore the impact of climate change education on nurses’ clinical practice.

This literature review made it possible to determine whether the existing literature adequately supports the integration of climate change content, as related to nursing practice, into academic curricula and continuing education, by detailing, among other things, the impact of educational interventions on nursing practice. Indeed, the proliferation of nursing schools around the world and the growth in the number of articles published in scientific nursing journals are proof that nursing is a flourishing science and there is a need to develop knowledge specific to this discipline, as distinct from other health professions (Baker et al., 2021; Banks-Wallace et al., 2008; Collins & Hewer, 2014). The present study could help strengthen the scientific bases underpinning the nursing practices taught in nursing programs. It could also help identify gaps in the literature where more research is needed. In addition, it could be used as a reference point or basis for discussion by organizations wishing to enhance the training they provide by synthesizing current initiatives in nursing education. The integration of climate change into nursing education has the potential to improve the quality of patient care and positively impact their health. The first step remains to identify and document existing efforts to integrate this theme in nursing education while highlighting the gaps what can still be done to optimize educational strategies and their impact on nursing practice.

Methods and Procedures

In order to achieve this objective, an exploratory literature review in the form of a scoping review was carried out, based on the methodology developed by Arksey and O’Malley (2005) and Levac et al. (2010). A detailed version of the search protocol, review steps and search strategies used in the different databases is available in open access online (Diallo et al., 2023). All elements of the PRISMA-ScR guidelines were considered in the development of the methodology and in the reporting of the results (Tricco et al., 2018).

Identification of the Research Question

The research question that guided the literature search was: How are issues related to climate change addressed in the nursing curriculum and in nursing continuing education?

Identification of Relevant Studies

The creation of detailed search strategies enabled us to identify the literature relevant to the integration of climate change content into nursing education. The search strategies were revised several times by members of the research team with the help of a librarian specialized in health sciences. The main concepts chosen were climate change, nurses and education, which formed the basis for the selection of free and controlled vocabularies that were included in the search strategies. The documentary search was carried out in four databases: MEDLINE (PubMed), CINAHL, Embase and Web of Science. The detailed search strategies are available in Table 1. All studies in English and French, regardless of the country in which they were carried out or the date of publication, were considered. Qualitative and quantitative empirical studies as well as conceptual papers, discussion papers and editorials were considered. The initial search of the databases was carried out in January 2022. An update was carried out in January 2024 to identify potential new articles published in 2022 or 2023.

Table 1.

Search Strategies

PubMed via MEDLINE (January 29th, 2024).

#	Query	Search Details	Results
		2022–2024	68
11	#10 AND #3	(((“Nurse”[Title/Abstract] OR “nurses”[Title/Abstract] OR “nursing”[Title/Abstract]) AND (“educat”[Title/Abstract] OR “curricul”[Title/Abstract] OR “training”[Title/Abstract] OR “student”[Title/Abstract] OR “academia”[Title/Abstract] OR “school”[Title/Abstract])) OR (“education, nursing”[MeSH Terms] OR “students, nursing”[MeSH Terms] OR “School Nursing”[MeSH Terms])) AND (“climate change”[Title/Abstract] OR “global warming”[Title/Abstract] OR “climate crisis”[Title/Abstract] OR “climate warming”[Title/Abstract] OR “climate issue”[Title/Abstract] OR “climate vulnerabilit”[Title/Abstract] OR “climate emergenc”[Title/Abstract] OR “Greenhouse Effect”[Title/Abstract] OR “climate action”[Title/Abstract] OR (“Climate Change”[MeSH Terms] OR “Greenhouse Effect”[MeSH Terms]))	170
9	“Education, Nursing”[Mesh] OR “Students, Nursing”[Mesh] OR “School Nursing”[Mesh]	“education, nursing”[MeSH Terms] OR “students, nursing”[MeSH Terms] OR “School Nursing”[MeSH Terms]	108,123
8	(Nurse[Title/Abstract] OR nurses[Title/Abstract] OR nursing[Title/Abstract]) AND (educat[Title/Abstract] OR curricul[Title/Abstract] OR training[Title/Abstract] OR student[Title/Abstract] OR academia[Title/Abstract] OR school[Title/Abstract])	(“Nurse”[Title/Abstract] OR “nurses”[Title/Abstract] OR “nursing”[Title/Abstract]) AND (“educat”[Title/Abstract] OR “curricul”[Title/Abstract] OR “training”[Title/Abstract] OR “student”[Title/Abstract] OR “academia”[Title/Abstract] OR “school”[Title/Abstract])	155,196
7	#6 AND #3	(((“Nurse”[Title/Abstract] OR “nurses”[Title/Abstract] OR “nursing”[Title/Abstract]) AND (“educat”[Title/Abstract] OR “curricul”[Title/Abstract] OR “training”[Title/Abstract] OR “student”[Title/Abstract] OR “academi”[Title/Abstract])) OR (“education, nursing”[MeSH Terms] OR “students, nursing”[MeSH Terms])) AND (“climate change”[Title/Abstract] OR “global warming”[Title/Abstract] OR “climate crisis”[Title/Abstract] OR “climate warming”[Title/Abstract] OR “climate issue”[Title/Abstract] OR “climate vulnerabilit”[Title/Abstract] OR “climate emergenc”[Title/Abstract] OR “Greenhouse Effect”[Title/Abstract] OR “climate action”[Title/Abstract] OR (“Climate Change”[MeSH Terms] OR “Greenhouse Effect”[MeSH Terms]))	162
6	#4 OR #5	((“Nurse”[Title/Abstract] OR “nurses”[Title/Abstract] OR “nursing”[Title/Abstract]) AND (“educat”[Title/Abstract] OR “curricul”[Title/Abstract] OR “training”[Title/Abstract] OR “student”[Title/Abstract] OR “academi”[Title/Abstract])) OR (“education, nursing”[MeSH Terms] OR “students, nursing”[MeSH Terms])	202,458
5	“Education, Nursing”[Mesh] OR “Students, Nursing”[Mesh]	“education, nursing”[MeSH Terms] OR “students, nursing”[MeSH Terms]	102,780
4	(Nurse[Title/Abstract] OR nurses[Title/Abstract] OR nursing[Title/Abstract]) AND (educat[Title/Abstract] OR curricul[Title/Abstract] OR training[Title/Abstract] OR student[Title/Abstract] OR academi[Title/Abstract])	(“Nurse”[Title/Abstract] OR “nurses”[Title/Abstract] OR “nursing”[Title/Abstract]) AND (“educat”[Title/Abstract] OR “curricul”[Title/Abstract] OR “training”[Title/Abstract] OR “student”[Title/Abstract] OR “academi”[Title/Abstract])	153,030
3	#1 OR #2	“climate change”[Title/Abstract] OR “global warming”[Title/Abstract] OR “climate crisis”[Title/Abstract] OR “climate warming”[Title/Abstract] OR “climate issue”[Title/Abstract] OR “climate vulnerabilit”[Title/Abstract] OR “climate emergenc”[Title/Abstract] OR “Greenhouse Effect”[Title/Abstract] OR “climate action”[Title/Abstract] OR “Climate Change”[MeSH Terms] OR “Greenhouse Effect”[MeSH Terms]	88,524
2	“Climate Change”[Mesh] OR “Greenhouse Effect”[Mesh]	“Climate Change”[MeSH Terms] OR “Greenhouse Effect”[MeSH Terms]	37,170
1	“climate change”[Title/Abstract] OR “global warming”[Title/Abstract] OR “climate crisis”[Title/Abstract] OR “climate warming”[Title/Abstract] OR “climate issue”[Title/Abstract] OR “Climate vulnerabilit”[Title/Abstract] OR “Climate Emergenc”[Title/Abstract] OR “Greenhouse Effect”[Title/Abstract] OR “climate action”[Title/Abstract]	“climate change”[Title/Abstract] OR “global warming”[Title/Abstract] OR “climate crisis”[Title/Abstract] OR “climate warming”[Title/Abstract] OR “climate issue”[Title/Abstract] OR “climate vulnerabilit”[Title/Abstract] OR “climate emergenc”[Title/Abstract] OR “Greenhouse Effect”[Title/Abstract] OR “climate action”[Title/Abstract]	78,838

CINAHL (January 29th, 2024)

#	Question	Résultats
	2022–2024	83
S7	S3 AND S6	216
S6	S4 OR S5	213,893
S5	(MH “Students, Nursing+”) OR (MH “Education, Nursing+”)	117,100
S4	TI ((Nurse OR nurses OR nursing) AND (educat* OR curricul* OR training OR student* OR academi)) OR AB ((Nurse OR nurses OR nursing) AND (educat OR curricul* OR training OR student* OR academi*))	160,052
S3	S1 OR S2	8,460
S2	(MH “Climate Change”) OR (MH “Greenhouse Effect”)	4,500
S1	TI (“climate change” OR “global warming” OR “climate crisis” OR “climate warming” OR “climate issue” OR “Climate vulnerabilit” OR “Climate Emergenc” OR “Greenhouse Effect” OR “climate action”) OR AB (“climate change” OR “global warming” OR “climate crisis” OR “climate warming” OR “climate issue” OR “Climate vulnerabilit” OR “Climate Emergenc” OR “Greenhouse Effect” OR “climate action”)	6,700

Embase (January 29th, 2024)

	2022–2024	75
9	#3 AND #8	192
8	#6 AND #7	214,060
7	#4 OR #5	726,527
6	educat:ti,ab,kw OR curricul:ti,ab,kw OR training:ti,ab,kw OR student:ti,ab,kw OR academi:ti,ab,kw	2,234,029
5	nurse:ti,ab,kw OR nurses:ti,ab,kw OR nursing:ti,ab,kw OR ‘nurse'/exp OR ‘nursing role'/de	693,862
4	‘nursing student'/exp OR ‘nursing education'/exp	113,884
3	#1 OR #2	104,128
2	‘climate change'/exp OR ‘greenhouse effect'/de	75,733
1	‘climate change':ti,ab,kw OR ‘global warming':ti,ab,kw OR ‘climate crisis’:ti,ab,kw OR ‘climate warming':ti,ab,kw OR ‘climate issue':ti,ab,kw OR ‘climate vulnerabilit':ti,ab,kw OR ‘climate emergenc':ti,ab,kw OR ‘greenhouse effect':ti,ab,kw OR ‘climate action':ti,ab,kw	76,940

Web of science (January 29th, 2024)

	2022–2024	62
3	#1 AND #2	178
2	TS = ((Nurse OR nurses OR nursing) AND (educat* OR curricul* OR training OR student* OR academi*))	142,397
1	TS = (“climate change” OR “global warming” OR “climate crisis” OR “climate warming” OR “climate issue” OR “Climate vulnerabilit” OR “Climate Emergenc” OR “Greenhouse Effect” OR “climate action”)	468,352

Selection of Studies

The studies identified in the databases were next imported into the Covidence platform (Veritas Health Innovation). First, the duplicates were removed. Next, two members of the research team (MR, TD) carried out an initial independent selection of studies based on article titles and abstracts. These two researchers then selected a smaller number of articles, based on a reading of the full text of the studies. In cases where the two researchers disagreed about whether to include an article, the opinion of a third team member (AB) was sought.

Studies that examined environmental issues other than climate change in the context of nursing education were excluded, as were articles that did not focus specifically on nurses. The full list of inclusion and exclusion criteria is available in Table 2.

Table 2.

Inclusion and Exclusion Criteria.

Inclusion criteria	Exclusion criteria
The study focuses on the integration of climate change issues into the academic curriculum (undergraduate to postgraduate programmes by nursing schools or faculties) or continuing education (hospital-led programmes or workshops, courses provided by nursing organisations) of nurses.	The study focuses on the integration of environmental issues other than climate change into the academic curriculum or continuing education of nurses.
The article is an empirical study (qualitative or quantitative), a conceptual paper, a discussion paper or an editorial focused on the integration of climate change in nursing education.	The study focuses on the integration of climate change issues into the academic curriculum or continuing education of other health professionals, in general.
	The documents are published in a language other than English or French.

A total of 480 scientific articles were identified through the search strategies used in the databases. As soon as the articles were imported into Covidence, 253 duplicates were removed. Of the 227 articles that were selected based on title and abstract, 39 articles were retained. The full text of these articles was consulted, and 23 studies were excluded because they did not meet the established inclusion criteria. Only 16 articles were included in this scoping review. Figure 1 provides further details regarding the reasons for article exclusion in the form of a PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) diagram. In addition, 11 documents or texts from the grey literature originating from nursing organizations were retained. The updated literature search strategy carried out in January of 2024 identified four additional studies that were incorporated into the discussion. No relevant grey literature was published by the targeted associations for the period of 2022 to 2024.

Figure 1.

Flow Chart.

Data Extraction

The research team used an Excel spreadsheet to extract data from the selected articles. The information collected included the authors, year of publication, country of study, study objectives, method, number of participants (if applicable) and most relevant results.

Analysis, Synthesis and Presentation of Results

The data was then analyzed by the research team and consisted in an in-depth examination of the findings directed toward answering the research question through a narrative summary. The results were grouped according to the following broad topics: teaching methods and educational content, the challenges of integrating climate change into nursing studies, and the authors’ recommendations concerning nursing education. Qualitative and quantitative data were analyzed and integrated for joint presentation in the Results section.

Grey Literature Search

In addition to consulting the abovementioned scientific databases, the research team screened the grey literature. Members of the team consulted the websites of various nursing organizations, associations and groups to identify publications focused on nursing education and climate change. Organizations from the province of Québec, Canada and the United States were identified, as well as a number of international nursing associations. Publications on social media were not considered.

Results

Scientific Literature

Table 3 shows the number of articles retained from each database used in the search.

Table 3.

Number of Retrieved Articles per Database.

Selected databases	Articles (n =)
MEDLINE via PubMed	106
CINAHL Plus with Full Text (EBSCO)	140
Embase	117
Web of Science	117
Total	480

Grey Literature

A total of 12 websites from nursing organizations in Québec, Canada, the United States and abroad were consulted. From these sources, 11 relevant documents or texts were identified through eight of the organizations. Table 4 specifies the organizations from which these texts were collected, as well as their geographical affiliation, the number of papers identified per association as well as relevant content associated with climate change and nursing education in these documents.

Table 4.

Overview of Relevant Documents per Association.

Location	Name of the association or organization	Specific Search	Papers (n =)	Title of the papers	Relevant content
Québec	Ordre des infirmières et infirmiers du Québec (OIIQ)	Changements climatiques (n = 348)	3	Article in clinical magazine: Climate change and nursing: From knowledge to practice (Spring 2021)	Must create knowledge regarding climate change and impacts on health in order to adequately assess health condition. Broaden metaparadigm's concept of “environment” to include ecological components. Perspectives with which to study the environment: health promotion, disease prevention and relief of suffering, as an expression of care for humanity and the environment. Teaching about community resources supporting vulnerable populations.
				Statement of position: The impacts of climate change on Population Health and and Nursing Practice (2019)	Encourage nurses to learn about climate change and health through base curriculum.
				Opinion of the youth committee: CLIMATE CHANGE AND NURSING PRACTICE : TAKING YOUR PLACE AS A KEY PLAYER (February 2020)	Integrate concepts related to climate change and its impacts on health base currirulum, particularly with regard to vulnerable populations. Designing low-cost education that is accessible to all members of the nursing profession
	Association Québécoise des Infirmières et Infirmières (AQII)	No	0
Canada	Canadian Association of Nurses for the Environment (CANE)	Climate change (n = 111)	2	Poster abstract: Beyond the Slogans: Understanding the ecological consciousness of nurses to advance ecohealth knowledge and practice (2018)	Six main themes were highlighted: Awakening consciousness, finding opportunities, limitations, conclusions, and moving forward. Students expressed a need for early integration of environmental health teaching into their curriculum.
				Education Committee page	To prepare curriculum resources and learning activities that can be used by schools of nursing to integrate environmental and ecoliteracy content and theory into nursing curriculum. Activities: Create a collection of existing resources related to planetary health, conduct an environmental scan of resources and activities offered by nursing schools, conduct a review of literature and available resources, design a survey to gather input from nurses and nursing faculties about topics to focus on, develop learning activities on a variety of planetary health and ecoliteracy topics, organize educational events.
	Canadian Federation of Nurses Unions (CFNU)	No	1	Discussion paper: Climate Change and Health: It's Time for Nurses to Act (June 2019)	Nursing education should support a basic level of climate change literacy. Specific links between climate change and human health should be included in curricula as this education will assist nurses in their clinical practice.
	The Canadian Nurse Educator Institute (CNEI)	No	1	Continuing education course: BUILDING CLIMATE CHANGE COMPETENCIES AMONG BACCALAUREATE NURSING STUDENTS	Learning outcomes: Describe climate change science, emerging driving factors of climate change, and sustainable efforts to reduce the impact of climate change nationally and globally. Explain the relationship between climate change and vector-borne diseases, such as Lyme disease and West Nile virus in Canada. Identify the epidemiology and changing landscape of vector-borne diseases in Canada, as well as primary and secondary preventive strategies to address these diseases. Reflect on advocacy strategies to address climate change and vector-borne diseases as practicing health care professionals. Understand opportunities for cross-curricular integration of climate change and vector-borne disease content. Develop appropriate teaching and learning strategies to enhance climate change competencies among baccalaureate nursing students.
	Canadian Association of Schools of Nursing (CASN)	Climate change (n = 2)	1	Guidelines for Undergraduate Nursing Education on Climate-Driven Vector-Borne Diseases (2020)	Provide direction for nursing faculty regarding curriculum development on the topic of climate-driven vector-borne diseases. Supplemented by an e-resource to foster the integration of the entry-level learning outcomes into the curricula of nursing schools across the country. Includes a series of online tools and learning activities related to the modules, such as case studies, self-assessment quizzes, and virtual patient scenarios.
United States	American Nurses Association (ANA)	Climate change (n = 14)	1	ANA's Principles of Environmental Health for Nursing Practice with Implementation Strategies (2007)	Nurse educators are responsible to themselves and their students to ensure that basic knowledge and concepts (relationships between populations and environment, basic mechanisms and pathways of exposure to environmental hazards, basic prevention and control strategies, interdisciplinary practice, and research; assessment and referral; advocacy, ethics, and risk communication; legislation and regulation) are incorporated into both basic and advanced nursing educational curricula. Nursing faculty need a sound understanding of environmental health issues in order to include appropriate course-specific content across the learning continuum.
	Alliance of Nurses for Healthy Environments (ANHE)	Climate change (n = 14)	1	Web page: Curriculum recommendations	Baccalaureate: Appropriate Environmental Health Content, Teaching Strategies and Resources, and Related Environmental Health Competencies from ANA and ANHE for each Specific Classes/General Content Areas in Entry-Level Curricula. Priority areas are also identified within each class/content area. Associate: Suggested Environmental Health content ideas to incorporate into existing courses, Teaching Strategies and Resources for immediate adoption and use, Related Environmental Health Comptencies. RN-BSN programs: Specific classes or general content areas, Appropriate environmental health content, Teaching strategies and resources, competencies. Graduate: Courses, Curricular content, Teaching strategies, competencies.
	American Association of Colleges of Nursing (AACN)	No	0
	National Student Nurses’ Association (NSNA)	No	0
Interna-tional	International Council of Nurses (ICN)	Climate change (n = 33)	1	Position statement: Nursing, climate change and health (2018)	Recommendation: Embed the concept of sustainability in nursing practice as well as climate change-related knowledge into nursing curricula and in post-registration continuing education.
Total			11

Characteristics of Selected Studies

The 16 studies selected made use of a variety of methods. Four of these (25%) are quantitative empirical studies, while three (18.75%) are qualitative empirical studies. Two of the 16 studies (12.5%) are literature reviews, including one systematic review. The majority of the articles retained were discussion papers, which account for seven of the 16 articles (43.75%). The selected studies were published between 2012 and 2021, with nine of the 16 papers (56.25%) having been published during 2019. The majority of the studies, nine in all (56.25%), were carried out in the USA, or discuss topics specific to that country. Three studies (18.75%) were carried out in the UK, one study (6.25%) came from Finland, and three studies (18.75%) involved participants from more than one country, including Saudi Arabia, Iraq, Egypt, the Palestinian Territories, the Netherlands, Spain and Germany. Fourteen studies (87.5%) present results related to academic curricula, and eight of the studies (50%) address continuing education. More details on the studies and significant data are available in Table 5.

Table 5.

Overview of Selected Studies.

Authors and publication date	Location	Study type	Aims	N*	Relevant elements regarding integration of CC in education
Álvarez-Nieto et al. (2018)	Spain, UK, Germany, Netherlands	Quantitative; observational cross-sectional design	Test and evaluate digital educational materials on environmental sustainability and health, in the context of university nursing education in different European countries	299	Teaching modalities: Case studies, problem-solving activities, evaluations, e-learning are suggestedPopulation: Students and professionalsOutcomes: Generate reflection on environmental issues, generate critical thinking, becoming responsible and concerned citizens
Aronsson et al. (2020)	UK	Qualitative; cohort study with self-completion questionnaires	Provide sustainability education to undergraduate student nurses and midwivesExplore whether students were able to apply their sustainability knowledge and to challenge unsustainable nurse practice during clinical placements	240	Teaching modalities: Educational sessions on the relevance of climate change and sustainability to health and healthcarePopulation: Students, potentially integrable into clinical environmentsOutcomes: lack of confidence, resistance to change, lack of time and facilities, and unfavorable attitude make some students feel unable to challenge unsustainable practice in clinical setting; being able to change their waste management practices and being able to influence others make other students feel able to challenge unsustainable practice in clinical setting
Barna et al. (2012)	UK	Literature review	Identify sustainability initiatives in other health professions and share resources for curriculum development in nursing	−	Teaching modalities: Theoretical frameworks containing clinical skills and a perspective for sustainable practiceChallenges: raising awareness and empowering nurses, little room in curricula for ecocentric paradigmPopulation: Undergraduate to postdoctoral studentsRecommendation: Align with current standards of health promotion and public health; schools should provide basic literacy about sustainability
Cruz et al. (2018)	Saudi Arabia, Iraq, Egypt, Palestinian Territories	Quantitative; descriptive-comparative study	Assess the factors influencing the attitudes of Bachelor of Science in Nursing students toward climate change and environmental sustainability and the inclusion of these concepts in the nursing curricula of four Arab countries	1059	Questionnaire: SANS-2Outcomes: attitude differs depending on the country of residence, type of community, and knowledge about sustainability.Teaching modalities: Cover evidence-based environmental sustainability skills to make students realize the relevance of environmental health in nursing, adapt the NurSus Toolkit, integrate sustainability to community health and nursing rolesPopulation: Students
Demorest et al. (2019)	USA	Discussion paper	Presenting the Nurses Climate Challenge created for educating 5,000 health professionals on climate and health	−	Recommendations: Highlight nurse climate “champions”, periodical motivational e-mailsPopulation: Students and in-practice nursesOutcomes: sessions’ attendees eager to incorporate changes in their home and work setting
Divakaran et al. (2016)	USA	Discussion paper	Describe the role of nursing in taking action on climate change now and in the future	−	Recommendations: Emphasize nursing's ethical obligations to promote healthy environments for all, addressing knowledge gaps and personal beliefs to increase the perceived relevance and vulnerability to climate changeTeaching modalities: Activation skills, extracurricular events on climate change, pledges to take action
Eide and Odom-Maryon (2019)	USA	Quantitative; cross-sectional study with online survey addressed toward organizations	Collect evidence for presence or lack of curricular content addressing climate change	213	Recommendations: Use regulation organizations’ guidelines to develop curricula and professional opportunities, include climate change in accreditation standards, presence of a committee at faculty levelPopulation: students, equally exposed to climate change and environmental sustainability in public and private universities but highest instruction in smaller programsTeaching modalities: Content about predicted health effects, consequences, role of the nurse and public health, personal actions to reduce carbon emissions
Tiitta et al. (2021)	Finland	Qualitative; descriptive study with semi-structured focus group interviews	Identify the health issues that Finnish registered nurses associate with climate changeDetermine nurses’ perception of their preparation to address the health impacts of climate change	6	Challenges: Lacking essential knowledge to provide evidence-based care, not having enough education to feel prepared to address health effects of climate change and associate health changes to climateOutcomes: Participants identify vulnerable populations to climate change health effects and recognize the impacts of changing seasons on healthRecommendation: Climate change should be part of schools of nursing and professional development
Kerr et al. (2019)	USA	Qualitative; workshops followed by interviews	Highlight the success of a nurse-led leadership development effort in addressing climate change	7	Outcomes: actions plans generated were implanted for the majority, movement of social change fueled by individualsPopulation: NursesRecommendations: Value the interprofessional nature of the program, emphasize taking action, build nurses’ confidence
Leffers et al. (2017)	USA	Discussion paper	Examine the calls to action, the status of climate change in nursing education, and challenges and recommendations for nursing education related to climate change and human health	−	Challenges: Students not adequately prepared regarding health impacts of climate change and nursing profession response, no reported competencies on climate change to guide curriculum development, lack of engagement from students, limited knowledge regarding the relation between nursing practice and climate events, resistance to inclusion in curriculaRecommendations: Include a theoretical framework such as the Ecological Planetary Health Model, develop climate change-related competencies in curricula, insert climate change content into already existing educational content
Lopez-Medina et al. (2019)	Spain, UK, Germany, Netherlands	Systematic review of the literature	Present a review of literature that focuses on the environmental competencies required and pedagogic approaches used to embed sustainability in curricula in nursing	−	Challenges: Raise awareness amongst nurses, limited attention to skills and competenciesTeaching modalities: Topics should cover resources, food, health promotion, globalism, environmental impact and disease management, and cover knowledge, skills, attitudes, behaviors, and competencies; cross-disciplinary working; case-studies, scenarios, focus groups, plays, simulations, group discussions, debates, skill sessionsRecommendations: University commitment to curricular development and environmental awareness, upskilling teachers, action research, student-centered learning; critical evaluation and appraisal of programs and student outcomes
McDermott-Levy et al. (2019)	USA	Discussion paper	Identify educational strategies in major content areas across undergraduate nursing curricula in 4 climate-related areas: use of health care resources, air quality and extreme heat, mental health, and natural disasters	−	Recommendations: Include climate science and nursing interventions related to climate change in curricula; use the Ecological Model for Planetary Health or another evidence-based framework; make students think beyond patient care delivery and consider systemically; integrate organizations’ competencies in curricula; content from beginning to end of curriculum; integrate climate health information in existing contentTeaching modalities: Content should include health care resources, air quality, extreme heat, impact on mental health, and natural disasters; adding a nursing leadership course and a policy course; interdisciplinary experiences; clinical simulations
Neal-Boylan et al. (2019)	USA	Discussion paper; theoretical model development	Describe the impetus for developing the first nurse-led Center for Climate Change, Climate Justice and Health (CCCCJH), priorities and challenges, and the plan for curriculum integration of climate change knowledge	−	Recommendations: Integrate climate change education and impacts across all levels of education including continuing professional development; galvanize nursing communities to educate nurses in academic and professional settings; share curriculum's climate change integration with other educators; use a theoretical framework such as the Ecological Planetary Health ModelTeaching modalities: Integrate social determinants of health and life span issues, children as vulnerable populations, climate vulnerabilities, and roles of policy and advocacy
Nicholas et al. (2020)	USA	Discussion paper	Address the development and advancement of the Center for Climate Change, Climate Justice, and Health (CCCCJH)	−	Recommendations: Integrate climate change in curricula, continuing education, patient education material, and education of the public; engage in policy and advocacy regarding climate and health; integrate climate knowledge in clinical practice; create a center for coordination of educational efforts on climate change collaborating with communitiesTeaching modalities: Integrate knowledge of climate and health from baccalaureate through master's curricula and in the clinical doctoral program; workshops and symposium on climate change impacts on populations
Richardson et al. (2019)	UK	Quantitative; cohort study with questionnaires completion	Assess the contribution of scenario-based learning aimed at raising awareness of sustainability in health-care practitioners	145	Outcomes: Teaching sustainability and engaging students with sustainable development goal of climate action can favorably change their attitudes toward these topics; students with greater experience and maturity have more confidence in their knowledge and abilities, and therefore may be more willing to challenge unsustainable practiceTeaching modalities: Applied and active pedagogical approach or lectures
Wasco (2019)	USA	Discussion paper	Provide an introduction to the impacts of climate change on nursing care deliveryShare the pedagogy of an introductory course developed for an online, postlicensure RN-BSN program based at a university with deep roots in environmental sustainability	−	Challenges : Including climate change in already established curriculaPopulation: NursesRecommendations: Introductory course to define climate change, its causes, and to analyse how climate change influences human health; align with university's goals; follow professional nursing organization's recommendationsOutcomes: Positive feedback, better links between climate change and populations’ healthTeaching modalities: Elective online course; replacing textbooks with current publications and event resources; discussion forum; mobile learning

N*: Number of participants.

Methods for Integrating Climate Change into Education

Overall, the authors of the studies focused on two issues concerning the integration of climate change into the academic curricula or continuing education of nurses: the theoretical content that should be covered and the type of teaching interventions suitable for transmitting climate change-related knowledge and competencies.

The climate change-related topics to be covered in nursing education are numerous. Among the first topics that should be addressed is the relevance of climate change to health (Aronsson et al., 2020; Canadian Association of Nurses for the Environment [CANE], 2018; Cruz et al., 2018; Lopez-Medina et al., 2019; OIIQ, 2021a) and the health consequences of climate change (ANA, 2007; CFNU, 2019; Eide & Odom-Maryon, 2019), as this will foster awareness of the value of addressing climate change in nursing education. Study authors suggested covering social determinants and vulnerable populations (Neal-Boylan et al., 2019; OIIQ, 2021a, 2021b), climate disasters (McDermott-Levy et al., 2019) and the impact of climate change on mental health (McDermott-Levy et al., 2019). Specific aspects of the nursing profession should also be integrated into climate change-related education. For example, climate change should be associated with the nursing role in courses covering community health (Cruz et al., 2018; Eide & Odom-Maryon, 2019), health promotion (Lopez-Medina et al., 2019; OIIQ, 2021a) or population advocacy (ANA, 2007; Neal-Boylan et al., 2019). Content focused on legislation and policy should also be part of basic climate change education (ANA, 2007). Technical competencies should be taught (Cruz et al., 2018; Divakaran et al., 2016), as should communication and decision-making competencies (Lopez-Medina et al., 2019). Finally, content focused on attitudes toward climate change (Lopez-Medina et al., 2019) or personal actions that can reduce carbon emissions (Eide & Odom-Maryon, 2019) can be integrated into education.

The methods that can be used to convey this content are equally varied. Study authors suggested both in-class sessions (Aronsson et al., 2020) and online content (Álvarez-Nieto et al., 2018), as well as adapted content made accessible on mobile devices at any time (Wasco, 2019). Several authors suggested integrating climate change into academic curricula from the bachelor to the doctoral level (ANA, 2007; CANE, 2018; Griffin et al., 2022; OIIQ, 2019; Nicholas et al., 2020), while other authors proposed addressing this content during extracurricular activities (Divakaran et al., 2016; Wasco, 2019). McDermott-Levy et al. (2019) indicated that a course focusing on nursing leadership and policy may be an appropriate context for introducing nurses to climate action in clinical settings. Interdisciplinary activities or courses may also be appropriate, considering that interprofessional collaboration is required for taking large-scale action against climate change (ANA, 2007; Lopez-Medina et al., 2019; McDermott-Levy et al., 2019). Some authors placed value on the creation of opportunities for students or nurses to speak out on climate issues (Divakaran et al., 2016), whether this be through discussion forums (Wasco, 2019) or debates (Lopez-Medina et al., 2019). Scenario-based simulation or case studies (Lopez-Medina et al., 2019; McDermott-Levy et al., 2019; Richardson et al., 2019) also provided opportunities to put into practice the theoretical competencies developed during training.

Impact on Students or Nurses

A few pedagogical initiatives have been developed and reported on in a structured manner in the literature, in efforts to integrate the topic of climate change into nursing education and assess the knowledge acquired by students. Álvarez-Nieto et al. (2018) developed and validated electronic educational materials based on the NurSusTOOLKIT Sustainability Literacy and Competency framework, in an effort to improve, among other things, knowledge about the effects of climate change and students’ competencies and skills in this area. For the study, 299 students, 20 professionals (teachers, clinicians, advisors) and two technical experts were questioned, and in general they suggested that theoretical content be presented using case studies or problem-solving situations. The use of e-learning was viewed by educators as a means of facilitating content integration (Álvarez-Nieto et al., 2018). Scenario-based learning, an applied and active teaching approach, was also evaluated by Richardson et al. (2019). Clinical situations dealing with the health effects of climate change were integrated into theoretical courses or practical activities throughout the three-year curriculum of nursing students to increase their awareness of and commitment to climate change and sustainability. Of the 145 students who were exposed to these educational activities over three years, the majority reported having more positive attitudes toward integrating sustainable principles into their clinical practice and intended to make an effort to counter climate-damaging practices in their clinical setting (Richardson et al., 2019). The authors also reported that students with more experience and maturity are more confident about their knowledge and competencies, and more inclined to want to combat environmentally harmful practices. Aronsson et al. (2020) tested a similar program and identified two student profiles at the end of the three years. Students who had been able to influence peers to change their habits or who had improved their own day-to-day waste management practices believed more strongly in their ability to transform clinical practices to make them more sustainable. Conversely, this perception was weaker among students who lacked confidence or were resistant to change, who perceived lack of time as a barrier to changing their practice, or who viewed sustainable practices unfavourably.

Climate-change related content has also been integrated in the field of continuing education. Demorest et al. (2019) highlighted the creation of the Nurse Climate Challenge, a website that offers several informative resources related to climate and the health impacts of climate change, while focusing on the short- and long-term benefits of climate action taken by nurses. Among the resources available are short presentations, a list of individual or collective actions for reducing GHG emissions or examples of messages designed to challenge colleagues to take action (Demorest et al., 2019). Nurses who have attended information sessions about the tools provided indicated that they intended to incorporate changes into their clinical and home practices. The team of Kerr et al. (2019) developed another program, called Be the Spark for Health Professionals. This program consists of three multidisciplinary group sessions aimed at enhancing understanding of both the individual and organizational resources required to address the health impacts of climate change, and the psychology of climate communication. Following these sessions, participants were asked to develop an action plan for addressing a climate issue. Kerr et al. (2019) reported that most action plans developed were implemented. These included organizing a conference on zoonoses, facilitating an informative webinar for nurses on the adverse health effects of climate change, and persuading an organizational leader to respond to a climate-related population issue.

An RN-BSN program team at the University of Pennsylvania, for its part, developed a seven-week elective course called Climate Change and Human Health, whose aim was to inform students about the health effects of climate change and instill in them a sense of responsibility toward the population and global health (Wasco, 2019). Learning activities included participating in discussion forums and reflecting on how the advocacy role of nurses can contribute to improving the health of populations affected by climate change. Students questioned after completing the full course held a positive opinion of the training provided. They felt better able to draw links between climate change and population health.

Discussion

The literature review demonstrates that some initiatives have been developed by nursing schools or in clinical practice settings to equip nurses to address climate change issues and integrate these into nursing practice. A variety of theoretical content is taught, with a focus on the populations most vulnerable to climate change and its impact on their health, and on the acquisition of various competencies relevant to interventions with individuals. Research shows that students and nurses are generally in favour of integrating these aspects into academic curricula or continuing education. Moreover, they subsequently demonstrate a desire to take action in their everyday life or in their workplace to limit their impact on the climate.

Challenges

There are a number of challenges involved in integrating climate change-related training into academic programs. Study authors pointed out that the first challenge is to make nurses aware of the issues surrounding the health effects of climate change (Barna et al., 2012; Lopez-Medina et al., 2019) and to instill in nurses a sense of empowerment relative to this issue (Barna et al., 2012). Registered nurses are not adequately prepared to limit the impacts of climate change, to facilitate population adaptation, or to strengthen the climate change resilience of individuals (Leffers et al., 2017). Limited attention is given in educational programs to competencies associated with environmental health or interprofessional collaboration, and few active, participatory teaching methods are incorporated to stimulate student learning (Lopez-Medina et al., 2019). Therefore, students are minimally engaged in applying the content taught (Leffers et al., 2017).

Chen and Price (2020) pointed out that one of the barriers to integrating climate change into academic curricula may come from the students themselves. Indeed, they may perceive climate change content as an addition that overburdens the training program if it is not integrated into the core curriculum and learning objectives. Aronsson et al. (2020) also reported that students perceive that they will be restricted in their future work environment from implementing sustainable clinical practices or from creating initiatives aimed at limiting the impacts of climate change in their practice. They attributed this to a strict organizational culture that resists both change and the use of evidence associated with the impacts of climate on care and health. Even when students are aware of the importance of taking action to limit climate change and of their professional obligation to protect population health, they are demotivated by a feeling of not knowing what to do given the enormity of the climate problem (Schenk et al., 2021). Other students have difficulty seeing the relevance of climate change to their education. They pointed out that the nurse's main role is to save lives and fail to associate climate change with impacts on patients’ physical and mental health (Anåker et al., 2021).

One of the main considerations is the apportioning of the program and the amount of content that must already be delivered to students. Little room is left in the curriculum for the integration of climate change content (Barna et al., 2012; Wasco, 2019). Moreover, faculty may resist including climate change in the curriculum due to the pre-existing burden created by program standards and accrediting body requirements for nursing programs (Leffers et al., 2017). Thus, climate competencies are left out of curricula because they are not deemed essential to programs, or they are not considered during curriculum development because they are not required by accrediting bodies (Leffers et al., 2017). Teachers, who themselves sometimes have little or no training on climate change, may feel anxious about integrating climate change into their existing course content or being called on to prepare sessions entirely devoted to climate change (Chen & Price, 2020).

As a result, practicing nurses in clinical settings lack evidence-based knowledge on which to base their care of individuals experiencing the impacts of climate change (Tiitta et al., 2021). Tiitta et al. interviewed six Finnish nurses who had not taken any courses focused on climate change and health. It was observed generally that they did not feel prepared to intervene to address the health effects of climate change, because they had not received any formal education on the subject. The nurses did, however, report being able to recognize the populations most vulnerable to the health impacts of climate change but did not know what to do about these effects and had no practice guidelines to help them (Tiitta et al., 2021).

Recommendations

Nevertheless, various authors suggest possible avenues toward better integration of climate change into nurses’ academic curricula or continuing education. One of these is to follow the recommendations of program accreditation bodies (Cadet, 2022; Eide & Odom-Maryon, 2019; McDermott-Levy et al., 2019; Wasco, 2019) or practice regulation bodies such as professional orders (Eide & Odom-Maryon, 2019) regarding climate change and sustainability when updating academic programs or continuing education options. For example, the Canadian Association of Nurses for the Environment (CANE, n.d.) developed and classified educational resources and activities that can be used by nursing schools to integrate environmental content and literacy into curricula. The Alliance of Nurses for Healthy Environments (ANHE, 2011) has also developed a guide with recommendations for integrating climate change content into baccalaureate programs, which includes a description of competencies to be developed and pedagogical strategies for achieving this. In addition, it is necessary to ensure critical evaluation of these programs by measuring outcomes in terms of the integration of climate change into students’ nursing practice (Lopez-Medina et al., 2019) or the development of the climate competencies detailed in the curriculum (Leffers et al., 2017).

Eide and Odom-Maryon (2019) and Nicholas et al. (2020) recommend establishing a faculty-level climate committee to coordinate efforts at climate change content delivery. These efforts should also be aligned with university or organizational goals for combating climate change and raising awareness of environmental impacts (Lopez-Medina et al., 2019; Wasco, 2019). The creation of the Center for Climate Change, Climate Justice, and Health at Massachusetts General Hospital's Institute of Health Professions is a case in point. One of the centre's objectives is to ensure the development, integration, and evaluation of climate change-related content, such as the health impacts of climate change, health policy and nursing leadership, through theoretical and clinical activities integrated throughout the nursing program (Bernhardt et al., 2023). The faculty's mission of research and knowledge development should also extend to the role of nurses with respect to climate change (ANA, 2007). Québec's Nurses’ Association (OIIQ, 2021a) argued that it is necessary to create knowledge relating to climate change and its health impacts to adequately assess the health status of populations. The findings of climate science and their relationship to nursing practice should be included in the nursing curriculum (McDermott-Levy et al., 2019) to equip students with a minimum level of environmental literacy (CFNU, 2019). In addition, action research focused on climate issues should be promoted (Lopez-Medina et al., 2019), and this research should involve the participation of the patient community and disseminate the results to them (Nicholas et al., 2020).

Various methods for integrating climate change content are proposed, while considering the current density of academic programs. Québec's Nurses’ Association (OIIQ, 2021a) proposed expanding the concept of the environment in the nursing metaparadigm to include ecological components. Leffers et al. (2017) and McDermott-Levy et al. (2019) advised inserting theory about climate change and its health impacts into already existing content; for example, discussing air pollution in a course on cardiorespiratory pathophysiology. The Canadian Association of Schools of Nursing (CASN, 2020) offers a guide to vector-borne diseases and nursing, with suggestions for curriculum integration, online resources and participatory activities, such as case studies and scenarios. If program load permits, Wasco (2019) recommended offering an introductory course on climate change, its causes and its health impacts. Content should be integrated at various points using innovative methods (Abebe et al., 2023) throughout academic training, from the bachelor to the doctoral level (ICN, 2018; McDermott-Levy et al., 2019; Neal-Boylan et al., 2019), or be offered at any time through continuing education focused on various aspects of nursing practice related to climate change (ICN, 2018; Neal-Boylan et al., 2019; Nicholas et al., 2020). Introducing innovative methods such as film presentations (Lopez-Medina et al., 2019; Ward et al., 2022) may require that teachers also receive updated training so that they are able to adequately convey content to students. The Canadian Nurse Educators Institute (CNEI, n.d.) has previously offered basic climate change training for teachers, to improve their understanding of the relationship between climate change and health and to help them develop learning strategies that facilitate the acquisition of environmental competencies by undergraduate students.

It was suggested that a theoretical model is needed to support the education of nurses, as well as the development of clear and concrete learning objectives (Leffers et al., 2017; McDermott-Levy et al., 2019; Neal-Boylan et al., 2019). Leffers et al. (2017) developed the Ecological Planetary Health Model, a model for integrating climate change into academic nursing programs, which focuses on global health and inter-connectivity between different societal systems. This model aims to broaden the perspective of nurses and students by showing them the different levels at which they can intervene, as well as the various mitigation, adaptation, and resilience factors applicable to climate change. The individual sphere concerns our individual impact on climate change, or inversely the impact of climate change on our behaviours (for example, the use of active transportation). The regional and national spheres, as well as the international sphere, represent the economic aspect of decisions relating to the environment and climate change, as well as the role of policy decisions in combating climate change. Finally, the planetary sphere represents the consideration of ecosystems and human survival from a sustainability perspective. Within these spheres nurses can act on various factors specific to each population. A theoretical framework of this kind accords with the recommendations of Divakaran et al. (2016), who suggested focusing attention on the ethical obligation to promote healthy environments for all, and of McDermott-Levy et al. (2019), who argued that it is necessary for nurses to reflect on climate change in a way that extends beyond the provision of care and to consider their interventions in systemic terms.

Finally, recommendations were also made in the literature concerning nurses who have already received climate change-related training or are taking action to combat its adverse health impacts. Demorest et al. (2019) suggested spotlighting climate champions; these are nurses committed to influencing their colleagues to learn about and combat climate change. To encourage nurses to more actively engage in combating or learning about climate change, organizations need to identify and address nurses’ knowledge gaps and personal beliefs when developing training, so that nurses more fully perceive the relevance of climate change (Divakaran et al., 2016). The cost of such training should remain affordable to encourage nurses to enrol (OIIQ, 2021b). The creation of academic or professional nursing communities would also promote peer-to-peer learning (Neal-Boylan et al., 2019) and consolidate nurses’ confidence in their knowledge and abilities (Kerr et al., 2019).

Limitations

One of the limitations of this scoping review is that the quality of the methodology and results of the scientific articles selected was not assessed. However, Arksey and O’Malley (2005) indicated that this step is optional when carrying out a scoping review. Only references written in French or English were retained. Relevant articles in other languages or the websites of nursing organizations in some countries were therefore not consulted. Additionally, some relevant results may have been contained in articles focused mainly on the concept of sustainability in nursing education. Finally, the research team did not interview any nurses in the context of the study, to validate the relevance of our findings. Nevertheless, preliminary results were presented at the International Council of Nurses 2023 Congress and at the World Nursing Science Conference 2023. The nurses present demonstrated a clear interest in the topic of climate change and affirmed the need to expose students and nurses to theoretical content and practical situations to increase their climate-related knowledge and competencies.

Conclusions

The results of this scoping review highlight the emergence of climate change-related content in the academic curricula and continuing education of nurses in recent years. Given the considerable impact of climate change on the physical and psychological health of the populations most vulnerable to its consequences, several academic and professional organizations have taken steps to adapt the training offered to nurses and provide them with the theoretical and practical knowledge they need to intervene with their patients. Once students and nurses become aware of the relationships between nursing practice, health, and climate change, they are more likely to adopt more environmentally responsible habits in their daily lives, to speak out about climate-related issues experienced by patients, and to seek out more opportunities to learn about climate change. Organizations have demonstrated that simple educational initiatives can be integrated into nurses’ academic curricula, despite already dense programs, and have a positive impact on nurses’ attitudes toward and interest in climate change. Academic organizations and healthcare institutions are encouraged to be creative in integrating climate-related factors into the training they offer, to enrich content with a theoretical perspective promoting climate action in different areas, and to encourage nurses to take action to combat climate change daily and in the context of patient care.

This article encourages the timely integration of climate change into nursing education and urges educators to take advantage of the generally positive attitude of students and nurses toward combating the impacts of climate change. Information about initiatives already underway can be disseminated through the publication of scientific articles highlighting local projects. Formal collaboration between academic leaders and healthcare organizations is also encouraged, so that the health impacts of climate change become a priority for nurses pursuing a clinical career, as well as for those pursuing advanced practice or research training.

However, integrating climate change into nursing education is not enough; the impact of these changes on patient care must be measured. To this end, future studies could focus on assessing the effectiveness and benefits of climate-related educational initiatives on nursing practice. Among other aspects, these evaluations should include a theoretical justification for the metrics assessed, the identification and application of climate issues to clinical situations by healthcare providers, patient health outcomes, and the improvement of nursing care quality indicators.

Thus, following efforts to disseminate research and best practices in integrating climate change into academic and continuing education, nurses from all backgrounds would have a variety of climate action levers at their disposal. They would be able to advance the vital role of the nursing profession in improving people's living conditions, while working toward the common goal of better planetary health.

Footnotes

Acknowledgements

For all her assistance in developing our bibliographic search strategy, we would like to express our gratitude to Marie-Claude Laferrière, our library consultant at Université Laval. Finally, we thank Nina Alexakis Gilbert for her support with linguistic revision of this article.

Data Availability Statement

The datasets generated during and/or analyzed during the current study are available from the corresponding author on reasonable request. Anyone may share or adapt the content of this study as by CC BY open access license description, as long as the original paper is properly cited.

Declaration of Conflicting Interests

The authors declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Funding

The authors disclosed receipt of the following financial support for the research, authorship, and/or publication of this article: We would like to thank the Faculty of Nursing Sciences of Université Laval for the research support fund granted (fund SAR–SR-133186).

ORCID iDs

Martin Roberge

Thierno Diallo

Anouk Bérubé

Pierre-Paul Audate

Nancy Leblanc

Author Biographies

Martin Roberge is a PhD candidate at Université Laval's Faculty of Nursing. His area of research include nursing education and palliative care.

Thierno Diallo is professor at the Faculty of Nursing at Université Laval. His area of research is climate change and health.

Anouk Bérubé is a registered nurse and research professional at Faculty of Nursing at Université Laval. Her area of research is environmental health.

Pierre-Paul Audate is a professor in the Department of Geography at Université de Montréal. His area of research is urban health and climate change adaptation.

Nancy Leblanc is professor at the Faculty of Nursing at Université Laval. Her area of research is child and family health.

References

Abebe

Bailey

Radu

(2023). Film as a pedagogical tool for climate change and mental health nursing education. International Journal of Mental Health Nursing, 32(6), 1503–1508. https://doi.org/10.1111/inm.13203

Alliance of Nurses for Healthy Environments [ANHE]. (2011). Environment, Health and BSN Curricula. [Online]. https://envirn.org/education/curriculum-recommendations/

Álvarez-Nieto

Richardson

Parra-Anguita

Linares-Abad

Huss

Grande-Gascón

M. L.

Grose

Huynen

López-Medina

I. M.

(2018). Developing digital educational materials for nursing and sustainability: The results of an observational study. Nurse Education Today, 60, 139–146. https://doi.org/10.1016/j.nedt.2017.10.008

American Nurses Association [ANA]. (2007). ANA’s Principles of Environmental Health for Nursing Practice with Implementation Strategies. [PDF]. https://www.nursingworld.org/∼4af4f2/globalassets/docs/ana/ethics/principles-of-environmental-health-online_final.pdf

Anåker

Nilsson

Holmner

Elf

(2015). Nurses’ perceptions of climate and environmental issues: A qualitative study. Journal of Advanced Nursing, 71(8), 1883–1891. https://doi.org/10.1111/jan.12655

Anåker

Spante

Elf

(2021). Nursing students’ perception of climate change and sustainability actions – A mismatched discourse: A qualitative, descriptive exploratory study. Nurse Education Today, 105. https://doi.org/10.1016/j.nedt.2021.105028

Arksey

O'Malley

(2005). Scoping studies: Towards a methodological framework. International Journal of Social Research Methodology, 8(1), 19–32. https://doi.org/10.1080/1364557032000119616

Aronsson

Clarke

Grose

Richardson

(2020). Student nurses exposed to sustainability education can challenge practice: A cohort study. Nursing & Health Sciences, 22(3), 803–811. https://doi.org/10.1111/nhs.12734

Aronsson

Nichols

Warwick

Elf

(2024). Nursing students’ and educators’ perspectives on sustainability and climate change: An integrative review. Journal of Advanced Nursing, 80(8), 3072–3085. https://doi.org/10.1111/jan.15950

10.

Baker

Cary

A. H.

da Conceicao Bento

(2021). Global standards for professional nursing education: The time is now. Journal of Professional Nursing, 37(1), 86–92. https://doi.org/10.1016/j.profnurs.2020.10.001

11.

Banks-Wallace

J. A.

Despins

Adams-Leander

McBroom

Tandy

L. A.

(2008). Re/affirming and re/conceptualizing disciplinary knowledge as the foundation for doctoral education. Advances in Nursing Science, 31(1), 67–78. https://doi.org/10.1097/01.ANS.0000311530.81188.88

12.

Barna

Goodman

Mortimer

(2012). The health effects of climate change: What does a nurse need to know? Nurse Education Today, 32(7), 765–771. https://doi.org/10.1016/j.nedt.2012.05.012

13.

Bernhardt

J. M.

Sipe

M. H.

Tagliareni

M. E.

O'Brien

L. B.

Donati

Evans

L. A.

Nicholas

P. K.

(2023). Leadership in nursing education for advancing a school of nursing-led center for climate change, climate justice, and health. Journal of Nursing Education, 62(9), 528–531. https://doi.org/10.3928/01484834-20230509-10

14.

Boden

T. A.

Marland

Andres

R. J.

(1999). Global, regional, and national fossil-fuel co2 emissions (1751–2014)(v. 2017) (No. osti: 1389331; doi: 10.3334/CDIAC/00001_V2017; cdiac: doi 10.3334/CDIAC/00001_V2017). Environmental System Science Data Infrastructure for a Virtual Ecosystem (ESS-DIVE)(United States).

15.

Butterfield

Leffers

Vásquez

M. D.

(2021). Nursing’s pivotal role in global climate action. BMJ, 1049. https://doi.org/10.1136/bmj.n1049

16.

Cadet

M. J.

(2022). Integrating climate change concepts into advanced practice registered nurses curricula with the application of the national organization of nurse practitioner faculties competencies. Journal of Professional Nursing, 41, 157–165. https://doi.org/10.1016/j.profnurs.2022.05.006

17.

Canadian Association of Nurses for the Environment [CANE]. (2018). Beyond the Slogans: Understanding the ecological consciousness of nurses to advance ecohealth knowledge and practice. [Online]. https://cane-aiie.ca/educational_resource/beyond-the-slogans-understanding-the-ecological-consciousness-of-nurses-to-advance-ecohealth-knowledge-and-practice/

18.

Canadian Association of Nurses for the Environment [CANE]. (n.d.). What we do. [Online]. https://cane-aiie.ca/what-we-do/#education

19.

Canadian Association of Schools of Nursing [CASN]. (2020). Guidelines for Undergraduate Nursing Education on Climate-Driven Vector-Borne Diseases. [PDF]. https://www.casn.ca/wp-content/uploads/2020/04/CASN-VBD-Education-Guidelines-EN-FNL.pdf

20.

Canadian Federation of Nurses Union [CFNU]. (2019). Climate Change and Health: It's Time for Nurses to Act. [PDF]. https://nursesunions.ca/wp-content/uploads/2019/05/CFNU_climatechange-web.pdf

21.

Canadian Nurse Educators Institute [CNEI]. (n.d.). Building climate change competencies among baccalaureate nursing students. [Online]. https://cnei-icie.casn.ca/our-programs/past-webinars-courses/building-climate-change-competencies-among-baccalaureate-nursing-students/

22.

Chen

M. J.

Price

A. M.

(2020). Comparing undergraduate student nurses' understanding of sustainability in two countries: A mixed method study. Nurse Education Today, 88, 104363. https://doi.org/10.1016/j.nedt.2020.104363

23.

Collins

Hewer

(2014). The impact of the Bologna process on nursing higher education in Europe: A review. International Journal of Nursing Studies, 51(1), 150–156. https://doi.org/10.1016/j.ijnurstu.2013.07.005

24.

Costello

Abbas

Allen

, et al. (2009). Managing the health effects of climate change. Lancet, 373, 1693–1733. https://doi.org/10.1016/S0140-6736(09)60935-1

25.

Cruz

J. P.

Felicilda-Reynaldo

R. F. D.

Alshammari

Alquwez

Alicante

J. G.

Obaid

K. B.

Rady

H. E. A. E. A

Qtait

Silang

J. P. B. T.

(2018). Factors influencing Arab nursing students’ attitudes toward climate change and environmental sustainability and their inclusion in nursing curricula. Public Health Nursing, 35(6), 598–605. https://doi.org/10.1111/phn.12516

26.

Dalapati

Nick

S. E.

Chari

T. A.

George

I. A.

Hunter Aitchison

MacEachern

M. P.

, …, Muzyk

(2023). Interprofessional climate change curriculum in health professional programs: A scoping review. Education Sciences, 13(9), 945. https://doi.org/10.3390/educsci13090945

27.

Demorest

Spengeman

Schenk

Cook

Weston

H. L.

(2019). The nurses climate challenge: A national campaign to engage 5,000 health professionals around climate change. Creative Nursing, 25(3), 208–215. https://doi.org/10.1891/1078-4535.25.3.208

28.

Diallo

Roberge

Bérubé

Audate

P. P.

(2023). Integrating climate change into nursing curricula and continuing education: A scoping review protocol. BMJ open, 13(1), e068520. https://doi.org/10.1136/bmjopen-2022-068520

29.

Divakaran

Lembeck

Kerr

Calmus

Potter

(2016). Nurses see “the big picture”: Addressing climate change as a social determinant of global health. Creative Nursing, 22(4), 243–248. https://doi.org/10.1891/1078-4535.22.4.243

30.

Eckelman

M. J.

Sherman

J. D.

MacNeill

A. J.

(2018). Life cycle environmental emissions and health damages from the Canadian healthcare system: An economic-environmentalepidemiological analysis. PLOS Medicine, 15(7), e1002623. https://doi.org/10.1371/journal.pmed.1002623

31.

Eide

Odom-Maryon

(2019). Environmental and climate change initiatives in nursing education. Annual Review of Nursing Research, 38, 131–144. https://doi.org/10.1891/0739-6686.38.131

32.

Freifeld

A. G.

Todd

A. I.

Khan

A. S.

(2023). The climate crisis and healthcare: What do infection prevention and stewardship professionals need to know? Antimicrobial Stewardship & Healthcare Epidemiology, 3(1), e136. https://doi.org/10.1017/ash.2023.170

33.

Gosselin

Bustinza

Bélanger

(2021). Les changements climatiques-Abrégé à l'intention des professionnels de la santé. Institut national de santé publique du Québec (INSPQ). https://www.inspq.qc.ca/sites/default/files/publications/2777-changements-climatiques-abrege-professionnels-sante.pdf

34.

Griffin

M. T. Q.

Alfes

C. M.

Chavez

E. E.

Lynn

K. A.

Rafferty

M. A.

Fitzpatrick

J. J.

(2022). Incorporating climate change into doctor of nursing practice curricula. Journal of Professional Nursing, 42, 156–161. https://doi.org/10.1016/j.profnurs.2022.06.008

35.

Health Care Climate Council. (2020, July). Climate Action: A Playbook for Hospitals. https://climatecouncil.noharm.org/

36.

Intergovernmental Panel on Climate Change [IPCC]. (2023). Sections. In Core Writing Team , Lee

Romero

(Eds.), Climate change 2023: synthesis report. contribution of working groups I, II and III to the sixth assessment report of the intergovernmental panel on climate change (pp. 35–115). IPCC. https://doi.org/10.59327/IPCC/AR6-9789291691647

37.

International Council of Nurses [ICN]. (2018). Nurses, climate change and health. [PDF]. https://www.icn.ch/sites/default/files/inline-files/ICN%20PS%20Nurses%252c%20climate%20change%20and%20health%20FINAL%20.pdf

38.

Kalogirou

Dahlke

Davidson

Yamamoto

(2020). Nurses’ perspectives on climate change, health and nursing practice. Journal of Clinical Nursing, 29(23-24), 4759–4768. https://doi.org/10.1111/jocn.15519

39.

Kerr

Nerbonne

J. F.

Potter

(2019). Sparking a movement for a healthy climate through leadership development. Creative Nursing, 25(3), 216–221. https://doi.org/10.1891/1078-4535.25.3.216

40.

Leffers

Butterfield

(2018). Nurses play essential roles in reducing health problems due to climate change. Nursing Outlook, 66(2), 210–213. https://doi.org/10.1016/j.outlook.2018.02.008

41.

Leffers

Levy

R. M.

Nicholas

P. K.

Sweeney

C. F.

(2017). Mandate for the nursing profession to address climate change through nursing education. Journal of Nursing Scholarship, 49(6), 679–687. https://doi.org/10.1111/jnu.12331

42.

Lesk

Rowhani

Ramankutty

(2016). Influence of extreme weather disasters on global crop production. Nature, 529(7584), 84–87. https://doi.org/10.1038/nature16467

43.

Levac

Colquhoun

O'Brien

K. K.

(2010). Scoping studies: Advancing the methodology. Implementation Science, 5(1), 1386. https://doi.org/10.1186/1748-5908-5-69

44.

Lilienfeld

Nicholas

P. K.

Breakey

Corless

I. B.

(2018). Addressing climate change through a nursing lens within the framework of the united nations sustainable development goals. Nursing Outlook, 66(5), 482–494. https://doi.org/10.1016/j.outlook.2018.06.010

45.

Liu

Varghese

B. M.

Hansen

Zhang

Driscoll

Morgan

, …, Bi

(2022). Heat exposure and cardiovascular health outcomes: A systematic review and meta-analysis. The Lancet Planetary Health, 6(6), e484–e495. https://doi.org/10.1016/S2542-5196(22)00117-6

46.

Lopez-Medina

I. M.

Álvarez-Nieto

Grose

Elsbernd

Huss

Huynen

Richardson

(2019). Competencies on environmental health and pedagogical approaches in the nursing curriculum: A systematic review of the literature. Nurse Education in Practice, 37, 1–8. https://doi.org/10.1016/j.nepr.2019.04.004

47.

McDermott-Levy

Jackman-Murphy

K. P.

Leffers

J. M.

Jordan

(2019). Integrating climate change into nursing curricula. Nurse Educator, 44(1), 43–47. https://doi.org/10.1097/NNE.0000000000000525

48.

Milton

C. L.

(2018). Will nursing continue as the most trusted profession? An ethical overview. Nursing Science Quarterly, 31(1), 15–16. https://doi.org/10.1177/0894318417741099

49.

Neal-Boylan

Breakey

Nicholas

P. K.

(2019). Integrating climate change topics into nursing curricula. Journal of Nursing Education, 58(6), 364–368. https://doi.org/10.3928/01484834-20190521-09

50.

Nicholas

P. K.

Breakey

(2017). Climate change, climate justice, and environmental health: Implications for the nursing profession. Journal of Nursing Scholarship, 49(6), 606–616. https://doi.org/10.1111/jnu.12326

51.

Nicholas

P. K.

Breakey

Tagliareni

Tuck

Neal-Boylan

Ladd

, …, Lussier-Duynstee

(2020). Advancing a school of nursing center for climate change, climate justice, and health. Annual Review of Nursing Research, 38(1), 145–158. https://doi.org/10.1891/0739-6686.38.145

52.

Seppänen

A. V.

(2024). The role of the health sector in tackling climate change: A narrative review. Health Policy, 105053. https://doi.org/10.1016/j.healthpol.2024.105053

53.

Ordre des infirmières et infirmiers du Québec [OIIQ]. (2019). Les impacts des changements climatiques sur la santé des populations et la pratique infirmière. [PDF]. https://www.oiiq.org/documents/20147/237836/5517-changements-climatiques-prise-position-web.pdf/5d120b3e-14af-8d01-16da-1b5664f57934

54.

Ordre des infirmières et infirmiers du Québec [OIIQ]. (2021a). Les changements climatiques et les soins infirmiers: De la connaissance à la pratique. Perspective Infirmière, 18(2), 64–72.

55.

Ordre des infirmières et infirmiers du Québec [OIIQ]. (2021b). Le rôle de la relève infirmière dans la lutte contre les changements climatiques. [PDF]. https://www.oiiq.org/documents/20147/1306159/cj-avis-changements-climatiques-20200217.pdf/4d1568c1-8864-f1f4-ba77-a0ad9765d421

56.

Parham

P. E.

Michael

(2010). Modeling the effects of weather and climate change on malaria transmission. Environmental Health Perspectives, 118(5), 620–626. https://doi.org/10.1289/ehp.0901256

57.

Polivka

B. J.

Chaudry

R. V.

Mac Crawford

(2012). Public health nurses’ knowledge and attitudes regarding climate change. Environmental Health Perspectives, 120, 321–325. https://doi.org/10.1289/ehp.1104025

58.

Richardson

Clarke

Grose

Warwick

(2019). A cohort study of sustainability education in nursing. International Journal of Sustainability in Higher Education, 20(4), 747–760. https://doi.org/10.1108/IJSHE-02-2019-0064

59.

Romanello

Di Napoli

Green

Kennard

Lampard

Scamman

, …, Costello

(2023). The 2023 report of the lancet countdown on health and climate change: The imperative for a health-centred response in a world facing irreversible harms. The Lancet, 402(10419), 2346–2394. https://doi.org/10.1016/S0140-6736(23)01859-7

60.

Schenk

E. C.

Cook

Demorest

Burduli

(2021). Climate, health, and nursing tool (CHANT): Initial survey results. Public Health Nursing, 38(2), 152–159. https://doi.org/10.1111/phn.12864

61.

Silva

R. A.

West

J. J.

Lamarque

J. F.

Shindell

D. T.

Collins

W. J.

Faluvegi

, …, Zeng

(2017). Future global mortality from changes in air pollution attributable to climate change. Nature Climate Change, 7(9), 647–651. https://doi.org/10.1038/nclimate3354

62.

Tiitta

McDermott-Levy

Turunen

Jaakkola

Kuosmanen

(2021). Finnish nurses’ perceptions of the health impacts of climate change and their preparation to address those impacts. Nursing Forum, 56(2), 365–371. https://doi.org/10.1111/nuf.12540

63.

Tricco

A. C.

Lillie

Zarin

O'Brien

K. K.

Colquhoun

Levac

, …, Straus

S. E.

(2018). PRISMA Extension for scoping reviews (PRISMA-ScR): Checklist and explanation. Annals of Internal Medicine, 169(7), 467–473. https://doi.org/10.7326/M18-0850

64.

United States Environmental Protection Agency [US EPA]

(2023). Global Greenhouse Gas Emissions Data.

65.

Valentine-Maher

S. K.

Butterfield

P. G.

Laustsen

(2018). Environmental health. Advances in Nursing Science, 41(1), 57–69. https://doi.org/10.1097/ANS.0000000000000194

66.

Ward

Heart

Richards

Bayliss

L. T.

Holmes

Keogh

Best

(2022). Reimagining the role of nursing education in emissions reduction. Teaching and Learning in Nursing, 17(4), 410–416. https://doi.org/10.1016/j.teln.2022.02.003

67.

Wasco

J. J.

(2019). Strategies for teaching online RN-to-BSN students the health impacts of climate change. Creative Nursing, 25(3), 1–8. https://doi.org/10.1891/1078-4535.25.3.e1

68.

Watts

Adger

W. N.

Agnolucci

Blackstock

Byass

Cai

Chaytor

Colbourn

Collins

Cooper

(2015). Health and climate change: Policy responses to protect public health. The Lancet, 386(10006), 1861–1914. https://doi.org/10.1016/S0140-6736(15)60854-6

69.

World Health Organization [WHO]. (2023). Climate change and health. https://www.who.int/news-room/fact-sheets/detail/climate-change-and-health

70.

Yang

Liu

Hess

Phung

Huang

(2019). Health professionals in a changing climate: Protocol for a scoping review. BMJ Open, 9(2), e024451. https://doi.org/10.1136/bmjopen-2018-024451

Climate Change Integration in Nursing Academic Curricula and Continuing Education: A Scoping Review

Abstract

Background and Purpose

Methods and Procedures

Results

Conclusions

Keywords

Background and Purpose

Methods and Procedures

Identification of the Research Question

Identification of Relevant Studies

Selection of Studies

Data Extraction

Analysis, Synthesis and Presentation of Results

Grey Literature Search

Results

Scientific Literature

Grey Literature

Characteristics of Selected Studies

Methods for Integrating Climate Change into Education

Impact on Students or Nurses

Discussion

Challenges

Recommendations

Limitations

Conclusions

Footnotes

Acknowledgements

Data Availability Statement

Declaration of Conflicting Interests

Funding

ORCID iDs

Author Biographies

References