Sustainability and nursing: an integrative literature review

Definitions used in the present study

For this review, we have taken the UN definition of sustainability as meeting the needs of the present without compromising the ability of future generations to meet their own needs, as set out in the Report of the World Commission on Environment and Development: Our Common Future (UN 1987) and global health as medical and health issues with global impact, in which its main task is to seek for global solutions to the issues with global health impact as set out in the Editorial Board Meeting of Global Health Research and Policy (Chen et al., 2020).

Search strategy and selection criteria

Databases were searched using keywords chosen according to the thesaurus Descriptors in Health Sciences (DeCS) and the thesaurus Medical Subject Headings. The pages of Associations and Official Bodies were searched for expert reports, documents and official reports of recommendations. The keywords chosen according to the terminology ‘Mesh’ and ‘Desh’, combined with Boolean operators, to search the databases were: ‘Sustainable development’, ‘Millenium Development Goals’ and ‘nurs*’. Although the term ‘Millenium Development Goals’ refers to an agenda that has ended in 2015, there are still papers addressing the achievements and challenges in the implementation of these goals. Therefore, we decided that the inclusion of this term would be appropriate. The search strategy was thus defined: (((‘sustainable development’ [All Fields] OR ‘millennium development goals’ [All Fields])) AND ‘nurs*’ [All Fields])) AND (y_5[Filter]). Papers published in the last 5 years in English and Spanish were included. Exclusion criteria were studies showing data before 2019 and, studies on non-health-related sustainability. A summary table of the search strategy is set out in Table 1.

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Table 1.

Search strategy.

Database	Strategy	Papers found	Selected papers (inclusion/exclusion criteria)	Items included
PubMed	((‘sustainable development’ OR ‘sustainable development goals’ OR ‘millennium development goals’) AND (‘nursing care’ OR ‘nurs*’))	868	412	9
Scopus		955	241	2
WoS		722	241	5
CINHAL		364	41	1

Source: Self-made.

Bold values: Integrative search between out using databases.

Study selection

The screening procedure was carried out in order to identify relevant studies based on the selection criteria. Firstly, duplicate publications were removed and then reviewers screened the references by title and abstract. Finally, texts were read in full, and those meeting eligibility criteria were included. All procedures were carried out by two reviewers independently and, if there was a disagreement, another reviewer was consulted. Zotero and Mendeley were used to process the bibliographic records.From a total of 2909 references, according to the inclusion and exclusion criteria 143 documents were selected based on title review. Abstracts were reviewed and 84 studies were identified for full text review by two reviewers. Seventeen papers were included in the study Figure 2. Flowchart for the inclusion of papers in the review.

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Figure 2.

Flowchart for the inclusion of papers in the review.

Data extraction

One reviewer was in charge of extracting and analysed the data from the papers, which was subsequently verified by another reviewer. Once the data had been extracted, a table was drawn up including authors, year, country, purpose of the study, methods and a summary of the major findings. The summary tables were thoroughly reviewed by all the reviewers independently, with critical discussions of the extracted data. This information is set out in Table 2 below.

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Table 2.

Results.

Author	Year/Country	Methodology	Goals	Main results	Categorisation of results
Ajuebor et al.	2019 Switzerland	Cross-sectional mixed methods study	Analyse the evolution of the WHO Member States in the implementation of the recommendations to strengthen nursing.	Data are reported on the implementation of new promising measures in nursing that encourage a future towards global health. Along this path, political literacy is a current challenge for nurses.	C
Brand et al.	2023 USA	Case study	Learn about a novel planetary health education resource for health professionals.	Focusing attention on indigenous knowledge is important to improve planetary education by connecting and translating it to nursing practice.	C
Chotchoungchatchai	2020 Thailand	Policy and practice report	Examine the potential and limitations of Primary Care (PC) in achieving the SDGs.	The variety of services, systematically addressing the broader determinants of health and fostering community co-creation are important means of PA to achieve global health.	A
Fields et al.	2021 Australia	Expert opinion/Commentary	Explore how critical pedagogy can provide a transformative framework for SDG education for nursing students.	With this educational methodology, nursing can progress by supporting students to recognise their position in society and empowering them to fight for social justice towards the achievement of the SDGs.	C
Hassmiller and Kuehnert	2019 USA	Editorial	Explore the potential and tools of nurses towards global well-being.	Nursing research is key to achieving the SDGs and must strengthen this, policies and associations between health professions, other sectors and the community to achieve them.	B
Li et al.	2021 China	Cohort study	Explore the relationship between the intention of green behaviour, it and how this influence can be improved in the health system.	The greater the presence of ethical leadership among nurses, the stronger the relationship between intentionality and actual ecological behaviour in achieving global health.	C
Mendes et al.	2020 Brazil	Documentary research	Analyse the guiding axes of nursing movements and their recommendations.	The challenges for global health and their socioeconomic implications demand that nursing be recognised, equipped and valued to meet current and future health demands.	B
Oerther et al.	2020 USA	Expert opinion/commentary	Expose the relationship between sustainability, inequalities and the nursing function.	The ideal nursing position allows you to mediate the path towards equity through the coordination of care, preventive care and social education.	A
Porta et al.	2019 USA	Expert opinion/Commentary	Compare traditional nursing training models with current ones and their notable initiatives focused on sustainability.	Interprofessional education, simulation and experiences abroad are positioned as new avenues for nursing training in sustainability.	C
Roca et al.	2019 Spain	Policy and Practice Report	Evaluate the evolution of climate change, its repercussions on health and the role of nursing in this regard.	The negative health consequences of climate change translate into an overwhelming increase in morbidity, demanding action from nurses.	A
Romanello et al.	2022 USA	Policy and Practice Report	Study the global burden of disease in relation to climate change and the health system’s actions to combat it.	Health impacts add additional pressure on health systems, requesting urgent adaptation among nursing professionals. However, the authorities are not responding to the necessary extent.	A
Rosa et al.	2019 USA	Expert opinion/Commentary	Expose the relevance of the nursing workforce in achieving the SDGs.	The holistic bio-psycho-social-environmental approach that encompasses the SDGs presents enormous opportunities for nursing, aligned with the founding philosophy and purpose of the profession.	B
Rosa et al.	2021 USA	Expert opinion/Commentary	Explore the political and professional leadership skills at the national level of Nursing.	More and more organisations recognise, support and invest in nursing to raise the level of political skills and achieve more resilient changes with the environment.	B
Rosa et al.	2021 USA	Discussion Paper	Know the current and emerging roles of nursing and midwives in sustainable development.	By focusing on social justice, environmental health and partnership-building, great health and sustainability results can be achieved.	B
Salvage	2020 Switzerland	Expert opinion/Commentary	Explore how global health is being addressed, its problems and consider the implications for nursing.	Greater training and representation in politics is necessary, so that nursing has a greater scope in the history of sustainable global health.	B
Upvall et al.	2019 USA	Expert opinion/Commentary	Explore the integration of the SDGs in nursing education with an international and national vision.	Real didactic and clinical experiences at the national and international level strengthen global vision and the acquisition of social values.	C
Wright et al.	2019 South Africa	Expert opinion/Commentary	Explore the implementation of the circular economy (CE) in low and middle income countries as a resource in health systems.	CE is positioned as a useful tool in health, it can help achieve the SDGs, but the negative implications for health and the protection of the most vulnerable must be assessed.	A

Category A: Sustainability in the health system and its influence on nursing professionals

Sustainability has become both a call to action and a form of progress; seeking to improve quality of life, promote intergenerational equity, and preserve the health of the environment. Within this context, the need to develop both technical solutions and to bring about changes in lifestyle and social practices is recognised.

To realise such a transformation, both individuals and communities must engage in a process that requires both learning and significant ‘unlearning’. Health systems, as both recipients and contributors to the effects of climate change, must incorporate certain concepts and processes into their practice to reduce these detrimental impacts, while fulfilling their role in educating society. Given that the mission of the health sector is to protect and promote health, it has a responsibility to fulfil the Hippocratic oath to ‘do no harm’ in relation to its own climate footprint. It must also influence other sectors to take similar actions (Romanello et al., 2022).

The effects of climate change on health exacerbate other existing crises, which may be perceived as more immediate and divert attention and resources needed to address climate change. Among the major changes taking place that directly affect health are alterations in the distribution and transmission of vector-borne, food-borne, and waterborne infectious diseases. There is also an increase in temperatures and, as a result, heat waves, which are associated with an increased risk of acute kidney injury, worsening cardiovascular and respiratory diseases, increased non-accidental deaths, heat stroke, pregnancy complications, mental health problems, and sleep disorders. Another group of diseases that may increase with global warming are mental health disorders, as they are influenced by geographical, social, environmental, financial, and political factors and any climate impact on physical health also becomes a risk factor for mental health (Hassmiller and Kuehnert, 2020).

According to the results of the WHO Global Health and Climate Change Survey 2021, only about half of the countries (49 out of 95) report having a national plan focused on health and climate change. Within this group, 62 countries (65%) report a moderate or lower level of implementation, while 67 countries (70%) cite insufficient funding as the main barrier to progress. The lack of adequate adaptation to climate change has exposed the vulnerability of health systems to climate-related health risks. Currently, only 48 out of 95 countries have assessed their requirements for adapting to climate change, and only 63% reported a high or very high level of implementation in health emergency management at 2021 (Oerther and Rosa., 2020).

Health as an SDG aims to ensure healthy lives and promote well-being for all at all ages, so it is clear that nursing has a responsibility in relation to this goal, as well as other goals relating to education and poverty. The rationale for nurses’ contribution to achieving the SDGs is based on four main reasons. The first is that nurses inherently care for others; the second that the SDGs present the opportunity to apply knowledge as nurses to create a healthier and better world; the third reason is that change is possible - improvements in life expectancy, lower child mortality rates, higher rates of child schooling, reduction of extreme poverty or improved access to safe water and sanitation are all achievable with such action; the fourth reason is that it is about everyone’s health, achieving these goals will improve the lives of people in the communities and families closest to them and even one’s own health. There are a variety of ways to enhance and improve the health and well-being of individuals and populations, whether in clinical practice, working with individuals and their families, through community support and development programmes, national health initiatives and policies or international commitments, and agreements to improve access and quality of healthcare. Nurses can play an important role at all levels, whether providing care, conducting accurate needs assessment, designing the clinical or policy response or evaluating outcomes and effectiveness (Oerther and Rosa, 2020; Romanello et al., 2022).

On the other hand, the healthcare sector, as a consumer of a large amount of primary resources such as water, energy, metals, and chemicals; and a producer of significant volumes of waste, must implement measures to gain efficiency and reduce negative effects. The circular economy (CE) is the antithesis of the linear scheme that is prevalent in the current health sector and is a great ally on the road to sustainability. However, the very connotations that surround healthcare practice, such as hygiene or safety, make it difficult to implement, and it is mostly used in those cases where the availability of material goods is scarce, requiring this ‘circularity’ in these countries. But it is because of this need that CE is not carried out safely because of poverty and unemployment, with no regulation to protect workers from the risks that arise in the process. If a cross-sectoral approach is adopted, CE aligns with other SDGs such as: Responsible Production and Consumption (SDG 12), Sustainable Cities and Communities (SDG 11), as well as SDG 6 (Clean Water and Sanitation), SDG 7 (Clean and Affordable Energy), and SDG 15 (Life of Terrestrial Ecosystems). Similarly, with the necessary research, it can generate indirect synergies and accelerate the achievement of important targets, such as fostering economic development and employment (SDG 8), eradicating poverty (SDG 1) and combating hunger (SDG 2). Thus, some of the measures could include extending the useful life of medical equipment, valuing its repair instead of its replacement, another measure could be to change the concept of ‘ownership’ to ‘use’ in health services, which would allow the acquisition of certain equipment only when necessary and would save the cost of maintaining, preserving and updating equipment, saving and using fewer resources (Wright et al., 2019).

Previous studies agree that climate change affects global health through multiple direct and indirect pathways, and each year, weather- and climate-related disasters cause thousands of deaths worldwide and contribute to the global burden of disease. Di Napoli et al. (2022) and Karliner et al. (2019) agreed with our findings that as understanding and awareness of the health dimension of climate change grows, there is greater demand for feasible and efficient tools that can inform climate change mitigation and adaptation strategies to deliver human health benefits at all levels.

Along the same lines, Gascóns (2011) showed how primary care is still far from achieving this central role in the system in order to guide towards a more sustainable process. This slow process is marked by the decrease in public spending on primary care and the parallel increase in specialised care, the lack of a global vision, and the conflicts in incorporating new demanding criteria of productivity and efficiency. In addition to the structure of management, functional organisation and financing of public provision, rather than the achievement of high results through optimal use of resources.

One of the aspects on which our review focuses is the influence that sustainability has on nursing practice and how this performance mediates within the system. In two previous meta-analyses, Lambrinou et al. (2012) in reference to heart failure and Tshiananga et al. (2012) in diabetes, coincidentally reflected how the performance of nurses in these pathologies that generate high costs in the health system, allowed favourable results regarding the impact of nurses leading care scenarios and efficiency.

Another of the issues addressed by our study is sustainability within the healthcare system itself. In this regard, De Diego et al. (2023) concluded that the CE is a great opportunity to bring healthcare systems closer to this goal of resilience.

However, Espaliaut (2018) refuted our results, arguing that in a sector where technical advances and being at the forefront of technology are privileged advantages, the consideration of this circular resource is difficult, coupled with the low economic attractiveness it generates and the impediments of the pharmaceutical industry.

Category B: Main difficulties to incorporate sustainability into nursing practice and actions to overcome them

Nursing, which represents 59% of the global healthcare workforce, with approximately 27.9 million professionals, is rooted in a concern for social well-being, and the ability to provide holistic care is a quality of these professionals, positioning them as key players on the path to achieving the 2030 Agenda for Sustainable Development. This agenda is the United Nations’ global action plan, adopted in 2015 by all UN member states, to guide progress towards sustainability. The SDGs provide an overarching global framework for health practice and policy, driving the activity of numerous global bodies, thus placing them in a politically contested and exponentially expanding terrain of complexity. At the interface between the community and the health system itself are nurses, who see first hand how policy affects people and who have crucial information to inform change. However, the data are not received with the enthusiasm that one might expect among policymakers, and competencies in this area are not consistently developed (Salvage and White, 2020However, the need to address acute problems, ongoing and future staff shortages, and rising demands is making the vital contribution of nursing more evident than ever. (Mendes et al. 2020; Rosa et al., 2021; Salvage and White, 2020).

Indeed, one of the expected competencies of the nursing profession is such advocacy to address instability and human rights abuses. Hassmiller and Kuehnert (2020) emphasised that if nurses are to be aware of their value in achieving this ambitious agenda, education must provide tools for knowledge and understanding of the interconnectedness of all levels for global well-being. Rosa et al. (2019) proposed that such education should be based on skills such as: civic and political skills to participate in decision-making, fostering self-awareness to prevent the emergence of exclusionary nationalism, critical thinking to question unfounded assertions, and media and information literacy to critically evaluate information sources and participate responsibly in digital citizenship. Thus, there is a need to include in nursing education curricula the concepts of social justice and global citizenship, as well as clinical experiences that increase community engagement (Venkatasubramanian 2022). Integrating such academic dialogue and practice rooted in global society avoids ‘privileging’ the Western lens and empowers nursing advocacy defined by the ethic of social equity and inclusion (Rosa et al., 2019). The promotion of a culture of health must be based on reliable evidence, which must be the product of increased research, centred on communities and patients (Hassmiller and Kuehnert, 2020). To this end, the creation of a ‘policy track’ could be positioned as an innovative way to promote leadership among nursing professionals, so that they become better trained in research in schools and eligible for participation at policy-making tables, where they can implement such evidence to improve lives. Within this it must be recognised that often the policies that most affect health are not always health policies (Salvage et al. 2020).

Despite the role that nurses have as the largest group of health professionals, daily personal or professional actions alone will not be enough, but policy change is needed at all levels, from local to global, and forceful action is required (Hassmiller and Kuehnert, 2020). Global policies are mostly set by large organisations and agencies. These are then policies that then guide local, regional and global levels, and it is in these spaces that nursing knowledge is excluded from the comprehensive framework and planning despite having the most substantial scope. ithout preparing groups of nurses with the capacity to take on leadership roles in aspects of clinical practice as well as in the social justice arena immersed in politics and away from medical care, the achievement of the SDGs will be unfeasible. Thus, new ways of ensuring the contribution of the profession can be explored, for example, by integrating the workings of politics and how to work in those spheres involved, as a curricular requirement at all levels of education, or by offering opportunities to experience policy forums and interact with Non-Government Organisations. Partnerships with leaders in other sectors, such as education, community development, transport or the environment, will be necessary. Health promotion, and therefore primary care, will be more in demand and will require more roles and cooperation, including with patients and concerned citizens. Contributions that nurses and midwives can make in their localities include encouraging change through health promotion and demonstrating its realisation in reality, ranging from the growth of nurse-led Non-Communicable Diseases clinics to ‘reverse innovation’ (the process where an innovation is first developed and implemented in a low- or middle-income country, often out of necessity and resource constraints, and is later adapted and applied in high-income countries between staff in different countries (Rosa et al., 2019).

Another way to engage with global health may be through disseminating ideas and achievements at conferences or debates, after conducting research, or within your own work circle, forming groups that enable knowledge sharing with each other and with external peers, or learning what we have within our regional, national or local organisation so that we can take action (Salvage and White, 2020). The Global Nursing Leadership Institute, which identifies and advocates for the role of nursing according to health priorities, has carried out several projects to achieve the SDG targets, including the initiative to supply and accommodate exponential vaccination that took place during COVID-19, which focused on mitigating epidemics and pandemics caused by communicable diseases (targets 3.3 and 3.8). It lobbied state-level governors to implement emergency measures to reduce inequalities in vaccinating people. Another contribution was based on policy coherence by mediating to make policies more congruent with reality, a need reflected in SDG 17- Partnerships for the Goals, aiming to strengthen global conversations that integrate nursing practice (Rosa et al., 2021).

The promotion of palliative care advocacy articulated in target 3.8 of the SDGs (Achieve universal health coverage, including financial risk protection, access to quality essential health-care services, and access to safe, effective, quality and affordable essential medicines and vaccines for all) has also been a priority due to the increase in the universal burden of suffering in recent years, which has proposed palliative nursing experts as agents to address the growing inequalities in access and establish it as a component of universal health coverage (Rosa et al., 2021). In addition, various actions have been carried out by multiple organisations such as the ICN, which developed core competencies in disaster management to guide nurses before climatic emergencies, or the Alliance of Nurses for Healthy Environments (ANHE) and Healthcare Without Harm, which seeks to educate nurses about the importance of palliative care for the health and well-being of patients. About 50,000 nurses in the United States with the Nurses Climate Challenge, as well as ANHE and Project Drawdown (a nonprofit organization and research initiative that identifies, evaluates, and promotes the most effective solutions to stop climate change and achieve “drawdown” — the point at which levels of greenhouse gases in the atmosphere stop climbing and begin to decline) partnered to launch Nurses Drawdown (2020), an initiative that primarily seeks to decrease GHG emissions. Nursing Now (2018–2021) aims to improve the quality of healthcare globally (Mendes et al., 2020). This campaign was based on a series of documents showing the relevance of nursing in global health, positioning it as an investment and not as a cost for institutions, knowing the opposite priority of the administration based on minimising costs without modifying the quality of care (Mendes et al., 2020).

Among the challenges facing nursing in the application of sustainability in daily practice, Aguirre Raya (2020) pointed to training, working conditions and health policies, which aligns with our results. In the current global fabric, these axes limit the participation of nursing in the integration of these changes, despite its key position in the health system.

Similarly, Álvarez et al. (2017) agreed that in order to achieve nursing leadership in the field of sustainability and health systems, environmental health research must be consolidated, management plans or policy changes that support these results must be promoted, and training in this area must be improved, given that there are major shortcomings in teaching practice and the incorporation of environmental knowledge. Other studies point to further current problems facing the profession, including lack of staff and resources, limited potential for contribution and difficulties in recruitment, retention and re-entry into the profession (All-Party Parliamentary Group on Global Health, 2016).

Finally, the actions carried out to overcome these difficulties are also analysed in our study, in accordance with the Spanish Nursing Code of Ethics, nurses must form part of the councils in which health policies are established (Organización Colegial de Enfermería, 1973). Thus, and in favour of what is indicated in our results, there are numerous actions initiated and with promising results in this line, both carried out by nurses, as well as others in which their participation has been fundamental (for example the United Kingdom All-Party Parliamentary Group (APPG) on Global Health, 2016).

Category C: Nursing education in sustainability

Nursing students must be knowledgeable about global issues and interconnectedness at the local level, redefining the personal and professional self, then expanding with critical education, so that despite not knowing the context of others they possess the ability to question their own assumptions and invite ethical action through reflection.

Studies agree that students are currently not trained and skilled to think critically and solve complex real-life situations, which is why Venkatasubramanian (2022) addressed new concepts focused on encouraging students to engage with the well-being and sustainability issues identified in their own settings, reflecting on these in search of practical solutions. This supports the position of Daza de Caballero et al. (2005), explored the need to provide personalised education to nursing professionals given the little attention given to the acquisition of knowledge and competencies in response to global challenges within traditional education, with regard to not harming the environment so that it does not harm current and future generations as a goal of the profession.In view of the need for improvements in universities given their link with the generation and dissemination of knowledge about sustainability and their critical and constructive contribution to sustainable development, the Conference of Rectors of Spanish Universities (CRUE, 2020), in accordance with the Action Plan for the Implementation of the 2030 Agenda, presents a series of actions that incorporate participatory teaching methods and new skills in the curricula, which increase awareness and debate on the SDGs in the classroom, incorporating them as a university quality criterion. In line with the new methods that are emerging, we find scenario-based learning as a great ally in this curricular innovation. Richardson et al. (2019) demonstrated how this methodology brings students closer to reality and the possible challenges of their work. Through pedagogical approaches, systemic thinking is created that integrates climatic events and threats to resources used in daily practice into nursing education, leading to significant changes in the attitudes of these future professionals and the relevance of these issues.