The U.S. health care system's impact on the environment has resulted in potentially harmful public health effects (Eckelman & Sherman, 2016). The authors believe that quantifying the pollution and disease burden caused by the health care sector is a necessary step in improving the quality and safety of health care practices. According to the World Health Organization (2018) statistics, 23% of all global deaths and 11% of U.S. deaths during 2012 could be attributed to people living and working in unhealthy environments. These statistics represent disease outcomes that could be avoided by reducing pollution to the air, soil, and water caused by chemical or biological agents, ultraviolet and ionizing radiation, and climate changes. It is estimated that hospital beds produce 29 pounds of waste per occupied bed per day, which means U.S. hospitals produce more than 5 million tons of waste per year (Practice Greenhealth, 2019). In addition, pharmaceutical and biological products requiring complex manufacturing produce potentially toxic by-products that can lead to hazardous solid, air, and water emissions (Jameton & Pierce, 2001). As far back as Florence Nightingale and Lillian Wald, nurses have recognized their role in limiting the influence of environmental factors on the health of individuals, families, communities, and populations. Additionally, provision four of the American Nurses Association (ANA) Principles of Environmental Health for Nursing Practice states that healthy environments are sustained through multidisciplinary collaboration (ANA, 2007). As frontline health care workers, nurses have an important role as environmental activists.
Sustainability in Nursing Education
In 1995, the Institute of Medicine (IOM) presented the need to develop nursing competencies in environmental health and recommended that these concepts be included at all levels of nursing education (IOM, 1995). Four key competencies were identified: (a) knowledge and concepts; (b) assessment and referral; (c) advocacy, ethics, and risk communication; and (d) legislation and regulation (Larsson & Butterfield, 2002). Moreover, the International Council of Nurses (ICN) encouraged national nurses' associations, in collaboration with their respective governments, to include the concept of sustainability in nursing practice curricula and continuing education for practicing nurses (ICN, 2018).
The ANA principles of environmental health state that knowledge of environmental health concepts is essential to nursing practice (ANA, 2007). This principle also calls for nurse educators to ensure that environmental health competencies are incorporated into both basic and advanced nursing curricula. Furthermore, the ANA Scope and Standards of Practice 3rd edition (ANA, 2015b) addresses environmental health in standard 17. Although the ANA Code of Ethics (2015a) does not explicitly address sustainability as an ethical duty, it can be deemed a moral value and principle that arises out of a professional standard (Riedel, 2015). Specifically, provision 6.3 emphasizes nurses' right to work in an environment that is safe for themselves and others (ANA, 2015a).
The need to include environmental sustainability in nursing education is well documented (Goodman, 2011; McDermott-Levy et al., 2019; Richardson et al., 2017). The link between environmental sustainability, climate change, and positive health outcomes makes sustainability an important topic for educators to include in nursing curricula. According to Anåker and Elf (2014), the defining attributes are ecology, the environment, the future, globalism, holism, and maintenance. The authors define antecedents to sustainability as environmental awareness, confidence in the future, responsibility, and willingness to change.
A variety of social media techniques have been identified that could help incorporate sustainability into the curriculum. Lopez-Medina et al. (2019) found that case studies, scenarios, role-play, simulations, group discussion, social media, and debates were helpful in this endeavor. Grose and Richardson (2016) concluded that delivering an evidence-based sustainability-teaching scenario to nursing students in a clinical session was relevant and meaningful to nursing practice and concluded that this had the potential to become best practice. Richardson et al. (2016) determined that social media, in the form of Twitter, was an effective way to engage students in discussion on sustainability. A study on the use of digital educational materials relevant to environmental sustainability and health in nursing education found that the overall outcome was positive, with students giving high scores to the education materials (Álvarez-Neito et al., 2018). Garrity et al. (2014) reviewed blogging as a pedagogical tool in nursing education. The authors indicated that blogging applies the social aspects of learning and could enhance knowledge acquisition and provide stimulating learning opportunities. Roland et al. (2011) offered some additional support for using blogs to store and share nursing education knowledge and improve analytical thinking and communication.
After reviewing the literature and our current learning management system (Blackboard Learn™), we determined that blogging was the most appropriate vehicle for introducing sustainability to our students. This format allows students to be creative and provides them with the freedom to develop content over multiple blog postings. It also provides them with a balance between completing a formally written assignment and the opportunity to express themselves and their ideas about current issues in a low-risk environment. Blogging also provides students in higher level courses with the opportunity to create. As indicated in the revised Blooms' Taxonomy, creating involves actions such as designing, constructing, generating, planning, and producing (Anderson et al., 2001).
Study, Design, Setting, and Sample
This pilot study followed a pretest/posttest design. The aim of this study was to elicit student attitudes related to sustainability in health care. A secondary aim was to investigate the changes to student attitudes based on the impact of a learning module and blogging activity. The research took place at a public university located in the midwestern region of the United States. Eligible subjects were RN-to-Bachelor of Science in Nursing (BSN) students enrolled in the final program course that synthesizes nursing knowledge. All students in the course completed the faculty-created sustainability in nursing learning module. Participation in the study was voluntary. This study was approved by the university institutional review board as exempt research.
The Sustainability Attitudes in Nursing Survey (SANS-2; Richardson et al., 2019) questionnaire was used in this study. The pretest and posttest consisted of nine 7-point Likert scale questions (1 = strongly disagree to 7 = strongly agree). The SANS-2 questionnaire has been used internationally and has demonstrated good psychometric reliability (Cronbach's alpha ranges from .82 to .86) and validity (Richardson et al., 2016). Richardson et al. used an earlier version of the SANS-2 to assess the dimensionality of the SANS. A principal component analysis suggested one or two components recovered 55% and 70% of the variance in the original correlation matrix, respectively. Because the second component only explained 15% of the variance, the authors elected to move forward with the unidimensional model. The research using the SANS-2 shows that nursing students and professionals change their attitudes toward sustainability in a positive direction through education and raising awareness (Richardson et al., 2016; Richardson et al., 2019).
The current research assumed the unidimensional model and investigated the change in individual sustainability attitude items using a paired t-test procedure. Effect sizes (Cohen's d) were calculated for variables with statistically significant t values. Following the work of Richardson et al., we focused on the individual items of the SANS-2 to identify the attitudes most impacted by the intervention.
Following the identification of a gap in sustainability education within the online RN-to-BSN program curriculum, faculty studied the literature and then developed the sustainability in nursing learning module that was added to the program's synthesis course. The project spanned 4 weeks and accounted for approximately 25% of the total grade. Students were supplied with various learning materials to help them learn and understand the importance of sustainability in nursing. Video presentations by faculty and leaders in health care sustainability were uploaded to the learning module. Printed materials from the ANA Code of Ethics (2015a), ANA Standards of Practice (2015b), ANA Principles of Environmental Health (2015c), and Alliance of Nurses for Healthy Environments (Leffers et al., 2016), and the Hazardous Chemicals in Health Care (Wilding et al., 2009) were provided. A sustainability in nursing workplace assessment table was developed to help students to gather information about their practice environment. Student learning activities incorporated the creation of four blog posts based on the learning materials and their clinical practice observations. The blog posts were shared among students who were then asked to comment on their classmates' posts.
The course faculty recruited students to complete the pre-test and posttest through course announcements, videos, and email correspondence. Data collection took place during the 2019 winter and spring semesters. The pretest was completed prior to exposure to the online learning materials, and the posttest was completed at the end of the learning modules. Students completed both surveys via online Qualtrics® links.
Nursing students enrolled in two sections of the synthesis course participated in the sustainability project. Ninety-one students agreed to participate; 91 (100%) completed the pre-test, and 89 (97%) completed the posttest. Only participants with both pretest and posttest data were included in the data analysis. Participants had higher average scores on the post-test for all variables except one (“I feel unable to challenge unsustainable practices in my work environment”). The lower score on this item suggested that respondents appeared to have identified ways to challenge unsustainable practices in their work environments after the intervention.
It is noteworthy that the standard deviations of the difference scores were highly variable. The items about workplace practices showed the highest variance, suggesting that the work environment requires special attention in planning future sustainability interventions.
Paired t Test
Paired t-test results are presented in Table 1. Statistically significant differences were found on all nine items in the pretest and posttest scores. This finding suggests that the intervention likely contributed to improved attitudes about sustainability in the workplace. The effect size measures the magnitude of difference between the pretest and posttest items (effect sizes ranged from 0.285 to 0.864). Thematically, the large effects were obtained from the items that focus on the specific issue of climate change—that it is important and should be a part of the nursing curriculum. The items with a moderate effect were those that focus on the importance of sustainability, applying sustainability, and being aware of and challenging unsustainability practices. Finally, the items with low effect include those that address applying sustainability at one's home and being unable to challenge sustainability practices at work.
Paired Sample t -Test Results
The reliability of the nine-item sustainability survey was assessed using Cronbach's alpha. The pretest reliability equals .762 (n = 91), and the posttest reliability equals .801 (n = 89).
Results from the statistical analysis indicated that the intervention contributed to nurses in the RN-to-BSN program developing new and positive attitudes toward sustainability in the workplace. There was a significant increase between pretest and posttest scores for eight of the nine survey items. The ninth item, which assessed the inability to challenge sustainability practices at work, decreased significantly, indicating a positive attitude change. In their studies, Richardson et al. also found significant differences between pretest and posttest scores using the SANS and SANS-2 questionnaires (Richardson et al., 2015; Richardson et al., 2017). These differences resulted in positive attitude changes toward sustainability among nursing students (Richardson et al., 2017; Richardson et al., 2019). Although teaching strategies were different, the overall results revealed similar positive changes in student attitudes regarding sustainability. These results indicate that incorporating various forms of instruction on sustainability content can lead to positive student change in this area.
Our results confirmed the use of blogs as an effective teaching strategy. Students responded favorably to blogs as a learning activity, which was confirmed in course evaluations.
In evaluating the effect sizes, the greatest effect in attitude change occurred with those items that focused on raising awareness of the importance of sustainability (items 1, 2, 3, 4, 7, and 8). The items with the least effect were attitudes that reflect personal agency (items, 5, 6, and 9). This may reflect a conflict between sustainability as a philosophical or belief position and what an individual is willing to do to promote sustainability. A possible perspective to foster and encourage change would be to use this dialectic to highlight an individual's cognitive dissonance between their personal philosophy and what behaviors they can enact to develop sustainability in health care.
This pilot study had some limitations. First, these findings are not generalizable beyond the small study sample from one university. Additionally, self-report surveys have the potential for social desirability bias. The researchers attempted to minimize this risk by giving students an anonymous survey link and encouraging them to provide honest feedback. Additionally, the two sections of the course were taught by different faculty, which could result in variances in pedagogical styles. To minimize such differences, both instructors used the same objectives, assignments, and grading rubrics in their sections.
The results of this pilot study are promising because the brief intervention had a significant effect on practicing nurses' attitudes about sustainability in their work environments. More research is needed to confirm the extent of these results. A psychometric evaluation of the tool in the United States is needed and currently underway. Additionally, research on the lasting effects of the intervention needs to be completed. Finally, to understand different student perspectives, additional studies should include other cohorts of nursing students, such as prelicensure or graduate students. With these future research aims identified, results from this survey can serve as a springboard for future sustainability studies focusing on the nursing profession and its relationship to the environment.
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Paired Sample t -Test Results
|Item||Premean||Postmean||Pre-Post Difference Mean||Difference, SD||95% CI||t Value||Significance||Cohen's d|
|1. Climate change is an important issue for nursing and health care.||5.13||6.10||−0.98||1.36||−1.27||−0.69||−6.72||.000||0.826|
|2. Issues about climate change should be included in the nursing curriculum.||4.67||5.82||−1.15||1.43||−1.45||−0.85||−7.55||.000||0.864|
|3. Sustainability is an important issue for nursing.||5.73||6.39||−0.66||1.29||−0.93||−0.38||−4.78||.000||0.600|
|4 . Sustainability should be included in nursing. a||5.63||6.24||−0.61||1.36||−0.90||−0.32||−4.18||.000||0.542|
|5. I apply sustainability principles at home.||5.53||5.83||−0.30||1.15||−0.54||−0.05||−2.42||.018||0.285|
|6. I apply sustainability principles in my nursing practice.||5.14||5.65||−0.51||1.24||−0.77||−0.25||−3.87||.000||0.438|
|7. I am aware of unsustainability practice in my work environment.||5.11||5.89||−0.77||1.84||−1.16||−0.38||−3.95||.000||0.570|
|8. I challenge unsustainability practice in my work environment.||4.38||5.10||−0.73||1.70||−1.09||−0.37||−4.01||.000||0.540|
|9. I feel unable to challenge sustainability practice in my work environment.||4.07||3.59||0.48||1.97||0.06||0.89||2.28||.025||0.304|