Sustainable nursing practice: the environmental impact of healthcare

Introduction

Climate change has been identified as the greatest threat to human health this century (Watts et al, 2019). Extreme weather events such as flooding, wildfires and heatwaves are increasing, contributing to higher levels of air pollution, water contamination and poor sanitation globally. The impact of these events on health is often felt by more vulnerable communities and individuals, such as older people and infants in lower and middle-income countries, with an exacerbation of chronic respiratory and cardiac disease, as well as water-borne infectious diseases (Watts et al, 2019).

In the UK, increased mortality because of air pollution and poor living conditions prompted the Nursing and Midwifery Council (2024) to release a position statement on its commitment to environmentally sustainable practice. Travel conducted by the NHS is a major contributor to air pollution, which is leading to an increased incidence of the UK’s biggest causes of morbidity, including stroke, cancer, respiratory and cardiovascular diseases (NHS England, 2023). Organisational-level change is required to move away from a reliance on fossil fuels to heat hospitals, improve the energy efficiency of existing buildings, switch over to electric vehicles and use more sustainable procurement and waste disposal streams (NHS England, 2022). Further efforts from specialities that contribute the most to NHS carbon emissions, such as anaesthetics and pharmaceuticals, are required for this large-scale systems approach to succeed.

Background and key terms

If healthcare were a country, it is estimated to be the fifth largest global emitter of carbon emissions (Healthcare Without Harm, 2019). These emissions are referred to as carbon dioxide equivalents (CO2e), which are made up of various harmful gases that contribute to global warming. The term carbon footprint refers to the amount of emissions that are released into the atmosphere by any individual activity, institution or country (Healthcare Without Harm, 2019). This allows for comparisons to be made regarding how ‘heavy’ the footprint is compared to alternatives and can be used to encourage reducing or offsetting the footprint by making more sustainable choices. For example, if a plastic clinical item used in the UK is made in China, then the footprint will consist not only of the manufacturing process and materials, but also the travel involved in bringing it to the UK and its disposal. A similar product that is made locally would have a lower carbon footprint.

The urgency of this problem has been identified in the Health and Care Act 2022 and the UK government’s commitment to reducing the carbon footprint of the NHS to net zero by 2040 (NHS England, 2023). Net zero means that the total greenhouse gas emissions produced would need to be equal to or less than those being removed from the environment. The required change to an environmentally sustainable healthcare model is known as a circular economy, where waste is reduced and recycled, and the life cycle of products is increased.

Sources of carbon emissions

The major healthcare contributors to carbon emissions are:

• medicines, medical equipment and other supply chains – 62%
• buildings and energy – 10%
• water and waste – 5%
• anaesthetic gases and metered dose inhalers – 5%
• travel and transport (ambulance fleet) – 4% (NHS England, 2022)

Direct emissions – these are produced by heating, transport and anaesthetic in hospitals and clinical areas. The NHS fleet of vehicles is committed to switching over to electric power, and many hospitals have clinician-led greener anaesthetic working parties looking to reduce the use of certain harmful gases.

Indirect emissions – these are produced by activities that a trust does not directly control, such as the energy sources that are powering electricity and the supply chain. Goods (such as medications) and equipment that are manufactured outside of the country and need to be transported to the clinical site produce indirect emissions. Trust procurement must consider using local suppliers and UK-based manufacturers to reduce this. Indirect emissions also come from patients and visitors to the clinical site.

Many actions, including workforce collaboration, commitment and innovation must be implemented across all disciplines in order to achieve net zero in the NHS.

Unsustainable practice: making evidence-based changes

An example of unsustainable practice in the NHS that was highlighted in the pandemic was the excessive use of personal protective equipment. Rizan et al (2021) identified that the use of personal protective equipment by healthcare professionals during the first 6 months of the pandemic produced 106 478 tonnes of CO2e, equivalent to the emissions for 244 return air journeys between London and New York. Tennison et al (2021) identified that this issue existed long before the pandemic, and presented a carbon footprint assessment of the NHS in England that could be used to identify these carbon hotspots. Targeted action by estates and procurement teams on the reduction and recycling of personal protective equipment is essential in reducing both environmental impact and financial cost. The considerate and appropriate use of personal protective equipment by all healthcare practitioners is also a crucial factor in reducing their detrimental impact.

Many trusts have now successfully implemented the educational-based initiative from the Royal College of Nursing (2022) known as the ‘Gloves off’ campaign. Healthcare professionals are supported by infection control and prevention teams to consider and reassess when personal protective equipment is required, avoiding inappropriate or excessive use and disposal. For example, carrying out observations, making a hospital bed or assisting mobilisation may not always require personal protective equipment if good hand hygiene is conducted. In addition to reducing carbon footprint, less use of personal protective equipment has also shown to improve adherence to hand hygiene, reduce infection rates and improve patient outcomes and quality of care (Royal College of Nursing, 2022).

Nurses make a difference

Nursing is a trusted profession that plays a central role in the delivery of high-quality patient care and maintenance of wellbeing. Many nurses already have concerns about the climate and have made changes in their private life in order to reduce their personal carbon footprint. As one of the largest workforce groups in the NHS, changes in professional practice will have an even greater impact in reducing the detrimental effects of healthcare on the environment.

Nurses should ‘be aware of, and reduce as far as possible, any potential for harm associated with practice’ (Nursing and Midwifery Council, 2018). This mandate to practice effectively, efficiently and safely, with a focus on patient-centred care requires nurses to find ways to practice in a more environmentally sustainable way and raise awareness in the profession.

Role modelling

Nurses can lead by example in the workplace by using the principles of sustainability to guide their practice in line with the Code (Nursing and Midwifery Council, 2018). They can demonstrate sustainable practice to colleagues, students, patients and the public by reducing the waste produced in the clinical environment and behaving in an environmentally responsible way. This may involve advocating the correct use of recycling bins in the clinical environment and simple individual actions, such as using individual water bottles rather than disposable plastic cups.

Education and mentorship

The scale of the problem can seem overwhelming and lead to fears that nothing can be done to significantly reduce the carbon footprint of the NHS. Pre- and post-registration nursing education is key to raising awareness of the environmental impact of healthcare and giving nurses the framework and tools to become agents of change in their practice (NHS England, 2022). The Nursing and Midwifery Council (2023, 2024) have included environmental sustainability in their recent sustainability plan and the revised education standards. There is a growing commitment to embedding sustainability into advanced nurse practitioner courses, so that it will have a direct impact on patient care and support continuing professional development (Cornish, 2023).

Educating and empowering patients: prevention and health promotion

The World Health Organization (2024) recognised that health professionals may feel unsure about discussing the environment with their patients and colleagues. In response, they have produced a communication toolkit for health professionals to help them have conversations with patients, colleagues and policy makers about the impact of the climate on health. By informing patients about sustainable practices, such as switching to environmentally-friendly inhalers, choosing a plant-based diet or walking in green spaces, patients can be empowered to help reduce the environmental impact of their care as well as improve their health, wellbeing and agency.

What changes can nurses make to their day-to-day practice to be more sustainable?

Simple steps to working in a more sustainable way can include:

• turn off the lights and equipment when not in use
• use a refillable water bottle and encourage others to do the same
• consider the way you get to work and see if there is a more environmentally-friendly alternative, such as a car share or cycle-to-work scheme
• use the right bin – can waste be recycled, up cycled, reused?
• using sharps boxes just for sharps
• look at your trust’s green plan and lobby senior management
• talk to the point-of-care nurses and ask to be involved in procurement decisions at local or trust level
• become a sustainability champion for the area

Considering new models of care: working smarter

It is vital for nurses to be aware that the climate emergency is also a health emergency. Nurses should feel empowered to adopt more sustainable practices that reduce carbon footprint, cost of care and improve patient outcomes (Mortimer et al, 2018).

Awareness of sustainable quality improvement frameworks can help nurses to identify areas of their practice where small, manageable acts of change could be achieved. For example:

• Can the number of single use plastics in the clinical area be reduced?
  • eg reduce unnecessary cannulations, repurpose unused items in packs, alternatives to disposable cutlery and cups
• Can sustainable alternatives be found for some items?
  • eg aprons, medication pots
• Can paper packaging and blister packs be recycled with easily accessible bins?
  • Although large-scale hospital disposal of blister packs remains problematic, there are companies, such as Terracycle, that offer sustainable disposal of these

Continuing professional development

Nurse should have a professional commitment to staying informed about environmental issues. A good place to start is registering and completing the e-learning for healthcare programme (NHS England, 2024). This resource provides a free introduction to environmentally sustainable healthcare with continuing professional development accreditation for all health professionals.

Participation and activism: become a sustainability champion

Nurses can get involved in green initiatives and actively promote the cause by joining organisations such as Health Care Without Harm and Care Without Carbon.

The Greener NHS programme is a government website that works with nurses and other health professionals to share ideas and actions that will reduce the impact of the NHS on the environment. It is free to access and contains informative resources and inspiration.

The Centre for Sustainable Healthcare is a collaborative charity whose resources, case studies and forums are invaluable to any nurse that is considering their role and responsibility towards the environment and sustainable practice.

Conclusions

The climate crisis is a healthcare emergency that requires organisational-scale change and commitment to sustain planetary health and the survival of its inhabitants. Nurses are experts in their field and know each step of the care pathways they provide. Nurses are very well placed to make small but significant changes that can reduce the cardon footprint of interventions and procedures, at the same time reducing inefficiencies and financial burden as well as crucially improving the quality of patient care. As trusted professionals, nurses can work with patients to make informed choices about their care that reduce the impact on the environment. Nurses can use the principles of sustainability by reducing, reusing, recycling and repurposing the precious resources used in practice to ensure the health of future generations.