Nurses’ perceptions of climate and environmental issues: a qualitative study

O R I G I N A L R E S E A R C H : E M P I R I C A L R E S E A R C H –
Q U A L I T A T I V E
Nurses’ perceptions of climate and environmental issues: a qualitative
study
Anna Anaker, Maria Nilsson, Asa Holmner & Marie Elf
Accepted for publication 23 February 2015
Correspondence to A. Anaker:
e-mail: [e-mail]
Anna Anaker RN
PhD Student
School of Education, Health and Social
Studies, Dalarna University, Falun, Sweden
Maria Nilsson PhD
Researcher
Department of Public Health and Clinical
Medicine, Epidemiology and Global Health,
Umea University, Sweden
Asa Holmner PhD
Researcher
Department of Radiation Sciences, Umea
University, Sweden
Marie Elf PhD RN
Associate Professor
School of Education, Health and Social
Studies, Dalarna University, Falun, Sweden
A N AK E R A . , N I L S S O N M . , H O L M N E R A. & E L F M . ( 2 0 1 5 ) Nurses’ perceptions
of climate and environmental issues: a qualitative study. Journal of Advanced
Nursing 71(8), 1883–1891. doi: 10.1111/jan.12655
Abstract
Aim. The aim of this study was to explore nurses’ perceptions of climate and
environmental issues and examine how nurses perceive their role in contributing
to the process of sustainable development.
Background. Climate change and its implications for human health represent an
increasingly important issue for the healthcare sector. According to the
International Council of Nurses Code of Ethics, nurses have a responsibility to be
involved and support climate change mitigation and adaptation to protect human
health.
Design. This is a descriptive, explorative qualitative study.
Methods. Nurses (n = 18) were recruited from hospitals, primary care and
emergency medical services; eight participated in semi-structured, in-depth
individual interviews and 10 participated in two focus groups. Data were
collected from April–October 2013 in Sweden; interviews were transcribed
verbatim and analysed using content analysis.
Results. Two main themes were identified from the interviews: (i) an
incongruence between climate and environmental issues and nurses’ daily work;
and (ii) public health work is regarded as a health co-benefit of climate change
mitigation. While being green is not the primary task in a lifesaving, hectic and
economically challenging context, nurses’ perceived their profession as entailing
responsibility, opportunities and a sense of individual commitment to influence
the environment in a positive direction.
Conclusions. This study argues there is a need for increased awareness of issues
and methods that are crucial for the healthcare sector to respond to climate
change. Efforts to develop interventions should explore how nurses should be
able to contribute to the healthcare sector’s preparedness for and contributions to
sustainable development.
Keywords: climate change, healthcare sector, nurse, nursing, perception,
sustainable development
© 2015 The Authors. Journal of Advanced Nursing published by John Wiley & Sons Ltd. 1883
This is an open access article under the terms of the Creative Commons Attribution-NonCommercial-NoDerivs License,
which permits use and distribution in any medium, provided the original work is properly cited, the use is non-commercial and
no modifications or adaptations are made.

Introduction
There is scientific consensus that the climate is changing
and that it is affected by human activity (Intergovernmental
Panel on Climate Change 2013). Climate change will influ-
ence human health; therefore, healthcare systems need
to address climate change and its potential implications
(Costello et al. 2009, Woodward et al. 2014). It is of inter-
national relevance to understand how nurses perceive their
role in a sustainable healthcare sector; developing a sustain-
able healthcare sector is a global challenge. In this paper,
we address a previously unexamined area of research on
how nurses perceive climate and environmental issues and
their role in contributing to the process of sustainable
development.
Background
Climate change is described as the most important global
health threat of the coming century. It will affect human
health in various ways, including the availability of food
and fresh water, rising sea levels affecting settlement pat-
terns, extreme weather events, migration, emerging diseases
and altered transmission patterns of vector-borne diseases
(Lindgren & Gustafsson 2001, Costello et al. 2009,
McMichael & Lindgren 2011, Tokarevich et al. 2011).
Among vulnerable populations, such as children, older
adults, individuals with pre-existing illnesses and the poor,
these changes will be particularly challenging because these
individuals have fewer resiliencies than individuals who
have additional resources and are well connected to their
community (Frumklin et al. 2008).
Barna et al. (2012) formulated key skills and perspectives
essential to achieving the goals of sustainable development
in the healthcare sector: knowledge of the facts, transport
and communication, diet, resources and materials and the
development of care models based on the notion of human
impact and dependence on the environment. They suggest
that human health is rooted in the stability and resilience of
the environment, thereby creating practical implications for
nursing. Healthcare education should provide a knowledge
base to prepare nurses for their role as representatives of a
sustainable healthcare sector. Nurses are the largest group
of healthcare staff and consequently play a critical role in
the healthcare sector’s sustainable development.
The definition of sustainability in the context of nursing
is an important and recently explored topic (Anaker & Elf
2014); nursing contributes to sustainable development, a
concept that can be defined based on ecology (global and
holistic). Employing the concept of sustainability entails
environmental considerations at all levels. The implementa-
tion of sustainable practice will contribute to and drive
developments towards maintaining an environment that
does not harm current and future generations’ opportunities
for good health. McMillan (2014) contends that the con-
cept of sustainability is fragile and highly dependent on the
processes and stakeholders who create its content. Thus,
there are diverse interpretations of the concept. Understand-
ing the concept’s complexity will improve nurses’ ability to
play a major role in, for example, sustainable health initia-
tives such as environmentally friendly hospital buildings.
The International Council of Nursing (ICN) contends
that nurses need to support actions seeking to reduce the
effects of global warming and climate change on health.
Consequently, nurses need to be aware of how climate
change affects human health and how to address these
potential health risks. Nurses have the potential to make an
important contribution to sustainable development,
described by the ICN as providing opportunities for groups,
individuals and communities to create a healthy society
(International Council of Nurses 2007, 2008). Despite this
Why is this research needed?
 The International Council of Nursing argues that nurses
need to support actions directed at reducing the effect of cli-
mate change on health. Consequently, nurses must be aware
of the health implications of climate change and possess the
skills necessary to address potential health risks.
 There is a lack of knowledge regarding nurses’ perceptions
of climate and environmental issues and such issues’ effects
on the healthcare sector.
What are the key findings?
 There is incongruence between climate and environmental
issues and nurses’ daily work.
 Nurses, as members of their profession, experienced a
sense of individual responsibility to influence the environ-
ment in a positive direction.
 Public health work is regarded as a health co-benefit of cli-
mate change mitigation.
How should the findings be used to influence policy/
practice/research/education?
 Nurses require greater knowledge to be able to be involved
and support actions towards climate change mitigation
and to adapt to protect human health.
 Efforts to develop interventions should explore how nurses
can contribute to the healthcare sector’s knowledge of, pre-
paredness for and contributions to sustainable development.
1884 © 2015 The Authors. Journal of Advanced Nursing published by John Wiley & Sons Ltd.
A. Anaker et al.

statement, few studies have been published that analyse
nurses’ experiences, attitudes or knowledge concerning cli-
mate change and other environmental issues.
An American study addressing the knowledge and atti-
tudes of public health nurses towards climate change indi-
cates that nurses believe that climate change exists and that
their profession has a responsibility to address the health
effects of climate change. However, this study also reveals
that nurses lack the ability to address the health effects of
climate change (Polivka et al. 2012). In addition, a UK
study by Richardson et al. (2013) reports that nursing stu-
dents possess limited knowledge of the natural resources
used in the production of items used in the healthcare sec-
tor.
Sustainable nursing work will be a key factor in the
future development of the healthcare sector; furthermore,
research is necessary to investigate how nursing care should
be designed to respond to climate change (Sayre et al.
2010, Barna et al. 2012). A recent study by Holmner et al.
(2014) supports replacing physical visits with telemedicine,
e.g. teleconferencing, as a potent carbon reduction strategy
in the healthcare sector.
By studying nurses’ perceptions of climate and environ-
mental issues and examining nurses’ perceptions of how
they can contribute to sustainable development, we can bet-
ter understand how nurses can participate in climate change
mitigation and adaptation to generate improved health
outcomes.
The study
Aim
The aim of this study was to explore nurses’ perceptions of
climate and environmental issues and examine how nurses
perceive their role in the creation of sustainable health care.
Design
The study was a qualitative, descriptive explorative study
and involved individual in-depth interviews and focus group
discussions. A qualitative research design was used to fully
understand nurses’ perceptions of climate and environmen-
tal issues and examine how they perceive their role in sus-
tainable development.
Sample
The informants in the study were RN. To achieve rich vari-
ation in the data, the informants were chosen purposefully
to represent hospital care, primary health care and emer-
gency medical services in a single county in Sweden. Infor-
mational letters were sent to the informants after
conducting a personal enquiry, where the purpose of the
study was presented.
Data collection
The data collection was conducted from April–October
2013 in Sweden. Eighteen nurses, a combination of women
(n = 15) and men (n = 3), participated in the study. The
study protocol included individual in-depth interviews
(n = 8) and two focus groups (n = 10) lasting between
45-60 minutes. Informants in this study had 1-26 years of
nursing experience.
First, in-depth interviews (n = 8) were conducted and
analysed. The interviews were performed in a semi-struc-
tured format and focused on informants’ views on climate
and environmental issues. An interview guide was used and
structured according to the purpose of this study (Table 1).
Focus groups (n = 2) employing a semi-structured format
were also conducted to achieve a deeper and broader dis-
cussion according to the study’s objective. The first author
performed all individual interviews and served as the mod-
erator of the focus group discussions. According to Seid-
man (2006), the flexibility of a semi-structured interview
allows researchers to discover areas worthy of consider-
ation that arise during an interview, while an interview
guide permits comparisons of the different interviews and
focus groups.
Before the individual interviews and focus group discus-
sions, the informants were provided written and verbal
information concerning the study and informed consent
was obtained. All interviews and focus group discussions
were recorded digitally. After each interview, the first
author listened to the recording once, which was tran-
scribed verbatim. All of the above steps were performed to
develop a comprehensive perspective on the data (Kvale &
Brinkman 2009).
Table 1 Example questions from the interview guide.
• What do you think of when you hear the topic of this study?
• What can nurses do to achieve the goal of sustainable develop-
ment?
• To what extent do you talk about climate and environmental
issues in your workplace?
• What responsibility does the healthcare sector have as a stake-
holder in climate and environmental issues?
• What barriers exist that we have to overcome to achieve the
goal of sustainable development?
© 2015 The Authors. Journal of Advanced Nursing published by John Wiley & Sons Ltd. 1885
JAN: ORIGINAL RESEARCH: EMPIRICAL RESEARCH – QUALITATIVE Nurses: climate and environmental issues