Dalarna University Study: Nurses' Perceptions of Climate Issues

This research study, published in the Journal of Advanced Nursing, explores nurses' perceptions of climate and environmental issues and their role in sustainable development. Conducted through individual interviews and focus groups with nurses from various healthcare settings in Sweden, the study identifies an incongruence between nurses' daily work and climate/environmental concerns. Key findings reveal nurses' sense of individual responsibility for environmental influence and the perception of public health work as a co-benefit of climate change mitigation. The research emphasizes the need for increased awareness and interventions within the healthcare sector to address climate change, highlighting nurses' potential contributions to sustainable development and improved health outcomes. The study underscores the importance of equipping nurses with the knowledge and skills necessary to actively participate in climate change mitigation and adaptation efforts.

ORIGINAL RESEARCH: EMPIRICAL RESEARCH –
QUALITATIVE
Nurses’ perceptions of climate and environmental issues: a qualitativ
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 RA. & E L F M . ( 2 0 1 5 )Nurses’perceptions
of climate and environmentalissues:a qualitative study.Journal of Advanced
Nursing 71(8), 1883–1891. doi: 10.1111/jan.12655
Abstract
Aim. The aim of this study wasto explore nurses’perceptionsof climate and
environmentalissues 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
increasinglyimportant issue for the healthcaresector. 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 recruitedfrom hospitals, primary care and
emergencymedical services;eight participatedin semi-structured,in-depth
individual interviewsand 10 participatedin two focus groups. Data were
collectedfrom April–October 2013 in Sweden;interviewswere transcribed
verbatim and analysed using content analysis.
Results.Two main themes were identified from the interviews: (i) an
incongruence between climate and environmentalissues and nurses’daily work;
and (ii) public health work is regarded as a health co-benefitof climate change
mitigation.While being green is notthe primary task in a lifesaving,hectic and
economically challenging context,nurses’perceived their profession as entailing
responsibility,opportunitiesand a sense ofindividualcommitmentto influence
the environment in a positive direction.
Conclusions.This study argues there is a need for increased awareness of issues
and methodsthat are crucialfor the healthcare sectorto respond to climate
change.Efforts to develop interventionsshould explore how nursesshould be
able to contribute to the healthcare sector’s preparedness for and contributions to
sustainable development.
Keywords:climate change, healthcaresector, 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 consensusthat the climate ischanging
and that it is affected by human activity (Intergovernmental
Panelon Climate Change 2013).Climate change willinflu-
ence human health; therefore,healthcaresystemsneed
to addressclimatechangeand its potentialimplications
(Costello et al.2009, Woodward et al. 2014). It is of inter-
nationalrelevance to understand how nurses perceive their
role in a sustainable healthcare sector; developing a sustain-
able healthcare sector is a globalchallenge.In this paper,
we addressa previously unexamined area ofresearch on
how nurses perceive climate and environmentalissues and
their role in contributing to the processof sustainable
development.
Background
Climate change is described as the mostimportantglobal
health threatof the coming century.It will affecthuman
health in variousways, including the availability offood
and fresh water,rising sea levels affecting settlementpat-
terns,extreme weather events,migration,emerging diseases
and altered transmission patternsof vector-borne diseases
(Lindgren & Gustafsson 2001, Costello et al. 2009,
McMichael & Lindgren 2011, Tokarevich et al.2011).
Among vulnerablepopulations,such as children, older
adults,individuals with pre-existing illnesses and the poor,
these changes willbe particularly challenging because these
individualshave fewer resilienciesthan individualswho
have additionalresourcesand are wellconnected to their
community (Frumklin et al. 2008).
Barna et al. (2012) formulated key skills and perspectives
essentialto achieving the goals of sustainable development
in the healthcare sector:knowledge ofthe facts,transport
and communication,diet, resources and materials and the
development of care models based on the notion of human
impactand dependence on the environment.They suggest
that human health is rooted in the stability and resilience of
the environment,thereby creating practicalimplications 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 largestgroup
of healthcare staffand consequently play a criticalrole in
the healthcare sector’s sustainable development.
The definition of sustainability in the context ofnursing
is an important and recently explored topic (Anaker & Elf
2014); nursing contributesto sustainabledevelopment,a
conceptthat can be defined based on ecology (globaland
holistic). Employing theconceptof sustainability entails
environmentalconsiderations at alllevels.The implementa-
tion of sustainablepracticewill contributeto and drive
developmentstowards maintainingan environmentthat
does not harm current and future generations’ opportunities
for good health.McMillan (2014) contends thatthe con-
cept of sustainability is fragile and highly dependent on the
processesand stakeholderswho create itscontent.Thus,
there are diverse interpretations of the concept. Understand-
ing the concept’s complexity willimprove nurses’ability to
play a major role in,for example,sustainable health initia-
tives such as environmentally friendly hospital buildings.
The InternationalCouncil of Nursing (ICN) contends
that nurses need to supportactions seeking to reduce the
effectsof global warming and climate change on health.
Consequently,nursesneed to be aware of how climate
changeaffectshuman health and how to addressthese
potential health risks. Nurses have the potential to make an
important contribution to sustainable development,
described by the ICN as providing opportunities for groups,
individualsand communitiesto create a healthy society
(InternationalCouncil of Nurses 2007,2008).Despite this
Why is this research needed?
The International Council of Nursing arguesthat 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 membersof their profession,experienced a
sense ofindividualresponsibility 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 changemitigation
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 studieshave been published thatanalyse
nurses’experiences,attitudes or knowledge concerning cli-
mate change and other environmental issues.
An American study addressing the knowledge and atti-
tudes ofpublic health nurses towards climate change indi-
cates that nurses believe that climate change exists and that
their profession hasa responsibility to addressthe health
effects ofclimate change.However,this study also reveals
that nurses lack the ability to address the health effects of
climatechange(Polivka et al. 2012). In addition, a UK
study by Richardson et al.(2013) reports that nursing stu-
dentspossesslimited knowledge ofthe naturalresources
used in the production of items used in the healthcare sec-
tor.
Sustainablenursing work will be a key factor in the
future developmentof the healthcare sector;furthermore,
research is necessary to investigate how nursing care should
be designed to respond to climatechange(Sayreet al.
2010,Barna et al.2012).A recent study by Holmner et al.
(2014) supports replacing physicalvisits with telemedicine,
e.g.teleconferencing,as a potent carbon reduction strategy
in the healthcare sector.
By studying nurses’perceptions ofclimate and environ-
mentalissuesand examining nurses’perceptionsof how
they can contribute to sustainable development, we can bet-
ter understand how nurses can participate in climate change
mitigationand adaptationto generateimprovedhealth
outcomes.
The study
Aim
The aim of this study was to explore nurses’perceptions of
climate and environmentalissues and examine how nurses
perceive their role in the creation of sustainable health care.
Design
The study wasa 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 representhospitalcare,primary health care and emer-
gency medicalservices in a single county in Sweden.Infor-
mational letters were sent to the informants after
conducting a personalenquiry,where the purpose ofthe
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 interviewswere performed in a semi-struc-
tured formatand focused on informants’views on climate
and environmentalissues.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 allindividualinterviews and served as the mod-
eratorof the focusgroup discussions.According to Seid-
man (2006),the flexibility ofa semi-structured interview
allows researchersto discoverareasworthy of consider-
ation that arise during an interview,while an interview
guide permits comparisons ofthe differentinterviews and
focus groups.
Before the individualinterviews and focus group discus-
sions, the informantswere provided written and verbal
information concerningthe study and informed consent
was obtained.All interviewsand focusgroup discussions
were recordeddigitally. 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 existthat 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
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Ethical considerations
Research EthicsCommitteeapprovalfor the study was
granted by Dalarna University Research Ethics Committee.
Informed consentwas obtained from allparticipants prior
to the interviews.Participants were free to withdraw from
the study at any time.
Data analysis
Qualitative content analysis was performed on the individ-
ual interviewsand focus group discussionsaccording to
the methodsof Granheim and Lundman (2004) and
Krippendorff(2013).The transcribed textsfrom both the
individualinterviews and the focus group discussion were
analysed together in one matrix.To structure and deduce
the meaning ofthe transcribed text,it was organized and
compared in a matrix with five differentheading levels
(meaning unit, condensed meaning unit, codes, sub-category
and category);all headings aimed to capture the manifest
content (Table 2).The focus of the analysis was to identify
and describesimilaritiesand differencesin the content.
During the procedure, central meaning units were lifted out
from the transcriptand were combined into condensed
meanings;thereafter,the condensed meaning unitswere
abstracted and coded.In the coding,the essenceof the
meaning unit, the manifest content, was clarified. The codes
were compared based on similaritiesand were organized
into sub-categories based on similarities between the codes.
All sub-categories formed four main categories.Finally,the
categoriesresulted in two themes.During the processof
analysis,the meaning units were analysed by both the first
author and research group together to reach consensus on
the codes, categories and themes.
Rigour
Strategieswere used to ensure a rigorous analytical
approach. Trustworthiness(Beck 1993, Granheim &
Lundman 2004)was achieved through a common qualita-
tive contentanalysismethod (Polit& Beck 2008) and a
parallelanalysis by the authors to achieve consensus on the
analysis. The researchers discussed the relationships between
meaning units, codes, categories and themes as the interpre-
tation proceeded. The authors’ continuous discussion of the
results ensuredcredibility and clarifying representative
quotationsfrom the transcriptwere added (Granheim &
Lundman 2004). The participants were selected to include a
variety of backgrounds to help corroborate findings related
to numerous different areas in nursing,including hospitals,
primary care and emergency medical services.
Findings
A total of four categoriesappeared and resulted in two
themes:(i) incongruence between climate and environmen-
tal issues and nurses daily work; and (ii) public health work
is regarded as a health co-benefit of climate change mitiga-
tion (Table 3).The categories describe how the informants
perceived climate and environmentalissuesand how they
could contribute to sustainable development.The perspec-
tives are considered at both the professionaland individual
level. The categoriesare presented below and discussed
using quotations from the interviews.
Being green is not a primary task in a lifesaving, hectic
and economically challenging context
The informants said thatclimate and environmentalissues
are not the first priorities in their daily work with patients.
They stated thattheir focus is on saving lives,preventing
infection and preventingantibioticresistance.They also
said that the healthcare sector is reactive; therefore, the task
of saving livesis the mostimportantissue:‘We are very
reactive in everything we do.And it is a big and important
task for us to perform surgery on people who become ill
instead ofpreventing them from becoming ill.’The infor-
mants stated thatthey were driven by a desire to support
the patient and consider the patient’s perspective.That one
should ‘always focus on the patient’ was a frequently recur-
ring phrase in the informants’responses.Their daily work
requires substantialeffort,leaving neither time nor energy
Table 2 Examples of meaning unit, condensed meaning unit, code, sub-category and category.
Meaning unit Condensed meaning unitCode Sub-category Category
‘Yes, it could be the time. I do not think that,
in a normal day, I would have time to think
about the environment. Sure, throwing away
a bag of antibiotics takes no time, but if there
could be more of something, in this case,
I think it would be time.’
In a typical day, we
do not have time to
think about the
environment.
Lack of
time.
Time as an obstacle
to thinking about
the environment.
Being green is not a
primary task in a
lifesaving, hectic and
economically challenging
context.
1886 © 2015 The Authors. Journal of Advanced Nursing published by John Wiley & Sons Ltd.
A. Anaker et al.

to considerenvironmentalhealth: ‘What is important?
What is the firstpriority? Yes,the patient.The patientis
here.The patientis the focus,you know.’The informants
also considered hygieneand safety measuresintended to
prevent infections to be a central concern and their primary
responsibility.Consequently,climate and environmental
issues were less important.
They also said that the economy represented a substantial
obstacleto addressingsustainabilityissuesand that the
health sector behaved as ifthe economy was more impor-
tant than the environment:‘Then thatis still the ultimate
question.I feel that cost is the determining factor.It is cru-
cial. Indeed.Yes I think so. Yes, cost is more important
than the environment.This is my conviction.’The infor-
mantsstated thatthe issuesinvolved were too complex,
overwhelmingly large and difficult to grasp and commented
that the limited time available resulted in climate and envi-
ronmentalissuesbeing relegated to thebackground.In
addition, they believed that being ‘green’ was not a priority
in their healthcare organizations. If they did occur, environ-
mentalquestionsand discussionswere secondary.Thus,
being innovative,for example,creating a programmeof
meat-free days at the hospital, was a challenge.
Climate and environmental issues are considered from a
local, not a global, perspective
The local perspective on climate and environmentalissues
was most prominent. The informants reported that they only
had time to focus on their own ward and work at the hospi-
tal. They explained that the healthcare environment closest
to the patientand their own work environmentwere the
most important. Environmental issues were discussed in rela-
tion to the daily work environmentconcerning how the
workplace is organized or how the psychosocialwork envi-
ronmentis manifested.Climate change and itseffectson
health care at the global level were subordinate concerns:‘I
sort waste and recyclables on the ward, but then. . . I don’t go
around and think aboutglobalwarming.It does notfeel
important.’‘The environment around the patient should be
good and a good bed and fewer other patients in the room.’
Awareness of one’s own responsibility to contribute to
sustainability in health care
Although climate and environmentalissues were secondary,
the informants expressed their responsibility to address cli-
mate and environmental issues in many areas. Their respon-
sibility ranged from workingmore proactively,such as
preventingillness through vaccination,to demonstrating
awarenessthat climate and environmentalissuesare sub-
stantialand elusive but crucial:‘We understand that vacci-
nation is proactive.There we have methods.We need to
find new ‘vaccines’for other areas,so to speak,not only
for diseases but also for health.’The informants noted that
their personal opinions on climate and environmental issues
shape how they behave and think as nurses.As the health-
care sectorconsistsof many individuals,the informants
Table 3 Nurses’ perceptions of climate and environmental issues outlined in sub-categories, categories and themes.
Sub-categories (examples) Categories Theme
Focus on infection, hygiene, safety and resistance.
Focus on daily work leaves no time for other matters.
Saving lives is important in healthcare.
Time as an obstacle to thinking about the environment.
The economy makes the environment come second.
Being green is not a primary
task in a lifesaving, hectic and
economically challenging context.
Incongruence between climate and
environmental issues and nurses
daily work.
The local perspectives on climate and environmental
issues come first.
The environment closest to the patient is the
most important.
Environment is equated with the work environment.
Climate and environmental issues are
considered from a local, not a
global, perspective.
The healthcare sector should engage more proactively.
Aware of the environmental problems.
Transportation is not good for the environment.
Drugs that are released into the environment are
harmful to the environment.
Awareness of one’s own responsibility
to contribute to sustainability in
healthcare.
Public health work is regarded as a
health co-benefit of climate change
mitigation.
Public health work as part of environmental work.
Riding a bicycling to work is good for health and
the environment.
A healthy lifestyle is good for the environment.
Health objectives can provide
environmental benefits.
© 2015 The Authors. Journal of Advanced Nursing published by John Wiley & Sons Ltd. 1887
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believed that it also creates differences in values:‘The big-
gest problem with climate and environmentalissues is that
I start from what I believe.I have one pointof view on
what I think is good for the environment.We think very
differently and we have different values about the environ-
ment. But I believe we have a responsibility.’
The informants were wellinformed that the release of a
drug, such as an antibiotic or hormone-disruptingsub-
stance,has a negative impacton the environment.They
also discussed the growing problem ofantibiotic-resistant
bacteria and they believed that they could contribute to sus-
tainability by being frugalwith resourcesand materials.
They asserted thatadministering drugs also generated tre-
mendous amounts of waste in the healthcare sector because
of packaging.When the informants were asked to discuss
how the healthcare sectorcould contribute to sustainable
development, waste management and reduced material con-
sumption were recurring topics:‘If we reduce the use of
antibioticsand the number of prescriptions,this will
‘reduce the use’and reduce environmentalimpact,but I
don’t think that the main factor influencing prescribing
decisions has been the environment.It is the development
of resistance and from a health perspective that is the most
threatening thing.’
The informants were also aware oftransportation chal-
lenges about sustainable development.Reducing travelwas
identified asa positive changefor the environment;the
nurses knew that they had a responsibility to reduce trans-
portation. Travel by patientsbetween theirhomesand
healthcarefacilitiesand travel by staff between various
healthcare facilities are substantial contributors. Transporta-
tion of materialwas also mentioned as an important issue:
‘We are discussing the transportation. That’s where we have
an environmentalperspective.Globally,we have to travel
less. If there is a product or if it is people, we have to travel
less. It is like the foundation.’ They compared the healthcare
sectorto other businessesand industriesand considered
how other industries had stricter requirements on environ-
mentalconcerns than the healthcare sector:‘But this brings
up the question ofwhy the health sector has gotten away
with less strict requirements compared to industry. Is it just
because we have to throw away a lot of junk because what
we do is vital? We do this for hygienic reasons and hygiene
and health go along with each other.Is that why we get
away with this? Because it is the matter of life and death?’
Health objectives can provide environmental benefits
The informants said that working towards sustainable devel-
opmentcould be linked to various lifestyleprogrammes
offered at the clinic,such as tobacco cessation and weight
loss programmes. Thus, even if working towards sustainable
developmentwas not a primary objective in theirwork,
they described how varioustasks created environmental
benefits,such as patients’measuring their blood pressure at
home and reporting it to the hospitalor primary care pro-
vider using the Internet:‘I think you should link itto the
lifestyle programmes.When you want to change your life-
style,it would be possible to expand thatdesire and not
simply stop atlosing weightand quitting smoking.I will
lose weight by biking more and in turn do something that
makes a difference for the environment,like not using the
car.’
Discussion
This study is one of the first to describe nurses’perceptions
of climateand environmentalissues.Research on public
attitudes on climate change has demonstrated that positions
on climate change correspond with demographical, ideolog-
ical and institutionalvariables(O0
Connor et al. 2002,
Brechin 2003).For example,previous research on medical
students’attitudestowards climatechangerevealed that
these attitudes are mutable and coloured by how the atti-
tudesappearwith respectto medicalopinion on climate
change (Prasad et al. 2011).
This study revealed thatthe nurses had a localperspec-
tive on climate and environmentalissues.They cited waste
managementon the wardsand the work environmentas
the most crucialcontributions that they make to a sustain-
able society.It is encouraging thatnursesare aware that
activities in their daily surroundings play an essentialrole
in protectingthe environment.However, none of the
respondentsmentioned sustainability atthe global level.
Their focus on the immediate environment might mean that
the nurses lack a systemic thinking approach,i.e. individu-
als’ behaviourin their immediate environmentaffectsthe
entire world.
Healthcare professionals mustbe well aware of climate
and environmentalissuesat the globallevel,such asthe
potentialfor more frequentand prolonged periods ofhigh
temperaturesthat could increaseillness and mortality
among theelder peopleand personswith heart disease
(Poumadere et al. 2005), and health problemsrelated to
the spread of vector-bornediseasesand food and water
shortagesdue to increasedtemperatures.These factors
are identified assome of the mostcritical global threats
faced by the healthcare sector due to climate and environ-
mentalproblems (St.Louise & Hess 2008,Costello et al.
2009, World Health Organization 2009).Consequently,
1888 © 2015 The Authors. Journal of Advanced Nursing published by John Wiley & Sons Ltd.
A. Anaker et al.

healthcare professionalsmay, for example,need to adjust
the number of available beds in relation to the temperature.
Thus, it is importantfor the healthcare sector to adopta
structure that supports an environmentallyconscious
approach.
In this study, the informants also expressed an awareness
of their individualresponsibility to positively influence the
environmentand be sustainable,but simultaneously,they
said thatbroad issue ofthe effectsof climate change on
health appeared to be overwhelming and difficult to grasp.
They noted thattheir personalopinionson climate and
environmentalissue shape how they behave and think as
nurses.As a workplace consists of individuals,the question
of how nurses can and should work to promote sustainabil-
ity is substantially influenced by an individual’spersonal
knowledgeand opinions about environmentalconcerns.
This is consistent with Lorenzoniand Pidgeon (2006),who
demonstratedthat individualsrelate to climate change
through personalexperience,knowledge and trustin other
actorsand tend to engage with problemsrelated to their
local school or/and institutions and not problems at the glo-
bal and international level.
We argue thatalthough nurseshave a responsibility to
work towards a sustainableenvironment,the healthcare
organization also has a responsibility to act.The director
of Public Health and Environmentat the World Health
Organization stressed theparadox facing hospitals,with
their core mission of curing and preventing illness,actually
representa threatto human health by contributing to cli-
mate change through theirheavy use ofenergy and non-
renewable resources (World Health Organization &
HealthcareWithout Harm 2009). The healthcaresector
can play an importantrole in climate mitigationand
adaptation activities.The healthcaresectoris large and
could become an importantrole modelfor other sectors
of society.By being informed at work, individualstaff
memberscan be encouraged to ‘bring home’what they
have learntand thereby furthercontribute to sustainabil-
ity. If the healthcare sector is systemically engaged in sus-
tainability efforts, this will support individual staff
members,such as nurses,to achieve sustainability goals in
their daily work.
A nurse’s awarenessof his/herown responsibility with
respectto climate and environmentalissuesis important
because itrepresentsa foundation foreffortsto shift the
healthcare sector from unsustainable to sustainable develop-
ment.The informantsalso said that although they were
aware ofclimate problems and their responsibility in that
area,this awareness seldom led to concrete actions, as such
efforts were hampered by the performance of those tasks in
the nurses’daily work thatwere considered more impor-
tant. It is extremely importantthat individualnursesbe
aware of their own responsibility.However,to act and
create a truly sustainable workplace,healthcare organiza-
tions must strategically collaborate to address environmen-
tal issues.It is necessary to develop a structure that allows
for a sustainability analysisof each activity atboth the
micro and macro level and an action plan for how individu-
als should act.Furthermore,this requiresthat healthcare
organization adopt a sustainability perspective in all aspects
of their activities, including services, education and
research.There is a need for systems thinking and an inte-
grated approach thattranscends the traditionalboundaries
between disciplines.
This study also highlights the importance ofintroducing
the topic ofsustainability in nursing education.The topic
should be incorporated throughoutnursing education pro-
grammes.It is important that nursing students be prepared
to cope with situations arising as a result of climate change.
Societyalso requiresknowledgeof potentialthreatsto
human health that will occur as the climate changes. Nurses
can be key actorsin such efforts.There is nothing novel
aboutthis suggestion and should be considered a natural
conclusion because nurseshave long been held to have a
responsibility to act in accordance with a pro-environmen-
tal perspective in the InternationalCouncilof Nurses Code
of Ethics (2012).It may be time to update this code.It is
necessary to have a greater emphasis on the ecologicalcon-
text in studiesof human health,and an increased under-
standingthat humanityis part of social, political and
economic systems.
Finally,an importantfinding ofthis study is the nurses’
recognitionthat offering various lifestyle change pro-
grammes represented an indirect contribution to sustainable
developmentand served asan ancillary effectof public
health work.This type ofcontribution is generally termed
the health co-benefitsof climate change mitigation (Hos-
king et al.2011).The informants said that the main focus
in their patient care plans was to improve health or prevent
illnessby developing health goals,for example,riding a
bicycle to work instead of travelling by car.The healthcare
sectorshould take note ofthis method and relate health
promotion to sustainable development. Hallberg (2010) and
the Swedish National Institute of Public Health (2011) sup-
port this perspective and the latter argues thathealth pro-
motion representsthe foundation for healthcaresector’s
efforts to create a sustainable society.If good physicaland
psychosocialhealth isnot established,the society willbe
unable to address broader globalissues,such as sustainable
development.
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Limitations and strengths
A limitation of this study is that the findings offer a specific
view related to one country. Although the study was
conducted in Sweden, the topic of climate change is interna-
tionally relevant.Researchersfrom variouscountrieshave
enriched nurses’ knowledge and ability to pursue sustainable
development,both globally and locally,in their work. An
additionallimitation concerned the first author’s preconcep-
tions of the subject.To minimize the risk of excessive
pre-understanding,the interviewswere performed using a
pre-preparedinterview guide.According to Kvale and
Brinkman (2009),the use of a pre-prepared interview guide
reduces the risk of bias.All authors also performed parallel
analyses to increase trustworthiness,which can reduce the
risk of preconceptions that can result in incorrect analyses.
The use of both individual interviews and focus group discus-
sions enriched and strengthened the data.The focus group
discussionsinvited spontaneity and emotionalexpressions
and the informants’ statements and arguments were strength-
ened through their interaction with other nurses.
Conclusion
This study highlighted nurses’ perceptions of climate and envi-
ronmentalissues and nurses’contributions to the process of
sustainable development. The results reveal nurses have a core
responsibility to addressclimate and environmentalissues,
but their sense of responsibility is overshadowed by other job
requirements that are considered more important than identi-
fying an environmentally sustainable approach to providing
care. Therefore, climate and environmental issues are consid-
ered a second-order concern. We argue that nurses’ attitudes
and practicesconcerning climate and environmentalissues
must change and that the basis for such change is increased
knowledge concerning the methods that the healthcare sector
can employ to contribute to sustainable development. Nurses
require greater knowledge to become involved in and support
actions targeting climate change mitigation and to adapt to
protect human health. Future theoretical studies and interven-
tions should continue to explore this field and how nurses can
contribute to the healthcare sector’s knowledge of, prepared-
ness for and contributions to sustainable development.
Funding
The study was conducted with supportfrom Dalarna Uni-
versity, research group Health and Welfare.
Conflict of interest
None.
Author contributions
All authors have agreed on the finalversion and meetat
least one of the following criteria [recommended by the
ICMJE (http://www.icmje.org/ethical_1author.html)]:
•substantialcontributionsto conceptionand design,
acquisition ofdata, or analysisand interpretation of
data;
•drafting the article or revising it critically for important
intellectual content.
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