
==== Front
Nurs Open
Nurs Open
10.1002/(ISSN)2054-1058
NOP2
Nursing Open
2054-1058
John Wiley and Sons Inc. Hoboken

10.1002/nop2.70043
NOP270043
NOP-2023-Oct-2072.R4
Scoping Review
Scoping Review
Practicing nurses' and nursing students' perceptions of climate change: A scoping review
Bérubé et al.
Bérubé Anouk https://orcid.org/0000-0002-6693-3482
1
Diallo Thierno https://orcid.org/0000-0002-0168-2299
1 2 3 thierno.diallo@fsi.ulaval.ca

Roberge Martin https://orcid.org/0000-0002-3317-431X
1
Audate Pierre‐Paul https://orcid.org/0000-0002-2475-6799
4 5
Leblanc Nancy https://orcid.org/0000-0002-7403-3441
1 2
Jobin Édith https://orcid.org/0000-0003-0855-8458
1
Moubarak Nisrine https://orcid.org/0000-0002-6571-7665
1 3
Guillaumie Laurence https://orcid.org/0000-0003-1138-8285
1 3
Dupéré Sophie https://orcid.org/0000-0002-5035-2851
1 6
Guichard Anne https://orcid.org/0000-0002-2215-4751
1 2
Goupil‐Sormany Isabelle https://orcid.org/0000-0002-0086-3848
3 7
1 Faculty of Nursing Sciences Laval University Quebec City Quebec Canada
2 Centre intégré universitaire de santé et de services sociaux de la Capitale‐Nationale ‐ Université Laval VITAM–Centre de Recherche en Santé Durable Quebec City Quebec Canada
3 Centre Hospitalier Universitaire de Québec–Université Laval Research Centre Quebec City Quebec Canada
4 Institut National de Santé Publique du Québec Quebec City Quebec Canada
5 Centre de Recherche en Aménagement et Développement Laval University Quebec City Quebec Canada
6 Centre de Recherche de Montréal Sur les Inégalités Sociales, les Discriminations et les Pratiques Alternatives de Citoyenneté Montreal Quebec Canada
7 Department of Social and Preventive Medicine, Faculty of Medicine Laval University Quebec City Quebec Canada
* Correspondence
Thierno Diallo, Faculty of Nursing Sciences, Laval University. Pavillon Ferdinand‐Vandry, 1050, rue de la Médecine Quebec City, QC, G1V 0H6, Canada.
Email: thierno.diallo@fsi.ulaval.ca

17 9 2024
9 2024
11 9 10.1002/nop2.v11.9 e7004310 8 2024
22 10 2023
04 9 2024
© 2024 The Author(s). Nursing Open published by John Wiley & Sons Ltd.
https://creativecommons.org/licenses/by-nc-nd/4.0/ This is an open access article under the terms of the http://creativecommons.org/licenses/by-nc-nd/4.0/ 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.

Abstract

Background

Human activities have significantly contributed to a persistent climate change trend, posing substantial threats to human health. Nurses regularly interact with patients experiencing the consequences of climate change, making their engagement in addressing this issue crucial. Nonetheless, our understanding of nurses' viewpoints regarding climate change remains limited.

Aim

This scoping review aims to identify practicing nurses' and nursing students' perceptions of climate change.

Design

To fulfil this objective, a documentary search strategy was developed using an iterative process.

Methods

The search strategy was tested in four bibliographic databases, as well as in the grey literature. A 2‐stage selection process was conducted, and relevant data were extracted from selected articles for analysis.

Results

Twenty‐two scientific articles and 11 documents from nursing associations were selected. The findings suggest that while many nurses and nursing students are concerned about climate change and its effects on their patients' health, their role in addressing the climate crisis is not well understood. Many barriers such as having a heavy workload and the lack of support hindered their ability to adjust their practice in response to the changing climate. Furthermore, many expressed a need for trainings on climate change issues.

Conclusions

These results raise a great and urgent demand for these professionals to receive appropriate training to cope with climatic threats to health. Future research should focus on the development of nursing climate leadership, and healthcare organizations should support nursing initiatives and help raise nurses' awareness regarding climate change.

climate change
environment
nurse
nursing
perception
perspective
scoping review
search strategy
Université Laval 10.13039/100007867 SAR‐SR‐133186 source-schema-version-number2.0
cover-dateSeptember 2024
details-of-publishers-convertorConverter:WILEY_ML3GV2_TO_JATSPMC version:6.4.8 mode:remove_FC converted:17.09.2024
Bérubé, A. , Diallo, T. , Roberge, M. , Audate, P.‐P. , Leblanc, N. , Jobin, É. , Moubarak, N. , Guillaumie, L. , Dupéré, S. , Guichard, A. , & Goupil‐Sormany, I. (2024). Practicing nurses' and nursing students' perceptions of climate change: A scoping review. Nursing Open, 11 , e70043. 10.1002/nop2.70043
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pmc1 INTRODUCTION

Our planet is experiencing major disruptions due to climate change. Since the 1850s, the concentration of greenhouse gases in the atmosphere has been rising sharply and is now at an all‐time high (Boden et al., 2017; Lee et al., 2023). This increase in emissions, resulting mostly from fossil fuel, industries and agricultural activities, contributes to a rapid global warming (US EPA, 2023c). Indeed, according to the National Oceanic and Atmospheric Administration (NOAA), the 10 warmest years in the historical record have all occurred since 2010 (Lindsey & Dahlman, 2023). These transformations contribute to rising sea levels, an increasing frequency of extreme weather events such as droughts, floods, and heatwaves, as well as changes in the distribution and behaviour of vectors and pathogens (US EPA, 2023b).

The Intergovernmental Panel on Climate Change recently released a report stating that climate change has already had significant and critical impacts on the physical and mental health and the well‐being of people worldwide (IPCC, 2022). Many health problems result from exposure to the direct effects of climate change such as heatwaves, wildfires, storms, drought or flooding (Watts et al., 2015). These extreme weather events are acute and traumatic and can lead to injuries, worsening of medical conditions, social and mental problems, and even deaths (Cruz et al., 2020; Hashim & Hashim, 2016; Weilnhammer et al., 2021). Between 1993 and 2012, more than 530,000 people died globally as a direct result of about 15,000 extreme weather events (Hashim & Hashim, 2016). In Europe, heatwaves and severe heatwaves are projected to be at least twice as frequent in the near future (2020–2049) (Lhotka et al., 2018), posing potentially a significant risk of loss of many human lives (Mitchell et al., 2016). Drought frequency and severity will increase across most of the globe (Cook et al., 2018), while large flood events that endanger lives and infrastructure will become more frequent (Wasko et al., 2021).

The exposure to the indirect effects of climate change, combined with disadvantaging social factors such as old age, low socioeconomic status, structural racism and restricted access to public health infrastructures, can also lead to health problems (Gutschow et al., 2021; Watts et al., 2015). Notably, poor air quality due to an increased exposure to allergens, pollution or to mold growing after storm or floods, can exacerbate respiratory and heart diseases, and air pollution increases the risk of strokes (National Institute of Environmental Health Sciences, 2023; Shah et al., 2015). Contamination of water sources by virus and bacteria can cause gastroenteritis, and vector‐borne diseases and zoonoses can emerge from changes in ecosystems and in the geographic distribution of disease vectors (Ebi et al., 2018; US EPA, 2023b). Other examples of indirect effects of climate change include food insecurity, population displacement, geopolitical conflicts, and mental health problems such as eco‐anxiety and PTDS (Watts et al., 2015). Furthermore, approximately 250,000 additional deaths per year are expected between 2030 and 2050 due to malnutrition, malaria, diarrhoea, and heat stress caused by climate change according to the World Health Organization (2021).

Unfortunately, these changes disproportionately affect those who are most vulnerable, including children, socially vulnerable people, the elderly, pregnant women, people of colour and people with chronic medical conditions or disabilities, including those with chronic mental illness (Gutschow et al., 2021; Tupinier Martin et al., 2024; US EPA, 2023b). These people are often the most exposed to the effects of climate change, are more sensitive to them and don't have the capacity to respond to climate change hazards, notably because of their income, age, living situation or access to health care (US EPA, 2023a). Therefore, healthcare systems need to be able to rapidly anticipate and prepare to be able to respond to the health challenges posed by climate change especially for the most vulnerable, in a health equity and sustainability perspective. In the 2023 report of the Lancet Countdown on health and climate change, 27% of cities surveyed said they were concerned that their health systems would be overwhelmed by the impacts of climate change (Romanello et al., 2023). Health professionals have a vital contribution in addressing health challenges linked to climate change (Yang et al., 2019). Among these professionals, nurses, who constitute a substantial portion of those dedicated to enhancing individual health and welfare (World Health Organization, 2020), play a vital role in mitigating and addressing health concerns arising from climate change (Leffers & Butterfield, 2018). The Future of Nursing 2020–2030 Charting a Path to Achieve Health Equity also recognized the need to address climate change in nursing (National Academies of Sciences Engineering and Medicine, 2021). Nurses are responsible for educating and informing patients about climate change (Nurses and Nurse Practicioners of British Columbia, 2022). Furthermore, thanks to their substantial public credibility (Milton, 2018), nurses can assume a leadership position within the healthcare system. They can accomplish this by fostering understanding of climate change as a health‐related issue and by taking the lead in instigating actions and promoting initiatives to combat it (Schenk et al., 2021). Nurses have an extraordinary opportunity to be key leaders on climate change (World Health Organization, 2018), but little is still known about their perceptions of the issue.

1.1 The review

While our understanding of nurses' perceptions of climate change remains limited, few recent studies have explored some aspects of this topic (Anåker et al., 2015; Buriro et al., 2018; Kalogirou, Dahlke, et al., 2020; Tiitta et al., 2021; Xiao et al., 2016). Two exploratory reviews of the literature have also been carried out. Conducted in 2018, the initial review focused on the knowledge, attitudes, perceptions, and practices of healthcare practitioners concerning climate change and its effects on health (Yang et al., 2019). The second review, carried out in 2022, focused on the awareness and attitudes of nursing students and educators in relation to sustainability and climate change (Aronsson et al., 2022). While the 2018 study encompassed healthcare professionals in general, the focus of the 2022 study was specifically on nursing students and educators. Therefore, we can conclude to the best of our knowledge that an in‐depth literature review aimed at identifying and synthesizing the perceptions of nurses concerning climate change has not yet been published.

1.2 Aims

This study aimed to identify nurses' perceptions of climate change, addressing the question: ‘What are nurses’ perceptions of climate change?' To do so, the objectives were to carry a portrait of the available literature, to identify perceptions and influencing factors, and to recommendations for nursing research and practice. To our knowledge, this scoping review was the first of its kind to specifically explore nurses' perceptions of climate change.

2 METHODS

2.1 Design

The detailed protocol for this scoping review, including the search strategy and the scoping review stages, has been published in a peer‐reviewed journal (Diallo et al., 2023). It can be found open access online (https://www.researchprotocols.org/2023/1/e42516/). As stated in the protocol, the exploratory literature review was conducted according to the steps described by Arksey and O'Malley (2005) and refined by Levac et al. (2010).

2.2 Search methods

To better understand nurses' perceptions of climate change, we carefully developed a search strategy through an iterative process to identify relevant studies. The search strategy included controlled vocabulary and free‐text search terms, related to the concepts of climate change and of nurses' perceptions. Searches were conducted in 2022, in four bibliographic databases: MEDLINE (PubMed), CINAHL, Embase and Web of Science. The characteristics of the searches in the databases, the keywords and an example of a search strategy can be found in the published protocol. No date limit was applied to maximize the probability of obtaining more results.

2.3 Selection of relevant and reliable studies

Identified studies were transferred to Covidence (Veritas Health Innovation) and duplicates were removed. An independent selection was conducted by two members of the research team (AB, TD) based on titles and abstracts. During a second stage of selection, the two same researchers selected the articles based on their full text.

2.4 Inclusion and exclusion criteria

All studies that addressed an environmental issue other than climate change, that concerned health professionals other than nurses, that were published in a language other than English or French or those that were not available in full text or didn't provide the authors' names or publication date were excluded. Only empirical studies were considered.

2.5 Data extraction from included studies

An Excel table was used by the research team members to extract the relevant data from the included studies, namely the title, authors, publication date, geographic area, study objectives, methodology, and key findings. First, data regarding the background characteristics of included articles were extracted. Second, key findings reported in the Results section and interpretations of authors in the discussion section were extracted. Data were copy and paste without reformulation.

2.6 Collating, summarizing, and reporting the findings

The extracted data were analysed by the research team according to the type of perception they addressed (e. g. perception of climate change, perception of nurses' role or needs regarding climate change). Both quantitative and qualitative data were analysed altogether and discussed within the research team. Thematic analysis was conducted on findings extracted in the key findings section of the extracting table, and themes were interpreted and discussed within the research team. Frequencies and percentages were used for the report of background information.

2.7 Grey literature search

A search of the grey literature was also conducted. Relevant published documents were retrieved from targeted Websites. Those of nursing and environment associations and organizations from the province of Quebec, the federal level in Canada and the United States and some at the international level were consulted. Social media sources were not considered. A table listing the associations websites we consulted is available in the published protocol (Diallo et al., 2023).

3 RESULTS

3.1 Overview

Combining all four databases, a total of 640 results emerged from the search strategy. After removing 287 duplicates, 353 were screened according to their title and abstract. Moreover, 32 studies were then assessed for eligibility, of which 10 of them were excluded due to not respecting the inclusion criteria. A total of 22 studies were included in this scoping review. The number of articles screened at each stage and the reasons for excluding the articles can be seen in the PRISMA‐ScR (Preferred Reporting Items for Systematic Reviews and Meta‐Analyses – Extension for Scoping Reviews) diagram (Figure 1). Eleven documents from nursing associations were also included.

FIGURE 1 PRISMA‐ScR inspired diagram.

3.2 Grey literature search

In total, the website of 16 nursing associations at the provincial, national, and international level were consulted. The complete list is available in the published research protocol. Six of these websites had documents relevant to this study. These associations, along with the number of selected documents per association site and the total number, are showcased in Table 1.

TABLE 1 Number of selected documents per association.

Location	Name of the association or organization	Articles (n=)	
Province of Quebec	Ordre des infirmières et infirmiers du Québec (OIIQ)	4	
Canada	Canadian Nurses Association (CNA)	1	
Canadian Association of Schools of Nursing (CASN)	1	
United States	American Association of Colleges of Nursing (AACN)	2	
International	International Council of Nurses (ICN)	2	
Secrétariat international des infirmières et des infirmiers de l'espace francophone (SIDIIEF)	1	
Total	6	11	

3.3 Characteristics of included studies

Of the 22 scientific articles included in the final scoping review, 68% (15/22) were empirical quantitative studies, while 22.7% (5/22) were empirical qualitative studies. Only 2 studies (9%) were of mixed methodology. The articles were published between 2012 and 2022, with the most studies published in 2018 (5/22) and 2021 (5/22). The geographical scope of the included studies shows that they were conducted in Europe, in America and in Asia. Indeed, in Europe, 4 studies took place in the UK, 1 in Finland, and 2 in Sweden. In America, 4 studies took place in the United States and 2 in Canada. In Asia, 2 studies took place in China, 1 in Pakistan, 1 in Saudi Arabia and 1 in Turkey. Furthermore, four studies included multiple countries in their sample: one included participants from the UK, Spain, Germany, Sweden, and Australia, another one included participants from the UK and China, whilst the other two included participants from Saudi Arabia, Egypt, Iraq, and Palestinian Territories. The 22 selected articles, including their authors, publication date, location, study type, aims, number of participants and type of perceptions regarding climate change are listed in Table 2.

TABLE 2 Overview of the eligible records, their aims, and the type of perceptions.

Authors and publication date	Location	Study type	Aims	Number of participants	Type of perceptions	
Álvarez‐Nieto et al. (2022)	UK, Spain, Germany, Sweden, Australia	Quantitative descriptive (multicentre cross‐sectional study)	Investigate nursing students' attitudes towards and awareness of climate change and sustainability issues and its inclusion in nurse education; explore differences across a range of countries; compare attitudes in 2019 with those from a similar sample in 2014.	846	Perception of climate change, perception of the health effects of climate change, perception of the nursing curriculum	
Anåker et al. (2015)	Sweden	Qualitative	Explore nurses' perceptions of climate and environmental issues and examine how nurses perceive their role in contributing to the process of sustainable development.	18	Perception of the impact of their work on climate change, perception of their role regarding climate change, perception of the organizations' role regarding climate change	
Anåker et al. (2021)	Sweden	Qualitative descriptive exploratory	Explore nursing students' perceptions of climate change and sustainability and examine how they perceive their role as nursing students in working towards a more sustainable development within the healthcare sector.	12	Perception of climate change, perception of the health effects of climate change,perception of their role in addressing climate change	
Buriro et al. (2018)	Pakistan	Quantitative (cross‐sectional)	Assess the knowledge, perception, and information sources of nurses about climate change.	105	Perception of climate change, perception of the health effects of climate change	
Chen and Price (2020)	China, England	Mixed methods	Explore sustainability education in nursing students in two countries.	101	Perception of their role regarding climate change, perception of the nursing curriculum	
Cruz, Alshammari, et al. (2018)	Saudi Arabia	Quantitative descriptive (cross‐sectional)	Investigate the predictors of Saudi nursing students' attitudes towards the environment and sustainability in health care.	280	Perception of their role regarding climate change, perception of the nursing curriculum	
Cruz, Felicilda‐Reynaldo et al. (2018)	Saudi Arabia, Egypt, Iraq, Palestine	Quantitative descriptive comparative	Assess the factors influencing the attitudes of Bachelor of Science in Nursing students towards climate change and environment sustainability and the inclusion of these concepts in the nursing curricula of four Arab countries.	1059	Perception of climate change, perception of the nursing curriculum	
Ergin et al. (2021)	Turkey	Mixed methods	Evaluate the knowledge and awareness of the nursing students taking the Public Health Nursing course about global warming, climate change, the impact on health and the role of the public health nurse.	154	Perception of climate change, perception of their role regarding climate change	
Felicilda‐Reynaldo et al. (2018)	Saudi Arabia, Egypt, Iraq, Palestine	Quantitative descriptive (cross‐sectional)	Explore the knowledge of and attitudes towards climate change and its effect on health among student nurses from four Arab countries.	1059	Perception of climate change, perception of the health effects of climate change	
Hanley and Jakubec (2019)	Canada	Qualitative	Explore factors that influenced eco‐consciousness, how it affected nursing work, and how it was integrated into practice.	40	Perception of their role regarding climate change, perception of the nursing curriculum	
M. Kalogirou et al. (2020)	Canada	Qualitative (ethnography)	Explore Canadian nurses' perspectives on climate change, health, nursing practice and the relationships between these concepts	22	Perception of climate change, perception of the health effects of climate change, perception of the impact of their work on climate change, perception of their role regarding climate change	
May and Noel (2019)	United States	Quantitative descriptive correlational	Assess the knowledge, attitudes, and behaviours of school nurses related to the health impacts of climate change.	40	Perception of the health effects of climate change, perception of their role, perception of their needs	
Polivka et al. (2012)	United States	Quantitative descriptive	Determine the knowledge and attitudes of public health nurses concerning CC and the role of public health nursing in divisions of health departments in addressing health‐related impacts of climate change.	786	Perception of climate change, perception of the health effects of climate change, perception of the role of public health nurses regarding climate change	
Richardson et al. (2015)	United Kingdom	Quantitative	Measure attitudes towards embedding sustainability and climate change in nursing curricula among nursing students who had participated in a sustainability and health skills session; and determine whether the session could improve knowledge of sustainability.	57	Perception of their role regarding climate change	
Richardson et al. (2017)	United Kingdom	Quantitative	Measure the impact of a sustainability‐focused, scenario‐based learning educational intervention on the attitudes and knowledge of student nurses and midwives.	676	Perception of climate change, perception of the nursing curriculum	
Richardson et al. (2019)	United Kingdom	Quantitative descriptive	Assess the contribution of scenario‐based learning aimed at raising awareness of sustainability in health‐care practitioners.	391	Perception of their role regarding climate change, perception of the nursing curriculum	
Richardson et al. (2021)	United Kingdom	Quantitative comparative	Investigate student nurses' attitudes about the crisis and sustainability at the start of their undergraduate studies in 2019 and compare them with those of student nurses starting their degree program in 2014.	546	Perception of climate change, perception of the nursing curriculum	
Ryan et al. (2020)	United States	Quantitative descriptive (cross‐sectional)	Assess medical, nursing and physician assistant student knowledge and attitudes regarding climate change, pollution from the health care sector, and responsibility for resource conservation within professional practice.	53	Perception of climate change, perception of their role regarding climate change, perceptions of barriers to action	
Schenk et al. (2021)	United States	Quantitative descriptive	Measure nurses' awareness, motivation, concern, self‐reported behaviours at work, and self‐reported behaviours at home regarding climate change and health.	489	Perception of their role regarding climate change, perception of barriers to action	
Tiitta et al. (2021)	Finland	Qualitative descriptive	Identify the health issues that nurses associate with climate change and to determine their perception of their preparation to address its health impacts.	6	Perception of the health effects of climate change, perception of their role, perception of their needs	
Xiao et al. (2016)	China	Quantitative descriptive (Cross‐sectional)	Determine the knowledge and attitudes of nurses concerning climate change and their role in addressing health‐related impacts of climate change in Central China.	330	Perception of the health effects of climate change, perception of their role, perception of their needs	
Yang et al. (2018)	China	Quantitative descriptive (Cross‐sectional)	Measure the knowledge and perceptions of medical, public health, and nursing students about climate change and its impacts, and to identify associations between the knowledge and perceptions.	1387	Perception of climate change, perception of the health effects of climate change	

3.4 Nurses' perceptions of climate change and its impacts on health

Regarding nurses' perceptions of climate change, results suggested that nurses and nursing students in general had high levels of concern about climate change, but moderate knowledge and awareness about the subject. Indeed, most nurses and nursing students that took part in studies between 2012 and 2021 acknowledged that climate change is influenced by human activity to a certain extent, and that it has negative impacts on both humans and animals (Ergin et al., 2021; Kalogirou, Dahlke, et al., 2020; May & Noel, 2019; Polivka et al., 2012; Yang et al., 2018). However, they had varying levels of knowledge about the relationship of climate change to health or practice (Buriro et al., 2018; Kalogirou, Dahlke, et al., 2020; Polivka et al., 2012; Yang et al., 2018). For instance, in an American study from 2012, nurses were on average able to identify only 5 of the 12 targeted health impacts of climate change (Polivka et al., 2012). In this study, respondents with an associate degree were more likely to consider climate change as uncontrollable compared to those with a baccalaureate or graduate degree (Polivka et al., 2012). Even if those results are 12 years old, they are in line with those of more recent studies on the subject (Kalogirou, Dahlke, et al., 2020; Yang et al., 2018). Also, some recent studies highlighted factors associated with knowledge about climate change. Nurses with greater knowledge of climate change were those with a personal interest in this subject, those who had travelled and witness the international environmental and health impacts of climate change, and those who developed eco‐consciousness through the influence of early nature experiences and early professional experiences (Ergin et al., 2021; Hanley & Jakubec, 2019; Kalogirou, Dahlke, et al., 2020; May & Noel, 2019). Another study conducted in Pakistan suggested that recently graduated students had more knowledge of climate change and had more positive attitudes towards climate action. Furthermore, only 27.9% of participants identified climate change as the most important environmental issue related to human health, while having limited knowledge on its effects on health (Buriro et al., 2018). However, nurses in a study from Finland did observe some changes in their patients which they thought could be attributed to climate change; they were able to identify populations vulnerable to climate change, and noted more skin, respiratory, gastro‐intestinal infections and mental health problems (Tiitta et al., 2021), which also corroborates the results of an American study (Schenk et al., 2021). Moreover, the results of a study from China revealed that 44% of nurses thought climate change could affect their daily work (Xiao et al., 2016).

Furthermore, some studies suggested that nursing students seemed to have a high level of concern about climate change and its effect on health. In a recent American study, 94.6% of the nursing students were concerned about the health impacts of climate change (Ryan et al., 2020). In another study, more than half the nursing students believed that climate change is important for nursing health care and that it should be included in the nursing curriculum, which corroborates the results from other studies selected in this review (Anåker et al., 2021; Ergin et al., 2021; Richardson et al., 2019). Of the nursing students taking part in a Chinese study, 80% agreed that climate change has negative impacts on human health, and 85% anticipated serious health impacts in the next 20 years at the local, national and international level (Yang et al., 2018). Lastly, Swedish nursing students were mostly aware of the impacts of climate change on health and considered that it could aggravate poverty and make places uninhabitable (Anåker et al., 2021). They had a pessimistic view of the future and considered that different spheres of life can be directly affected by climate change (Anåker et al., 2021).

3.5 Nurses' perceptions of their role in relation to climate change, their needs and barriers to action

Many of the selected studies investigated nurses' and nursing students' perception of their role and responsibilities towards climate change.

3.5.1 Nursing students' perceptions and their need to include climate change in their training

In a recent American study, 86.8% of nursing students felt it is important to understand this issue, because they recognized that nurses have an important role to play in educating patients and the public about the impacts of pollution and climate change on health (Ryan et al., 2020). Additionally, according to Swedish nursing students, nurses can be role models to inspire others to participate towards sustainability (Anåker et al., 2021). Based on the Sustainability Attitudes in Nursing Survey (SANS or SANS‐2) questionnaire, most nursing students perceived climate change as an important issue for nursing and considered that it should be included in the nursing curriculum (Álvarez‐Nieto et al., 2022; Chen & Price, 2020; Cruz et al., 2018; Richardson et al., 2015, 2017, 2019). Furthermore, one of these studies collected data in 2019 and compared them to data collected in 2014; it revealed that more nursing students perceived climate change as an important issue for nursing in 2019 than in 2014 (Álvarez‐Nieto et al., 2022). Also, according to another study, having previous knowledge and awareness of the subject was a predictor of thinking that climate change is an important issue for nursing (Cruz et al., 2018). Another factor that seemed to influence their perception of the relevance of this issue for nursing was their country of residence and the type of community they live in. In fact, in a multicentre study comparing the attitudes of students from the UK, Spain, Germany, Sweden and Australia, more positive attitudes towards the importance of climate change for nursing and for its inclusion in the curriculum were noted across students from Sweden and Germany (Álvarez‐Nieto et al., 2022). In another multicentre study, students from Saudi Arabia and those living in urban and suburban communities were more likely to think of climate change as relevant to nursing than students coming from Iraq, Egypt and the Palestinian Territories and those living in rural communities (Cruz et al., 2018; Felicilda‐Reynaldo et al., 2018). Finally, students from China had more positive attitudes towards the importance of climate change for nursing in a study using the same scale, compared to students from England (Chen & Price, 2020).

3.5.2 Nurses' perception of their role regarding climate change

Nurses see their role in the climate crisis as multi‐faceted. Table 3 showcases the different nursing roles and actions explored in the selected studies and the related barriers.

TABLE 3 Nurses' perceptions of their roles, needs and barriers to action regarding climate change.

Role	Barriers to action	Needs	
Reducing the practice's contribution to greenhouse gas

Recognizing the impacts of climate change on health

Addressing the impacts of climate change on health

Advocating for vulnerable patients health

Teaching about how climate change impacts health

	Time constraints and heavy workload

Lack of knowledge and training

Complexity of the issue

Patient safety and care quality

Lack of support and recognition from colleagues, employers, organizations, and the public

	Inclusion in the nursing curriculum

Continuing education on climate change

Increased awareness

Support from organizations

	

The first role is of reducing the practice's contribution to greenhouse gas in the nurses' daily work. In a study from China, 56% of nurses did not know that their practice can contribute to the development of climate change and only 39% though actions in their work could help mitigate it (Xiao et al., 2016). However, in other studies, nurses perceived the important production of waste generated by their work as well as the impact it has on transport. Avoiding material waste when possible while conserving high care quality and promoting remote consultations have been named by nurses as solutions to reduce the healthcare system's impact on climate change (Anåker et al., 2015; Kalogirou, Dahlke, et al., 2020). Another study suggested that even if many nurses seemed to perceive climate change as an important issue, they were uncertain of their role in addressing it and did not always understand how it was possible to incorporate environmental impact and environmentally responsible practice into their daily work (Kalogirou, Dahlke, et al., 2020). Indeed, it was often seen as a more personal preoccupation rather than with a social or global perspective and nurses reported more frequent actions for climate change at home than in the workplace (Schenk et al., 2021).

The second role is to be able to assist populations that are vulnerable to the health effects of climate change. School nurses who took part in a quantitative study agreed that the health of students has been impacted by climate change and therefore that they need to be frontline providers to a vulnerable population affected by climate change (May & Noel, 2019). However, their response was less positive about the role of school nurses in advocating for measures to address climate change at a more global level.

The third role is recognizing the health impacts of climate change on their patients and being able to address them. Public health nurses considered that public health nursing has a responsibility to address health‐related impacts of climate changes, but lacks the ability to address these impacts and is not prepared enough (Polivka et al., 2012). Furthermore, according to a qualitative study from Sweden, nurses' personal opinions about climate change shaped how they acted and thought in their daily work (Anåker et al., 2015). Moreover, nurses taking part in an American study had high motivation to change nursing practice to reduce greenhouse gases, to teach about how climate change impacts health and to prepare for its health impacts in their workplace (Schenk et al., 2021). The main reasons cited for their high motivation were to have clean air and water, for the future, to protect the planet, and for their family (Schenk et al., 2021).

Overall, both nurses and nursing students saw a significant need for education on climate change, its impacts on health and their role in addressing these issues, in both curriculum and continuing education (Álvarez‐Nieto et al., 2022; Anåker et al., 2015, 2021; Chen & Price, 2020; Ergin et al., 2021; Kalogirou, Dahlke, et al., 2020; Richardson et al., 2015, 2017; Ryan et al., 2020; Tiitta et al., 2021; Xiao et al., 2016). In a Chinese study, 45% of nurses thought that social media was the best way to learn about the health effects of climate change, compared to 15% for school (Xiao et al., 2016). In some studies, nurses also saw a need for awareness of the issues and solutions to enable the healthcare system to respond properly (Anåker et al., 2015; Ryan et al., 2020). Finally, they raised an important need for organizations to support initiatives aimed at reducing the impact of climate change in the workplace (Anåker et al., 2015).

3.5.3 Nurses' and nursing students' perceptions of barriers to action

According to nurses and nursing students, barriers to action included the lack of time to integrate climate content in their day‐to‐day practice and their heavy workload, the emotional demands of the job, not having enough knowledge and training, feeling overwhelmed by the complexity of the issue, the need to maintain high patient care quality and safety, and feeling unsupported and unrecognized in their efforts by colleagues, employers, organizations, and the public (Chen & Price, 2020; Hanley & Jakubec, 2019; Kalogirou, Dahlke, et al., 2020; Ryan et al., 2020; Schenk et al., 2021; Tiitta et al., 2021). Moreover, nurses didn't necessarily recognize their responsibility regarding climate change, and their daily work saving lives requires substantial effort, leaving neither time nor energy to consider environmental health (Anåker et al., 2015). Moreover, Swedish nurses thought that taking action towards climate change is not a priority for healthcare organizations compared to being cost‐effective, and because these issues seem too complex to be addressed (Anåker et al., 2015). They also thought that since saving lives is the main objective for nurses, it is the main thing addressed in the curriculum, which makes climate change difficult to apply to nursing (Anåker et al., 2021).

3.5.4 Nursing organizations' perception of the nursing role

Some of the associations whose websites were consulted as part of the grey literature review have taken a stance on nurses' role and responsibilities towards climate change. Firstly, the Quebec Nurses' Association (OIIQ), the province in which this literature review was carried out, took position in 2019. The organization's aim was to raise its members' awareness of the impacts of climate change on the health of populations, and to make them aware of their role and obligations about the assessment, monitoring and teaching of clients in the context of climate change (Ordre des infirmières et infirmiers du Québec, 2019). According to the association, nurses need to be able to recognize the health impacts of climate change and identify groups that are the most vulnerable (Ordre des infirmières et infirmiers du Québec, 2019). That same year, the Canadian Nurses Association (CNA) took a similar stand on these issues (Canadian Nurses Association, 2019). Furthermore, in 2020, the student members of the OIIQ published their own position paper. Indeed, the youth committee felt that nurses should serve as role models for society as leaders in the fight against climate change and proposed integrating notions of climate change and its impact on health into nursing training, and in low‐cost, accessible training programs. They also proposed setting up sustainability committees in all Quebec healthcare establishments (Comité jeunesse de l'ordre des infirmières et infirmiers du Québec, 2020). In 2020, the Secrétariat des infirmières et infirmiers de l'espace francophone (SIDIIEF) also spoke out on the collective responsibility to protect the planet from climate change (Secrétariat des infirmières et infirmiers de l'espace francophone, 2019). In 2019 and 2021, the International Council of Nurses (ICN) published position papers calling on the world's governments to take immediate action to avert a climate crisis that will have devastating effects on the health of people around the world (International Council of Nurses, 2019, 2021). Finally, the nursing organizations that have expressed their views on the subject were unanimous: nurses can make a huge contribution both to mitigating climate change and to helping people and communities adapt to its effects.

Some nursing associations also released guidelines about the inclusion of climate change in the nursing curriculum. In 2011, the American Association of Colleges of Nursing (AACN) issued recommendations aimed at fostering environmentally sustainable practices within its member nursing schools (AACN, 2011). In 2021, the AACN also stated that understanding the impact of climate change on environmental and population health represents an entry‐level competency for nurses to have (American Association of Colleges of Nursing, 2021). In 2020, the Canadian Association of Schools of Nursing (CASN) also released guidelines to define the key knowledge, skills, and attitudes that all new registered nursing graduates in Canada should possess to support and care for individuals, families, communities, and populations impacted by, or susceptible to the effects of climate change (CASN, 2020).

4 DISCUSSION

This scoping review of the literature sought to identify nurses' perceptions of climate change. To our knowledge, this study was the first scoping review to identify nurses' perceptions of climate change. Given that there have been recent studies conducted on this topic, conducting a comprehensive review of this growing body of literature became essential in order to gain a global perspective. Overall, results suggested that nurses and nursing students were generally concerned about climate change, but had varying levels of knowledge and awareness about the relationship of climate change to health, health inequities and practice and their role in addressing these issues as nurses (Buriro et al., 2018; Ergin et al., 2021; Kalogirou, Dahlke, et al., 2020; May & Noel, 2019; Polivka et al., 2012; Yang et al., 2018). Some factors seemed to influence nurses' and nursing students' concern and knowledge, such as the country of residence and type of community (rural of urban), the educational level, the graduation year, past travels, personal interest in the subject and past implications and experiences (Álvarez‐Nieto et al., 2022; Chen & Price, 2020; Cruz et al., 2018; Ergin et al., 2021; Felicilda‐Reynaldo et al., 2018; Hanley & Jakubec, 2019; Kalogirou, Dahlke, et al., 2020; May & Noel, 2019). However, more studies are needed to better understand these factors and their impact on nurses' knowledge and perceptions of climate change.

Moreover, while nursing organizations at the local, national, and international levels took stances on the importance of nursing leadership regarding climate change, surveyed nurses often expressed uncertainty about concrete actions they can take to mitigate the effects of climate change and help vulnerable population to adapt to its effects. Indeed, they were uncertain of how to incorporate environmental impact and environmentally responsible practice into their daily work and often saw it as a personal preoccupation rather than with a social or global perspective (Kalogirou, Dahlke, et al., 2020). They also faced multiple barriers in fully fulfilling their role, such as the lack of time and training, feeling overwhelmed by the complexity of the issue, and feeling unsupported and not recognized in their actions (Chen & Price, 2020; Hanley & Jakubec, 2019; Kalogirou, Dahlke, et al., 2020; Ryan et al., 2020; Schenk et al., 2021; Tiitta et al., 2021). Kalogirou, Olson, and Davidson (2020) have formulated theories to explain why nurses tend to approach the environment with a local rather than global perspective, a perspective that subsequently shapes their perceptions of climate change. According to these authors, nurses perceive the environment, along with their connection to it, primarily in terms of the individual patient. Consequently, nurses may have not been encouraged to grasp these concepts from a more expansive perspective during their training. This conceptualization therefore does not promote nurses to view the environment as something they can impact or as something their practice can influence whether positively or negatively. It also fails to recognize the significance of addressing the consequences of climate change in and out of the workplace. To address these limitations, the authors proposed a planetary health perspective as a theoretical foundation for nursing education, research and practice (Guzmán et al., 2021; Kalogirou, Olson, & Davidson, 2020). Potter (2021) also argued that planetary health is essential for nursing students to acquire the knowledge and skills to restore planetary health and the health of future generations. This perspective could be promising, and more research could allow to grasp its potential benefits in the training of future nurses.

Furthermore, to better understand their role regarding climate change, both nurses and nursing students raised a significant need for education, though undergraduate and graduate curriculum, continuing education and social media (Álvarez‐Nieto et al., 2022; Anåker et al., 2015, 2021; Chen & Price, 2020; Ergin et al., 2021; Kalogirou, Dahlke, et al., 2020; Richardson et al., 2015, 2017; Ryan et al., 2020; Tiitta et al., 2021; Xiao et al., 2016). Hence, education could be a promising way to fill the possible gap between the importance of the nursing role in addressing the health impacts of climate change and the lack of knowledge and awareness of nurses in this matter. The grey literature revealed that guidelines do exist for nursing schools in Canada and in the United States to includes these subjects in the curriculum (AACN, 2011; CASN, 2020). In 2022, the National League for Nursing, an association from the United States promoting excellence in nursing education, released a vision statement regarding the crucial need for nurses to be educated about the health impacts of climate change (National League for Nursing, 2022). This association notably recommended for climate change and planetary health to be embedded in the nursing curricula, including in didactic, clinical and simulation learning experiences. To better comprehend this need and the tools available to educational establishments to address it, a second review was conducted at the same time as this scoping review (Diallo, Roberge, Bérubé & Audate, 2023). The question it sought to answer was “How are issues related to climate change addressed in the nursing curriculum?” and the published protocol is available online (https://bmjopen.bmj.com/content/13/1/e068520.abstract). The results of this scoping review will be published in the following months.

Finally, nursing and healthcare organizations, educational institutions, and policy makers could use the results of this scoping review to identify the elements that would help prepare nurses to face this climate crisis and to identify promising strategies to empower them to carry out their advocacy role towards vulnerable patients. Since time constraints was a barrier for nurses to include climate action in their daily work, research could help identify effective actions organizations could take to reduce these constraints for policy advocacy. Research could also help better identify differences between the perception of nurses from different countries and possible reasons for these differences, such as a greater exposure to climatic hazards, more climate focused training or awareness in their country, or a difference in socio‐economic status.

4.1 Strengths and limitations of the study

This scoping review allowed us to identify nurses' perceptions of climate change. It used precise and transparent methods based on study and reporting guidelines by Arksey and O'Malley (2005) and refined by Levac et al. (2010). Despite rigorous analysis and the synthesis process used, certain limitations must be considered. The main limitation of this study is the possibility that the review may have missed some relevant studies. In fact, searching more bibliographic databases or including studies published in languages other than English or French could have allowed for more studies to be found. Furthermore, even if the inclusion of the grey literature constitutes a great strength of this scoping review, only a certain number of relevant nursing related websites could be consulted due to time constraints. Therefore, some relevant articles could be missing. The very nature of grey literature searches may also have introduced a degree of bias in the search results. Finally, as this review is not systematic, we did not assess the quality of the selected studies and consequently can't take the reliability, validity, or bias of these studies into consideration. As scoping review give an overview of the scope of literature available without producing statements to guide decision‐making, reviewing studies quality is optional in this approach (Munn et al., 2018).

5 CONCLUSION

The results of this study emphasize the importance of raising awareness about climate change, its effects on health and the role nurses can play in addressing this critical issue. In fact, most of the included studies have mentioned the demand for accessible trainings on climate change and climate actions among nurses and nursing students, both within their educational curriculum and as part of their professional development. This would empower and better prepare them to provide healthcare in a changing climate. Healthcare organizations should also strive to remove obstacles to action that nurses encounter. This could be achieved by providing support to nursing initiatives and prioritizing them within the organizational framework. The next steps considering these results are to encourage the diffusion of the nursing initiatives and research regarding climate change and to support a better early integration of climate change in curricula through program regulation. Building on the generally positive attitude of nurses and nursing students towards actions against climate change, participative learning opportunities focused on their role should be developed. This could allow them to fully act as representatives of global health and to advocate for their vulnerable patients.

AUTHOR CONTRIBUTIONS

AB, TD, MR and PA contributed to the design of the work, and to the acquisition of the data. AB and TD contributed to the analysis and interpretation for the work. AB drafted the manuscript. All authors reviewed the work critically for important intellectual content and approved the final version of the version to be published.

CONFLICT OF INTEREST STATEMENT

The authors declare no conflicts of interest.

ETHICS STATEMENT

This scoping review did not require ethical approval.

Supporting information

PRISMA‐ScR Checklist.

ACKNOWLEDGEMENTS

We would like to thank the Faculty of Nursing Sciences of Laval University for the research support fund granted to TD (fund SAR–SR‐133186). For all her assistance in developing our bibliographic search strategy, we would also like to express our gratitude to Marie‐Claude Laferrière, our library consultant at Université Laval.

DATA AVAILABILITY STATEMENT

Data sharing is not applicable to this article as no data sets were generated or analyzed.
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