Preparing Graduate Nursing Students to Lead Nursing Green Teams: Approach and Identified Greening Opportunities and Solutions
2024; Wiley; Linguagem: Inglês
10.1111/jan.16504
ISSN1365-2648
Autores Tópico(s)Healthcare Facilities Design and Sustainability
ResumoHealth care waste and pollution are world-wide problems (World Health Organisation 2018). Nurses are well-positioned to be leaders in addressing waste, climate change, and other pollution from health service delivery; however, they often are unaware and/or underprepared to take action (Akore Yeboah, Rodrigues Amorim Adegboye, and Kneafsey 2024; Luque-Alcaraz et al. 2024). Internationally, nurses are increasingly being called to action to apply environmental health concepts to nursing practice and follow the ethical principle of first do no harm (International Council of Nurses [ICN] 2018; American Nurses Association [ANA] 2007, 2010). The ICN published a "Nurses, Climate Change, and Health Policy Statement", indicating that nurses have a shared responsibility to sustain and protect the natural environment from depletion, pollution, degradation, and destruction (ICN 2018). The Institute of Medicine, ANA, and American Public Health Association (APHA) developed and disseminated standards of practice and policy statements that guide nurses to provide care in a way that is environmentally safe and healthy and become environmental health activists in their work settings (ANA 2007, 2010; APHA 2022; IOM 1995). Recently, the ANA disseminated a position statement, "The Nurse's Role in Addressing Global Climate Change and Human Health," which describes the critical roles that nurses must play in addressing climate change (ANA 2023). A common theme in these guidelines is the need to educate nurses globally about environmental health concepts, including climate change, and integrate this content into nursing school curricula to prepare nurses to apply environmental health principles in their practice and advocate for climate-smart health care (ANA 2007, 2023; ICN 2018). The purpose of this project is to educate graduate nursing students about environmental health, the contributions of health services to climate change and other forms of pollution, and strategies to mitigate these contributions, and engage students in working collaboratively as team members to identify opportunities to green their respective work environments and plan specific organisational changes to address the identified problems. Climate change is occurring because some gases in our atmosphere absorb energy from sunlight, trapping this heat rather than allowing it to be reflected back into space (United States Environmental Protection Agency [US EPA] 2023a). These greenhouse gases include carbon dioxide, methane, nitrous oxide, and fluorinated gases (U.S. Energy Information Administration [US EIA] 2022; US EPA 2023b). Approximately 80% of greenhouse gases from human activity have been attributed to carbon dioxide (US EPA 2023b). This energy from the sun is important to life on Earth and supports key processes, such as photosynthesis (US EIA 2022; University of California Regents [UCR] 2024). However, the energy budget, or the amount of energy that is absorbed versus reflected, needs to be balanced (UCR 2024). Currently, about 71% of the sunlight reaching the Earth is absorbed by the Earth's atmosphere and surface, which is slightly out of balance, resulting in warming of the planet (UCR 2024; University Corporation for Atmospheric Research 2024). This warming is associated with more extreme weather, rising sea levels, and adverse physical and mental health effects, especially among vulnerable populations (US EPA 2023c). Health service organisations contribute to climate change through direct and indirect activities, including through energy use, anaesthesia gases, use of plastics, waste management practices, and production and transportation of supplies, equipment, pharmaceuticals, and food (Eckelman et al. 2020; Gerwig 2015; Seervai, Gustafsson, and Abrams 2022; U.S. Department of Energy [US DOE] 2021, 2023). About 10% of energy consumption in commercial buildings in the United States is attributed to health services, from heating, cooling,ventilation, lighting, office equipment, refrigeration, medical equipment, and other uses (Shen et al. 2019; US DOE 2021, 2023). Inhaled anaesthesia gases, such as isoflurane, sevoflurane, and desflurane, are greenhouse gases that are emitted into the environment as waste gas, often vented off rooftops (Andersen, Nielsen, and Sherman 2023; Vollmer et al. 2015). Plastics, which are made from oil, gas, and coal, account for about one-third of health service waste (Health Care Without Harm 2021; Rizan et al. 2020). They contribute about 4% of total greenhouse gas emissions through their lifecycle (Organisation for Economic Co-operation and Development [OECD] 2023). Health service organisations in the United States generate more than five billion pounds of waste per year (Wisniewski et al. 2020). The amount per patient day ranges widely in different countries from approximately one pound in Morocco to 24 pounds in the United States (Janik-Karpinska et al. 2023). A large proportion of medical waste is incinerated, which has a major effect on climate pollution (Bauman 2019; Zero Waste Europe 2019). Indirect emissions occur from producing and transporting supplies, equipment, food, and other items to health service organisations, accounting for approximately 80% of emissions (Seervai, Gustafsson, and Abrams 2022). Nurses are well-positioned to support decarbonization of the health sector and lead and advocate for climate-smart health care initiatives (ANA 2023; Butterfield, Leffers, and Vasquez 2021). One way that nurses can get involved is to form or join green teams, which are voluntary groups who collaboratively plan and implement sustainability initiatives and educate and inspire others to take action (McDermott-Levy 2011; Mejia and Sattler 2009; Practice Greenhealth n.d.). Several green teams guides provide tips for creating green teams, such as using a top-down and bottom-up approach, including team members from multiple disciplines, planning a kick-off and follow-up meetings, developing a mission statement, conducting a needs assessment, collecting baseline data, creating team roles and norms, identifying champions, establishing priorities, developing measurable goals, monitoring and evaluating outcomes, and disseminating success stories (Practice Greenhealth n.d.; ZeroWaste Schools n.d.). The American Association of Colleges of Nursing (AACN n.d.) calls for a shift in nursing education to competency-based education. The AACN defines competency-based education as "a system of instruction, assessment, feedback, self-reflection, and academic reporting that is based on students demonstrating that they have learned the knowledge, attitudes, motivations, self-perceptions, and skills expected of them as they progress through their education (AACN 2024)." This is reflected in The Essentials: Core Competencies for Professional Nursing Education (AACN n.d., 2021, 2023). Several approaches to apply competency-based education are: specify clear competencies and expectations that have relevance to professional roles; structure the curriculum and learning experiences to build on skills and knowledge sequentially; create projects and activities that provide real-world experiences to apply critical thinking skills and solve problems; personalise the teaching approach, pace, and assessment strategy; provide constructive and timely feedback; and facilitate open communication and collaboration (AACN 2023, 2024; Neelakandan 2023). The 10 AACN Essentials domains, eight related concepts, and many competencies and sub-competencies are directly relevant to environmental education for nurses (AACN 2021). One AACN sub-competency that is relevant to environmental health is listed within Domain 3: Population Health, sub-competency 3.2d, Ascertain collaborative opportunities for individuals and organisations to improve population health (AACN 2021, p.34). A second example is Domain 5: Quality and Safety, sub-competency 5.1 m. Lead the development of a business plan for quality improvement initiatives (AACN 2021, p.40). The Environmental Health & Equity Collaborative, a group of environmental health professionals, was charged with developing a set of environmental health competencies (Martin and Latshaw 2020). This group reviewed the literature and collected survey data about environmental health skills and knowledge to develop a set of competencies, which they categorised into assessment, management, and communication (Martin and Latshaw 2020). The 14 competencies are information gathering; data analysis and interpretation; evaluation; problem solving; economic and political issues; organisational knowledge and behaviour; project management; computer and information technology; reporting, documentation, and record keeping; collaboration; education; communication; conflict resolution; and marketing (Martin and Latshaw 2020). In a systematic literature review focused on identifying environmental competencies that are relevant to nursing education, included studies (n = 32) focused heavily on knowledge and awareness; however, few identified competencies focused on modifying behaviours to reduce personal effects on climate and delivering more sustainable care (Lopez-Medina et al. 2019). Several identified competencies related to educating the public about climate change are communication, management, and decision-making skills. More generic competencies for health workers are "critical reflection and innovative problem solving" (Lopez-Medina et al. 2019, p.5). Table 1 displays additional examples of the alignment of AACN Core Competencies for Professional Nursing Education with expectations listed in the Leading Green Teams assignment and the Environmental Health and Equity Collaborative competencies (AACN 2021; Martin and Latshaw 2020). Domain 1: Knowledge for Nursing Practice 1.1f. Demonstrate the application of nursing science to practice 1.2f. Synthesise knowledge from nursing and other disciplines to inform education, practice, and research 1.2i. Demonstrate socially responsible leadership Students apply information about leadership, advocacy, communication, environmental health, and knowledge of their organisational practices to develop a green teams plan Several components of the green team plan are: Developing an agenda to lead the first green teams meeting; identifying greening opportunities in five categories; and recommending socially responsible evidence-based changes for each opportunity Problem solving Organisational knowledge and behaviour Project management Domain 3: Population Health 3.1l. Use established or evolving methods to determine population-focused priorities for care 3.1m. Develop a collaborative approach with relevant stakeholders to address population health care needs, including evaluation methods 3.2d. Ascertain collaborative opportunities for individuals and organisations to improve population health 3.3f. Incorporate ethical principles in resource allocation in achieving equitable health Students apply assessment skills and knowledge about organisational practices and environmental health to identify green team priorities, develop a plan to implement changes, and specify measures to demonstrate successful change As part of the decision-making process, students weigh the alternative approaches to delivering health services, including the effects on the health of patients, health workers, community, and planet Example: students may review published lifecycle analyses of reusable versus disposable plastic speculums with respect to environmental effects, durability, health and safety, and costs and weigh these factors in their decision-making Information gathering Problem solving Organisational knowledge and behaviour Project management Collaboration Domain 4: Scholarship for the Nursing Discipline 4.1j. Discern appropriate applications of quality improvement, research, and evaluation methodologies 4.2f. Use diverse sources of evidence to inform practice 4.2g. Lead the translation of evidence into practice Information gathering Data analysis and interpretation Problem solving Economic and political issues Organisational knowledge and behaviour Project management Domain 5: Quality and Safety 5.1m. Lead the development of a business plan for quality improvement initiatives 5.2i. Design evidence-based interventions to mitigate risk Students work collaboratively in teams to develop a written plan to improve health service delivery One section involves developing a plan to implement changes, including strategies to facilitate change and approaches to advertise, promote, and increase awareness of the plan Problem solving Organisational knowledge and behaviour Project management Educate Communicate Marketing Domain 6: Interprofessional Partnerships 6.2g. Integrate evidence-based strategies and processes to improve team effectiveness and outcomes 6.3d. Direct interprofessional activities and initiatives Collaboration Communicate Domain 7: Systems-Based Practice 7.2h. Design practices that enhance value, access, quality, and cost-effectiveness 7.3h. Design system improvement strategies that address internal and external system processes and structures that perpetuate structural racism and other forms of discrimination in health care systems Students develop plans that aim to improve value, quality, and cost-effectiveness by reducing wasteful, inefficient, and harmful practices This assignment helps to address structural racism because health care associated waste is sometimes incinerated; the related pollution is likely to inequitably affect under-resourced communities Problem solving Economic and political issues Project management Communicate Domain 9: Professionalism 9.1i. Model ethical behaviours in practice and leadership roles 9.3k. Address actual or potential hazards and/or errors 9.3m. Advocate for policies [and/or] practices that promote social justice and health equity Problem solving Economic and political issues Domain 10: Personal, Professional, and Leadership Development 10.1c. Contribute to an environment that promotes self-care, personal health, and well-being This paper describes an educational experience aimed to prepare graduate nursing students to work collaboratively on a team and enhance professional nursing skills related to forming and leading nursing green teams and identifying realistic opportunities and solutions to green health services. Additionally, a qualitative document review of student papers was conducted, and the results of student-identified greening opportunities and solutions are summarised. This educational experience was implemented one semester per academic year, from 2021 through 2023, in a required online 15-week Health Care Policy and Leadership course for students enrolled in the Master of Science in Nursing program. Students were enrolled in nurse practitioner and leadership tracks. Environmental health and greening of health care was the focus of one of 15 modules and occurred in week nine during 2023, week 10 during 2022, and week 12 during 2021. Prior to completing the Leading Green Teams assignment, students completed modules covering topics such as: introduction to health policy; health policy advocacy; leadership roles, skills, and strategies; leadership role in developing policy; communication; social media; influencing policy through professional groups; translating research to policy; evidence-based practice and policy; policy analysis and policy research; environmental policy; and greening of health services. The course content is displayed in Table 2. Educational resources for the Environmental Policy and Greening of Health Services module were provided to students initially on Sakai and later on Canvas. This class session was provided asynchronously. Student resources, posted to the online module, included a content summary, readings, websites, recorded presentations with presentation notes, handouts, videos, and a Leading Green Teams small group assignment. The three recorded presentation topics were: Part one—introduction to environmental health and greening of health care; Part two—policy approach to greening health care; and Part three—greening health care—problems and solutions. Students were assigned to read seven chapters in Greening Health Care: How Hospitals Can Heal the Planet as a project resource (Gerwig 2015). The ZeroWaste Schools (n.d.) green team guide was an additional resource. Earlier course content supported the project, including leadership, advocacy, communication, translating research to policy, and evidence-base practice and policy. Green Teams assignment expectations were provided to students as detailed instructions, a grading rubric, and a paper template with instructions, paper structure, and sample text. The components of the Green Teams project are: introduction to the green team plan and purpose statement; plan to identify and recruit stakeholders; agenda for initial green teams planning meeting; proposed approach to assess and identify opportunities for improvement; identify one greening opportunity for each of five categories; recommend changes to green health care—for each opportunity; plans to implement changes; measures to demonstrate greening success; summary table of opportunities, solutions, and measures; and team member contributions, collaboration, and integration (Table 3). The five categories to be addressed are food; "managing and minimizing hospital waste; green chemicals and detoxing of health care; environmentally preferred purchasing; and greening the built health care environment" (Gerwig 2015, Contents). Additional assignment details are displayed in Table 3. Written Plan: Leading Green Teams Introduction to the Green Team Plan and Purpose Statement Indicate one very specific opportunity for each of the five categories below; concisely describe each specific exposure or wasteful practice Food Managing and minimising hospital waste Green chemicals and detoxing of health care Environmentally preferable purchasing Greening the built environment For each of the five recommended changes, indicate one specific measure that would demonstrate success in greening each practice These measures may focus on: behaviour change, practice change, efficiency, effectiveness, equity, or some other relevant measure This educational experience focused on several environmental health competencies, including information gathering, problem solving and critical reasoning, organisational knowledge and behaviour, project management, documentation, collaboration, and communication (Lopez-Medina et al. 2019; Martin and Latshaw 2020). It also aligned with the AACN Essentials domains, including: knowledge for nursing practice; population health; scholarship for nursing discipline; quality and safety; interprofessional partnerships; systems-based practice; professionalism; and personal, professional, and leadership development (AACN 2021; Table 1). The AACN concepts that are most relevant for this learning experience are clinical judgement, communication, ethics, evidence-based practice, and social determinants of health (AACN 2021). All submitted student team projects, submitted during the fall semester of 2021, 2022, and 2023, were reviewed, and all greening of health care opportunities and solutions for each of the five environmental categories was abstracted: food; managing and minimising hospital waste; green chemicals and detoxing of health care; environmentally preferable purchasing; and greening the built environment (Gerwig 2015). Abstracted information was entered in five tables and assessed for relevance to greening or sustainability, fit with the category assigned by students, and whether the examples were specific enough and likely to be reasonable to implement by small volunteer green teams. Examples that were not greening issues were omitted, and some examples were redistributed into other categories to group similar examples. For example, food examples that were listed in minimising hospital waste were moved to the food category table; and many examples in preferrable purchasing were redistributed to other categories based on fit. Similar examples were combined. Broad greening examples, such as use of polyvinyl chloride (PVC) plastic materials in construction, are displayed even if these examples would be difficult to achieve by volunteer green teams. Greening opportunities, solutions, and performance measures are displayed in Tables 4–8. Food is wasted when: Patients have submitted requests for meals from the hospital menu and are then discharged home or transferred to another facility; the dietary department was not notified, and food is wasted because it was delivered to a patient's room Food trays are automatically delivered without patients being given choices Food quantities are larger than what the patient wants More food is prepared than is needed overall Patients are given extra portions of food that they do not finish The patient doesn't eat some types of food on the tray Expiration dates on food have passed, such as the sandwiches, cheese, and milk in refrigerators on the patient care units that are available for patient snacks When a patient is transferred to the floor unit or discharged home, the nurse, charge nurse, or health unit coordinator will call the food service department and let them know that the patient has been moved or has left Implement a process that provides patients, family members, and/or nursing staff the opportunity to specify food choices or preferences for foods; provide foods based on selected preferences and nutritional needs Reduce food portion sizes to meet the United States Department of Agriculture (USDA) My Plate recommendations Repurpose leftover food based on the Food and Drug Administration (FDA) guidelines; use the food in other dishes and/or donate the food Develop a system for checking expiration dates on foods routinely; designate a nurse champion on the unit to audit the refrigerator contents and communicate the supply and expiration dates to the dietary department; coordinate with the dietary department to stock the refrigerator routinely with fresh, nonexpired products Donate unused food to local organisations, such as local food banks, to divert waste from landfills and benefit the local community Compost: see details below Volume of food served Volume of food donated Volume of hospital waste Number of food trays that are not used Volume of food waste Volume of food composted Hospital-wide and unit-based expenditures for food Expenses for food kept on the unit Expenditures for waste disposal Compliance with patient food orders and correlate compliance with waste Practice changes Policy changes Composting: Compost bins are not widely available; composting is only available in food preparation areas The health system doesn't have a composting service Provide compost bins in the hospital cafeteria After patient food trays are returned to the food service department, staff can sort compostable food and other items from materials that can be recycled trays Develop a partnership with an organisation that picks up compostable food waste and converts it to green energy or fertiliser; commercial composters can often compost vegetable matter, meats, fish and chicken bones, dairy products, paper towels, compostable containers and utensils, pizza boxes, and more Volume of food composted Volume of food waste Dietary costs in the ED Waste volume and/or weight Patient satisfaction Number of "priority" replacement trays ordered Volume of food waste Address "plate waste" by offering flexible portion sizes, electronic ordering, and protected mealtimes Print the telephone number for making changes to meals on the menus for easy access; allow food orders to also be changed through an online ordering system, up to an hour before mealtimes Volume of enteral nutrition products used Volume of enteral nutrition products wasted Set up daily "check-ins" between our formula technicians and primary nurses assigned to patients requiring prepared formula to discuss expected discharge dates or times to limit the amount of prepared specialty formula that is made Purchase less formula at one time Stock less formula on the unit Create a formula logging system to track use and availability of pre-made formulas The hospital serves food that: is processed; grown with pesticides, antibiotics, and genetically modified organisms (GMO); is not locally sourced Many food options are not in season Food delivered to the hospitals travels a long distance in large trucks Encourage the health system to sign the Healthy Food in Health Care Pledge (Health Care without Harm), committing to buy locally sourced food, reduce amount of food served containing pesticides, growth hormones, and/or antibiotics, and adopt sustainable ways to procure food Develop and implement a policy to purchase locally grown food, generally only within 100 miles from the health center; source food from local and regional food systems, such as local farmers instead of purchasing from large corporate suppliers; establish a community-supported agriculture (CSA) with local farmers Purchase and serve foods that are not processed Purchase and serve foods that are in season Purchase food certified by a third-party as sustainably produced Purchase food grown or produced without pesticides, antibiotics, or added hormones Include a higher percentage of plant-based menu options in the cafeteria and patient meals Increase offerings of fruits and vegetables and decrease meat products Have farmers participate in recurring events to sell locally grown spray-free produce and dried goods; sponsor a farmers' market at the health system to provide patients and employees with fresh food Evidence that the Healthy Food in Health Care Pledge was signed and adopted Percent of food spent on sustainably produced food Proportion of food purchased that is grown sustainably Number and percent of menu items that are seasonal produce items Proportion of food purchased by the hospital that is grown without chemical pesticides Contracts established with local growers Steps are completed to establish farmers' market on the health system campus Build a rooftop garden with a water catchment system; use the garden products in cafeterias and sell them to employees and local residents at the farmers' market Seek volunteers and students of the horticulture program at a local community college to oversee maintenance and upkeep of the garden Percent of water purchased from city versus rainwater used Percent of food purchased versus grown and used from the garden Percent of foods served that are highly processed Bottled water is offered on the hospital menu Ice water is served in single-use plastic cups Food containers are made from plastic or polystyrene and are not recyclable or biodegradable The health system uses Styrofoam cups and trays to serve food; Styrofoam beverage cups are used on units for patients and staff Plastic utensils are used routinely Stop purchasing bottled water; if needed, replace with water in aluminium cans or paper cartons Encourage employees to use their own reusable water bottles At meals, staff will serve iced water in reusable cups, located on hospital units; water will come from water and ice dispensers on each unit Use reusable, biodegradable, paper, or aluminium food containers Use reusable cups, when feasible; if disposable ones are needed, use paper or compostable cups Nursing unit will purchase 8-oz reusable cups to be stored in the units' clean utility rooms; upon admission, patients will get a cup that can be washed and reused for the length of admission Use reusable plates, trays, and utensils in the hospital cafeteria Provide reusable or bamboo flatware or utensils Cost of water used for drinking Changes in drinking water practices Volume of drinks in plastic and aluminium containers purchased Volume and percent of containers purchased that are recyclable, reusable, and non-recyclable Volume of polystyrene or Styrofoam products purchased Percentage of products used in cafeteria that are eco-friendly Weight of garbage Measure baseline number of coffee creamers ordered or used each week Use a checklist, each week, and observe that there are no creamers in the nursing room break room Recycle or eliminate single-use plastic wrapping, plastic straws, and plastic lids Discontinue availability and use of plastic straws in cafeteria and on patient trays and be freely Place plastic recycling bins in the cafeteria and patient areas to properly dispose of recyclable plastic items Measure and record the volume of recycled plastic each month in pounds or kilograms Plot and display this information on the unit Conduct rounds of the unit to visualise recycling bins and their locations Provide reusable water bottles to each admitted patient for the patient(s) to use while hospitalised Purchase compostable or recyclable straws rather than plastic straws Number of disposable cups and water bottles that are used Cost of disposable cups and other related items Eighty-three graduate nursing students completed this educational experience over three semesters. Students were assigned to 37 teams of two to three students per team. Of 185 submitted opportunities and solutions, 178 focused on greening and seven were omitted for focusing on other topics. Specificity of greening opportunities varied widely. Three categories of students' food-related greening opportunities were identified: plastic and polystyrene use in food services (n = 22); formula and food waste (n = 17); and sustainability of food (n = 14) (Table 4). Several noted strategies for addressing plastic and polystyrene use are to stop purchasing bottled water; encourage employees to use reusable water bottles; serve drinks in reusable cups; switc
Referência(s)