Climate change is the term used to describe long-term changes in weather patterns that have the potential to create a broad range of health effects for the global population. Calls to action for nursing professionals from the Alliance of Nurses for Healthy Environments (ANHE) (Kurth, 2017; Lewis-Hunstiger, 2019) require the inclusion of formal nursing education regarding climate change and its impact on planetary health as crucial elements for health promotion and disease prevention. A position paper on nurses, climate change, and health by the International Council of Nurses (2018) calls for the inclusion of sustainability and climate change knowledge into nursing curricula and continuing education for all nurses.

In April 2020, the National League for Nursing responded to the call from ANHE to assist in efforts to address climate change as part of the Nursing Collaborative on Climate Change and Health initiative. Currently, the Global Consortium on Climate and Health Education (2022) seeks to develop a consistent curriculum for health professionals to address climate change and its subsequent health impact; however, as of March 2022, only 22 schools of nursing (SONs) in the United States joined the consortium to address this urgent need.

"Climate change presents an existential threat that, like the current coronavirus pandemic, requires sustained, strategic and systemic action to mitigate the long-term devastation it will inflict on communities, families, and individuals" (National League for Nursing, 2020). It is an urgent matter with critical implications for nursing education and the health of the nation. The aim of this research study was to investigate the perceptions of climate change and sustainability of faculty teaching in associate and baccalaureate degree nursing programs in South Carolina and their attitudes toward inclusion of relevant content in the nursing curriculum.

BACKGROUND

Climate change as a phenomenon has gained both national and global attention, yet it is currently a topic that receives limited discussion in most nursing education curricula (Demorest et al., 2019; Lewis-Hunstiger, 2019; Potter, 2019). According to a 2019-2020 report by the American Association of Colleges of Nursing (AACN, 2020), the average age of nursing faculty in the United States is older than 50m and few faculty have been academically prepared to address this topic. Furthermore, the research topic of faculty and student perceptions of climate change from a nursing viewpoint has been negligible at best in the United States. Nurses and nursing faculty must take a leadership role in addressing climate change (ANHE; Kurth, 2017). Medical and public health education currently lead the health care profession by incorporating curricula regarding this imminent issue (Kurth, 2017; Mercer, 2019). The recently approved AACN's The Essentials: Core Competencies for Professional Nursing Education will now include Competency 3.6b (understand the impact of climate change on environmental and population health) as essential curricular content for entry-level professional nursing education (AACN, 2021).

It is essential to critically examine the limited body of knowledge on climate change and sustainability from a nursing education perspective. Sustainability in the health care environment is defined as resources and health care that are used to meet needs without limiting the future availability of resources for population health (Alvarez-Nieto et al., 2018). Resources include materials, water, and energy sources that do not contribute to further planetary pollution.

Richardson et al. (2015) conducted one of the first studies to evaluate attitudes of nursing students (n = 57) in the United Kingdom regarding sustainability and climate change. Results of the Sustainability Attitudes in Nursing Survey (SANS) demonstrated that students were positive about the importance of sustainability, but results were mixed regarding the importance of including these topics in the nursing curriculum. A revised version of the survey (SANS_2) was administered as part of a larger study with nursing students (n = 916) from four European universities (United Kingdom, Spain, Switzerland, and Germany; Richardson et al., 2016). German students were found to be more likely to favor the inclusion of sustainability into the nursing curriculum than students from other countries, but these students did not include sustainability practices in their home environment.

Two additional studies to evaluate teaching strategies regarding sustainability with nursing students are reported from European countries. Grose and Richardson (2016) conducted a qualitative study with students (n = 290) following skill training to emphasize how clinical practice will be impacted by scarcity of resources resulting from climate changes. Thematic results revealed that infection control measures thwart efforts toward reducing waste and use of nonsterile gloves may extend beyond necessary application in the clinical environment. In a study by Alvarez-Nieto et al. (2018), three European universities (Spain, United Kingdom, and Germany) evaluated the use of a toolkit for teaching knowledge, skills, and abilities associated with sustainability and climate change with nursing students (n = 321). Learning regarding environmental sustainability was linked to clinical practice through the use of high-quality e-learning strategies.

In a study conducted in Saudi Arabia with nursing students (n = 280), the SANS_2 was used with the New Ecological Paradigm (NEP) Scale to measure environmental attitudes (Cruz, Alshammari, & Reynaldo, 2018). Students with less knowledge of environmental impact on health demonstrated fewer positive attitudes about climate change. Positive attitudes toward sustainability based on the SANS_2 appeared to be influenced by learning about environmental issues, climate change, and participation in training programs. In a larger study with students (n = 1,059) from four Middle Eastern countries (Egypt, Iraq, the Palestinian Territories, and Saudi Arabia) using the SANS_2 (Cruz, Felicilda-Reynaldo et al., 2018), the results were similar to studies conducted by Richardson et al. (2015) in the United Kingdom with positive attitudes toward sustainability; slightly higher value was given toward the inclusion of the topics into the nursing curriculum.

Turning our attention to the United States, the limited research on climate change and/or sustainability from the nursing profession becomes apparent. One study conducted with public health nursing administrators and public health nurses (n = 143) evaluated knowledge of climate change, associated health effects, and the ability to address the public health consequences associated with climate change (Polivka et al., 2012). Slightly fewer than half of respondents (46 percent) indicated that climate change was influenced by humans. More than half of respondents could identify specific health-related impacts of climate change, but approximately half did not associate malnutrition or water-borne illnesses as associated with climate change. Political affiliations (conservative vs. liberal) appeared to influence attitudes toward climate change, with liberals tending to have a more negative view of climate change. More than 75 percent of respondents felt that they did not have the resources or ability to fully address the impact of climate change for the future of public health.

A study was conducted with multidisciplinary students (n = 338) at a New England university to investigate knowledge and attitudes regarding climate change, willingness to change behavior to lessen its impact, and satisfaction with the amount of curricular content associated with it (Wachholz et al., 2014). Only 11 percent of the sample contained students from applied professions other than business; it is unknown how many students represented nursing. Results revealed that 65 percent of students were either very worried or somewhat worried about climate change, yet only 18 percent had taken any steps to mitigate the effects of climate change in their personal lives. Finally, over 54 percent felt their university was not providing them with enough information about climate change. Political affiliation seemed to influence beliefs similar to the results of Polivka et al. (2012). Approximately 80 percent of students who self-identified as liberals were either very or somewhat worried about climate change compared to 46 percent who identified as conservatives.

In June 2020, Yale University published results of a survey given to their medical, nursing, and physician assistant students (n = 280) regarding their own attitudes and knowledge toward climate change, pollution, and health care resource conservation (Ryan et al., 2020). More than half of the respondents agreed or strongly agreed that the relationship between health and climate change and pollution should be incorporated into the classroom setting. More than 75 percent of respondents agreed that because health care professionals have an important role educating patients and the public on climate change and health, it is vital that they understand the relationship between pollution, climate change, and health.

Only two studies appear to have focused on nursing faculty in the United States. Streich (2014) completed a thesis to evaluate knowledge of health effects of climate change among nursing faculty at Montana State University (n = 41). The majority of faculty did recognize that overall health effects related to climate change are already happening, but more than half of the sample had difficulty being able to identify specific health effects. The study did not address attitudes nor the inclusion of climate change information in the curriculum. One other study evaluated the inclusion of climate change and sustainability in SONs in the Pacific Northwest and California (Eide & Odom-Maryon, 2019). Of 213 programs, responses from 81 SONs at private and public universities and/or colleges indicated that only 17 percent to 18 percent included climate change content.

In summary, nursing education research related to climate change and sustainability from European and Middle Eastern countries has outpaced research efforts in the United States. Globally, nursing students are concerned about climate change and the ensuing health effects. Knowledge, attitudes, and inclusion of climate change and sustainability content in the nursing curriculum remain minimally explored. Acknowledging the lack of research from United States-based studies focusing on nursing education, this research gap reflects a highly innovative and timely need to address an emerging crisis confronting planetary health at the national level.

METHOD AND DESIGN

This cross-sectional, descriptive study focused on perceptions of climate change and attitudes of sustainability of nursing faculty. Inclusion criteria for participation required nursing faculty to be currently teaching (part-time or full-time) in a didactic or clinical course in an accredited associate or baccalaureate nursing program. A convenience sample of approximately 700 nursing faculty, employed with SONs located within the state of South Carolina, was recruited for this study.

Instruments

Data were collected via an online survey composed of three sections: 1) demographic questions, 2) the NEP Scale, and 3) the SANS_2. The demographic section consisted of eight questions to evaluate age, gender, ethnicity, degree completed, political affiliation, region of the state, type of program, primary teaching role (didactic versus clinical), and the inclusion of health implications for climate change and sustainability in current course content.

The NEP Scale is a 15-item, 7-point Likert scale (Dunlap, 2008) used to measure environmental attitudes, beliefs, and values (used with the permission of R. Dunlap, January 8, 2020). The 15 items focus on five environmental perspectives, including the "reality of limits to growth, anti-anthropocentrism, the fragility of nature's balance, rejection of exceptionalism, and the possibility of an eco-crisis" (Dunlap et al., 2000, p. 432). Scores range from 15 to 105, with higher scores indicating a proenvironment attitude. The scale demonstrated an acceptable internal consistency (Cronbach's alpha = .826) in a study with 364 undergraduate students (Harraway et al., 2012).

The SANS_2 is a five-item, 7-point Likert scale (Richardson et al., 2016) that focuses on attitudes toward sustainability in health care and the integration of relevant concepts into nursing school curricula (used with permission of J. Richardson, January 13, 2020). Higher scores on the SANS_2 indicate a positive attitude regarding environmental sustainability. The SANS_2 also has acceptable validity and reliability with a Cronbach's alpha of .82 (Richardson et al., 2016).

Procedure

Institutional review board approval for this exempt study was obtained prior to initiation. Data were collected via an online survey that met university data security standards. This study utilized convenience sampling to recruit participants from 31 SONs. The primary investigator met with the deans and/or directors of statewide SONs at a regional meeting in October 2020 to inform them of the study and encourage participation. Following the informational session, email invitations were sent to deans and/or directors to be forwarded to individual faculty. In the event a dean or director was not present or did not forward the invitation, emails were sent directly to individual faculty members using contact information located on SON websites. Individual requests were sent originally in November 2020 and again in December 2020; a final call to participate was sent in January 2021.

Faculty were invited to complete the online survey through an introductory email that briefly explained the intent of the research study and contained a link to the survey; the anonymous survey link was distributed to 464 individual faculty. Participation in the survey served as acknowledgment of informed consent and voluntary participation. To incentivize participation, twenty $50 gift cards were given to randomly selected participants once the data collection phase ended. As nursing faculty tend to have heavy teaching loads, it was essential to provide substantial incentives to maximize participation. Only respondents who desired to participate in the random drawing were asked to provide their name, address, and email; this personal information was deleted prior to the analysis phase of the study. To be eligible for the random drawing, respondents were required to complete the survey in its entirety.

Data Analysis

Descriptive statistics were calculated for categorical variables of age, gender, ethnicity, degree, political affiliation, regional location, program type, and teaching content. A one-way analysis of variance (ANOVA) was conducted for each individual scale (NEP and SANS_2) with specific demographic variables. Next, pairwise comparisons were made between total scores for each scale to determine which factors showed significant variation according to degree, political affiliation, and teaching content. Tukey's multiple comparison adjustment and associated confidence intervals were employed to calculate pairwise differences and control the analysis-wise Type 1 error rate at [alpha] = .05. Finally, a Pearson correlation coefficient was calculated to determine the relationship between the NEP total score and the SANS_2 total score. All analyses were conducted in R Version 3.6.2, Windows 10 platform (The R Foundation, Vienna, Austria).

RESULTS

A total of 122 complete surveys were submitted via the online platform; the response rate from the total number of solicited surveys was approximately 27 percent. One respondent failed to complete the SANS_2, leaving an analytic sample size of 121 for SANS_2 analyses. Most respondents were female (95 percent); 86 percent self-identified as Caucasian, with fewer than 8 percent reporting as African American. These demographics are consistent with the nursing workforce in the United States. Most participants fell within the age ranges of 30 to 39 years (28 percent), 40 to 49 years (28 percent), and 50 to 59 years (21 percent). The remaining 23 percent were younger than 30 or older than 60 years of age. The majority had completed a master's degree (56.6 percent), followed by a doctoral degree (38.5 percent) and baccalaureate degree (4.9 percent). Responses to the question about political affiliation indicated that 40.2 percent of the sample saw themselves as moderates, followed closely by conservative (39.3 percent); liberals were less prominent in the sample (20.5 percent).

Responses were received from 21 of the 31 SONs invited to participate in the survey (15 BSN/16 associate). Seven of the 10 SONs that did not respond were associate degree (ADN) programs. Of the 122 completed surveys, 72.1 percent were submitted from BSN programs and 27.9 percent from ADN programs. Approximately half of the respondents reported working in the upstate region (49.2 percent), one third from the low-country region (29.5 percent), and the remainder in the middle of the state (21.3 percent). This is consistent with state demographics; larger SONs tend to be located in the upstate or low-country regions. Finally, 78.7 percent of respondents taught predominantly in the classroom; the remaining 21.3 percent taught in the clinical setting.

Two questions evaluated the current inclusion of topics related to climate change and sustainability. Of note, 81 percent of respondents did not currently include health implications of climate change in their teaching content. Similarly, 67 percent did not include health implications of sustainability.

The mean score for the NEP (n = 122) was 61.44 (SD = 12.82). Cronbach's alpha was higher than previous literature at .89. A one-way ANOVA revealed a significant difference in NEP mean scores according to political affiliation, F(2, 119) = 11.88, p < .001. Tukey's honestly significant difference was used to determine the nature of the differences between political affiliations; it was found that faculty with a conservative political affiliation scored lower on the NEP (M = 55.23, SD = 12.36) than faculty with moderate (M = 64.14, SD = 10.70) or liberal (M = 68.08, SD = 12.75) affiliations. No significant differences were found when comparing age, degree, location, classroom versus clinical teaching, program type, or inclusion of climate change and sustainability content.

The mean score for the SANS_2 (n = 121) was 19.34 (SD = 8.67). Cronbach's alpha was higher than previous literature at .93. Computing a one-way ANOVA revealed a significant difference in the SANS_2 mean scores according to degree completed, F(2, 118) = 3.24, p < .05. Tukey's pairwise comparison revealed that faculty with doctoral degrees scored higher on the SANS_2 (M = 21.46, SD = 9.03) than faculty with master's degrees (M = 17.65, SD = 8.20). In addition, a significant difference was found when comparing SANS_2 mean scores with political affiliation, F(2, 118) = 13.11, p < .0001. Pairwise comparisons further revealed that liberals scored higher on the SANS_2 (M = 25.80, SD = 7.93) than moderates (M = 19.45, SD = 8.37) followed by conservatives (M = 15.81, SD = 7.40).

A significant difference was found when comparing SANS_2 scores with the inclusion of climate change content, F(1, 119) = 20.46, p < .0001, and the inclusion of sustainability content, F(1, 119) = 28.20, p < .0001. Comparisons revealed that those including climate change in their curricula were higher with respect to SANS_2 scores (M = 26.17, SD = 5.62) compared to those who did not include such content (M = 17.74, SD = 8.49). Similarly, SANS_2 scores were higher for those who included sustainability content (M = 24.72, SD = 6.66) compared to those who did not (M = 16.69, SD = 8.33). No significant differences were found when comparing age, location, classroom versus clinical teaching, or program type. Finally, a Pearson correlation was calculated to examine the relationship between participants' total NEP score and total SANS_2 score. A moderate correlation was found, r(119) = .606, p < .001.

DISCUSSION

The demographics of the respondents are consistent with the demographics of nursing programs in the United States. A response rate of 27 percent is low but higher than an online response rate of 19 percent from a study conducted in New York with nursing faculty (Cantamessa, 2018). Although the primary investigator made multiple contacts via email with the directors of programs to encourage participation, the response rate (<30 percent of the total responses) from ADN programs was substantially less than responses from BSN programs. It is unknown why response rates varied between the types of programs. In most cases where the SONs' responses were negligible, faculty emails were not available publicly.

One of the most notable findings is the current lack of content related to climate change or sustainability. Over 80 percent of respondents did not include health implications of climate change content, and over 60 percent did not include health implications of sustainability. The lack of climate change content is similar to the findings of Eide and Odom-Maryon (2019). This has significant ramifications as students are not being introduced to the health impacts of climate change or measures to move toward sustainability. Students need to be introduced to health topics that are being exacerbated by climate change, including vector-borne diseases, health-related illnesses, respiratory conditions associated with wildfires, and mental stress resulting from changes in the environment. Also, nurses of the future must be aware of sustainability practices in the health care environment (Richardson et al., 2015). It is unknown if faculty are covering these topics but do not recognize these issues as climate-related content.

Significant differences were found when comparing the NEP and SANS_2 scores with political affiliation. Although not surprising, it is concerning that political viewpoints may be influencing the inclusion of climate-related health content into the nursing curriculum. Of the 48 conservative responses, only 15 percent reported including climate change content. The responses from moderates were similar at 15 percent, whereas 36 percent of liberal respondents reported including climate change content. This connection between political affiliation and perceptions of climate change is consistent with findings from other researchers (Polivka et al., 2012; Streich, 2014; Wachholz et al., 2014) and raises a concern for future exploration. This is particularly relevant in light of recent calls to action by professional nursing organizations to address climate change and sustainability in the nursing curriculum. Other disciplines are making these curricular changes; therefore, it is imperative that nursing curricula align with efforts toward mitigation of negative climate-related health outcomes.

When comparing the NEP score with the questions related to inclusion of climate change and sustainability content, no statistical difference was found. However, the SANS_2 score was statistically significant for the inclusion of climate change and sustainability content. Faculty who include this content in their teaching are more likely to score higher on the SANS_2.

One last area of statistical significance is the link between the SANS_2 score and faculty degrees. Doctorally prepared faculty were more likely to score higher on the attitudes toward sustainability survey than master's prepared faculty; there was no statistical difference between the BSN degree and the doctoral degree in the SANS_2 score. The small sample of BSN respondents (n = 6) may have influenced the ability to determine statistical significance. Faculty with doctoral degrees are more likely to work in BSN programs; thus, they may have greater exposure to the multidisciplinary work of environmentalists and public health experts who focus on climate change and sustainability compared to ADN programs in community colleges.

Limitations

One limitation of the study is the potential for self-selection to respond by faculty who are interested in climate change and sustainability. This study did not require faculty to provide details of the climate change or sustainability content that they teach within their curricula. Utilization of a convenience sample from one state in the southern region of the United States limits generalizability of the results to other state populations. The predominant conservative political affiliation in the state clearly may have influenced the results. Seven of 10 SONs that did not respond were ADN programs; therefore, the results are potentially skewed toward BSN faculty. Finally, this study did not evaluate respondents' knowledge of climate change or sustainability information.

Recommendations for the Future

McDermott-Levy et al. (2019) identified key teaching strategies to integrate climate change into the nursing curriculum, but integration may be stymied by the perceptions of nursing faculty that climate change is not an essential component of the nursing curriculum. Nursing faculty's own limited knowledge of climate change (Streich, 2014) and sustainability may further limit the integration into content-laden courses. McDermott-Levy et al. (2019) suggest that to prepare a nursing workforce to address planetary health, it will be crucial to include climate change content consistently throughout the entire prelicensure nursing curricula. The establishment of climate-related health content represents a key outcome for the future of nursing education. It is essential to address faculty perceptions of climate change and sustainability and include the content in all nursing curricula.

Future studies will need to explore if nursing faculty's knowledge levels are sufficient to cover climate change and sustainability content in the nursing classroom or clinical setting. A next step for this research trajectory is to evaluate other states or use national professional organizations to seek a broader population of nursing faculty. This study appears to be one of the first efforts to evaluate nursing faculty's perceptions of climate change and sustainability attitudes in the United States.

CONCLUSION

Based on these results and the work of Eide and Odom-Maryon (2019), professional nursing organizations have preliminary scientific evidence of gaps and areas of need for curricular content related to climate change and sustainability. Curricular competencies are already being addressed for medical students and public health students to include climate change. It is imperative that nurses be academically prepared to engage in planetary health initiatives, along with population health. Nursing should be leading the research movement for health professions; thereby, their collaborative actions will advance the science of nursing through systems thinking approaches, population health prevention, and planetary nursing care.

In February 2021, the weather event affecting the state of Texas (deep freeze) provided a glimpse into the impact of not being prepared for changing weather patterns. Climate change is affecting and will continue to affect global public health in the future. Nurses have the power to lead the health care work force in efforts to mitigate negative outcomes through sustainable practices, both in the workplace and home environment. Until nurses of the future are introduced to this information, as a profession, we will fall short in addressing this looming public health crisis. We must be proactive for climate change, not reactive when millions of lives could be affected.

REFERENCES