Developing a Green Nursing Practice in a Profession That Contributes to Climate Change: One Nurse’s Journey

Integrating green practices into hospital care, especially in intensive care units (ICUs), can seem like an unsolvable dilemma with multiple barriers. Nursing is a socially responsible discipline that aids individuals and communities; however, the values of environmental stewardship and the desire to minimize the poor health outcomes caused by climate change do not always align with hospital patient care policies and procedures.^5,6  Patient care contributes to solid and medical waste disposal, toxicant exposure, environmental pollutants, and greenhouse gas emissions, which in turn lead to negative environmental impacts that significantly affect human health.⁷ 

Health care’s carbon footprint accounts for 5% of global greenhouse gas emissions that lead to climate change, a recognized global health crisis. According to Masud et al,^4(p2) a “vicious cycle between healthcare and climate change is created,” in which the health care system causes environmental harm that leads to the human physical and mental illnesses that nurses are dedicated to healing. Even if health care professionals are committed to environmental issues, the task of changing the cycle in the workplace can be overwhelming and create inaction.⁸ 

Other barriers to developing a green nursing practice include limited bandwidth and time, lack of leadership support, insufficient support by professional organizations, and lack of education and awareness related to how to implement such activities.^4,6,9  Workplace sustainability success requires change in organizational culture, leadership buy-in, improved policies and initiatives, sustainability education, and professional organization.^6,9–11 

With more time and resources, nurses have the potential to play a pivotal role in influencing climate change mitigation and environmental practices in health care. By developing a green practice, nurses can collectively influence the future of national and global health.^5,8,12 

Unfortunately, nursing and the broader health care system have been slow to recognize how environmental issues are interconnected with human health.^5,8  Nurses have often perceived climate change prevention and environmental stewardship as personal responsibilities rather than professional actions. The link between patient care and climate change has often been unrecognized by frontline nurses and the profession at large.^5,6 

Historically, nursing theory has narrowly focused on how the environment affects the individual patient rather than adopting a broader, more holistic perspective. The individualistic approach may have hindered the development of evidence-based practices centering on climate change and nursing’s involvement in sustainability measures. For instance, the first nursing publication on climate change research appeared in 1995, which was 30 years later than similar research in the medical and engineering professions.^11,13 

According to Butterfield et al,¹²  nurses in the United States participated in climate action in the 1990s to early 2000s when Health Care Without Harm and the Alliance of Nurses for Health Environments were formed. The American Nurses Association (ANA) has promoted green practice since 2007 with the booklet Principles of Environmental Health for Nursing Practice With Implementation Strategies (Table 1), in which climate change is acknowledged as “among the most critical environmental issues of concern for the nation and the world.”^14(p10) Sixteen years later, the ANA called for nurses to

Support for green nursing practice is still lacking among professional nursing organizations overall. According to Gaudreau et al,⁶  nursing organizations have provided only “modest leadership” in recommendations and education for their members on the importance of climate change issues in nursing practice. Most critical care nursing organizations in the United States have not released position statements or backed initiatives for sustainability measures in the ICU.⁴  Increased awareness and support for the nursing profession to help members understand their significant role in climate issues are crucial to planetary health.^11,12,16 

Although historically the nursing discipline has taken a narrow view of environmental stewardship, more recently it has noted the connection between health and the environment.¹¹  Health care professionals and nurses have demonstrated an increased desire to be environmentally friendly at work, take measures to educate themselves and patients about environmental health harms, and strive to advocate for climate action on a broader level or in their personal lives.^5,9  Nurses are interested in going green, but barriers in the workplace persist. High patient caseloads, lack of administrative support for implementation of environmental sustainability initiatives, and the overwhelming nature of the task of greening the workplace can keep nurses from becoming involved in change.^8,9 

Sustainability efforts and acknowledgment of climate change in health care are still emerging, and many hospitals do not yet have green programs or policies. Even if nurses value green practices, hospital support is lacking.^5,17  When workplace values are misaligned with personal values, the result can be dissatisfaction and mediocre performance. Sustainability projects and initiatives have been shown to improve patient care and foster employee well-being, loyalty, and productivity.^18,19  Increasing green nursing practice and the acknowledgment of the need for climate change actions in hospitals and all health care settings would improve patient care outcomes, increase employee engagement, and support nursing care standards.

Kotcher et al⁹  noted that health care professionals will continue to find the integration of green practices and advocacy for climate change mitigation in the workplace challenging and even almost impossible until the barriers have been eliminated. Organizational methods for removing or reducing such barriers include facilitating professional education, policy development, culture change that corrects misconceptions about climate change, detailed guidance on actions to take to achieve sustainability, and designated paid time for sustainability activities.^5,9  Improved efforts by nursing professional organizations and associations through research, professional education, patient education materials, policy statements, and advocacy recommendations are also vital to counteract insufficient sustainability support for nurses in the workplace.⁶ 

In a 2022 literature review, Lee and Lee¹⁰  concluded that green health practices cannot be realized without the complete support of upper administration and leadership or strong participation by employees in every department of a health care organization. Employees need to be provided with adequate education and empowered by leaders through hospital cultural change, support of environmental policies, and green initiatives. Leadership support and staff buy-in are critical to achieving a comprehensive green nursing practice in the workplace.^10,17 

Bill McKibben, the founder of the website 360.org, noted that in terms of reducing the effects of climate change and environmental degradation

The individual nurse can decrease greenhouse gas emissions by riding a bicycle to work, reduce waste when reusing water bottles, or conserve power by turning off lights at work, but to make large-scale changes in the workplace, collaborating within the profession through an interdisciplinary and multidepartment lens can be more effective.

For a nurse aspiring to adopt green practice, confronting the barriers discussed above may seem daunting. Developing a green nursing practice entails several important steps. These include accessing resources for continuing and professional education, finding mentors and organizations for support, influencing workplace leaders and administrators to be motivated to advance green policy or support initiatives, and developing peer and multidisciplinary groups to begin green innovation and action in the workplace.

Resources available through academic settings and organizations created by environmentally concerned nurses can provide invaluable support for research, education, and advocacy for green practices. Entities such as Practice Greenhealth (https://practicegreenhealth.org) and Health Care Without Harm (https://noharm.org) offer resources that administrators and leaders can use to start sustainability initiatives.^9,16  Nurses, alongside other health care professionals and staff members within health care systems, can initiate “green teams,” become green advocates, seek out mentors for sustainability practices, and participate in practice committees or nurse governance groups to initiate long-overdue efforts to reduce health care’s carbon footprint. Nurses do not have to go green alone.

Green nursing practice journeys can be ignited by pursuing further education in environmental issues. I received my Master of Science degree in nurse leadership in healthcare ecosystems in 2021 from Linfield University. The program aligned other life passions in areas of environmental and social justice with my nurse leadership goals. Dr Gary Laustsen, the author of multiple articles on greening in nursing practice and ecological nursing theory, directed the MSN program and developed a curriculum integrating the ecological aspects of health care and nursing practice with leadership principles. Laustsen taught that the human health ecosystem was connected to the environmental ecosystem through the laws of ecology, revealing the interconnectedness of the health care system, patients, nurses, and the community (Table 2).²¹  His mentorship clarified the importance of my role as a nurse in the greening of health care.

Unfortunately, Linfield’s program no longer exists, but other academic and educational opportunities are available for furthering professional education. At least 6 US schools of nursing have initiatives and programs that recommend frameworks for nursing curricula, offer education, and support nursing research in environmental areas. The MGH Institute’s Center for Climate Change, Climate Justice, and Health and the University of New Mexico Project ECHO programs provide webinars and online training, according to their websites. The nursing schools of Yale University, the University of Maryland, and the University of Minnesota provide education and certifications in environmental and planetary health for nurses (Table 3).

A nurse-led organization, the Alliance of Nurses for Health Environments (ANHE), is internationally recognized as a leader in environment and health actions. ANHE provides an abundance of opportunities for nurses to gain education, advocate, research, and act on environmental health issues and climate change. I use this organization’s website to access educational materials and resources for projects and for motivation. ANHE also provides access to nurse fellowships, Climate for Health Ambassador training, and inspirational group challenges like Nurses Drawdown and the Nurses Climate Challenge.^6,8  Other organizations such as the ANA guide nurses through the Principles of Environmental Health for Nursing Practice With Implementation Strategies booklet and support of green nursing in standards and policy statements on its website. The Planetary Health Alliance and the Western Institute of Nursing Environment (WINE) special interest group are organizations that provide professional education, networking opportunities, and policy to guide nurses in green practices. Participating in ANHE programs and initiatives is a good way to start developing a green practice.

Through such environmental nursing organizations I learned of Dr Elizabeth Schenk, an assistant research professor at Washington State University College of Nursing and Assistant Vice President of Environmental Stewardship for Providence Health System. She is active in climate change nursing research and environmental nursing education and allowed me to interview her. When one is developing a green nursing practice, finding mentors like Laustsen and Schenk can help with motivation and support. I looked to my mentors for ideas when starting my green nursing practice. Schenk encouraged me to “find other people, find leadership support, keep focused, and keep hanging in there” even through failures and the complexity of the journey (oral communication, April 26, 2021).

Organizations like Practice Greenhealth, Health Care Without Harm, and My Green Doctor (https://mygreendoctor.org) can be resources for developing sustainability initiatives and employee groups like hospital “green teams.” Practice Greenhealth and My Green Doctor (for clinics and offices) have free information on sustainability on their websites and provide comprehensive services with a paid membership. A Practice Greenhealth membership provides intensive support for initiation of hospital environmental stewardship; the benefits of their tried-and-true program could lead to greater success in changing a hospital’s culture. Practice Greenhealth and Health Care Without Harm collaborate annually on a health care sustainability conference called CleanMed. I received the Stephanie Davis Waste Reduction and Pollution Prevention Scholarship to attend the May 2024 conference. There, I acquired information to take back to the workplace to facilitate collaborative efforts with peers, gained ideas for projects, participated in brainstorming sessions on innovative solutions, and benefited from invaluable networking opportunities (Table 3).

The ANHE provides free, easy-to-access online resources that include environmental tool kits, guides for creating green teams, a climate change knowledge self-assessment survey, and the ANHE’s nursing textbook on environmental health. The document “A Beginner’s Guide to Sustainability in the ICU” and the “My Green ICU” series of articles in the journal Intensive Care Medicine are resources specific to critical care and provide step-by-step instructions for greening ICUs (Table 4).

For nurses to develop a green practice that is satisfying, effective, and influential, involvement of the highest administrative leaders in the hospital or health care organization is imperative. Top leadership engagement has been identified as the most critical component of hospital sustainability program success. A deeply embedded culture of environmental stewardship that aligns with the hospital’s core values is essential.^10,19  The frontline nurse who is busy with critical care patients, working 12-hour shifts and experiencing barriers such as exhaustion and time limitations, may wonder how they can influence the administration’s perspective on green nursing practice. This question has also occupied my thoughts over the past few years as I developed my green nursing practice.

The method by which nurses can influence administration is straightforward: use your voices. Nurses should find ways to connect with leaders through committees, employee forums, suggestion boxes, writing letters, asking to present at meetings, or even having casual conversations in the hallway. Gradually let leaders see your face, enthusiasm, innovation, and dedication. It is important to learn your hospital’s mission and values and apply them to discussions about sustainability.

In my interview with Dr Schenk, she noted that even though green practices do save money, nurses should begin conversations or presentations by highlighting how sustainability fits in with the hospital’s mission and the professional obligation to do no harm (oral communication, April 26, 2021). According to Practice Greenhealth, “it takes an authentic commitment from senior- and executive-level leaders backed up with resourcing, governance, modeling new norms, and ultimately shifting the organization’s culture” to create a green workplace.²² 

In my workplace I have provided posters to share with staff members and leaders on environmental issues, sent emails and messages to leaders about sustainability ideas and concerns, and started a unit green team. The most effective way I have found to discuss policies, evidence-based practice projects, or initiatives is by attending nurse governance committees or councils. Nurse governance meetings require leadership involvement and usually have a collaborative focus with open discussions so nurses can consider practice concerns and issues.²³  These meetings may result in the initiation of small sustainability projects or the development of a hospital-wide or systemwide green pledge or initiative. Sustainability efforts will be most effective if the organizational leadership develops a comprehensive program with outside guidance such as Practice Greenhealth membership and is dedicated to coordinating a sustainability program.^18,24 

Awareness, involvement, and engagement of staff members, especially nurses, have been identified as the most significant elements of creating successful green practices and a sustainability culture in the workplace.^10,17  The most recommended method of nurse involvement in sustainability action that I discovered in my literature review, discussions with mentors, and participation in the CleanMed conference was the initiation of a green team. Collaborative efforts by nurses and the involvement of other disciplines and departments on green teams “provide legitimacy and permanency to the work, increase awareness about individual actions, advocate for unit level changes, and provide an interface between nurses, the organization, and experts to help operationalize sustainable initiatives.”^3(p440) Green teams are made up of organizational and even community stakeholders who could be affected by the sustainability initiatives or green practice changes. Ideally, green teams are located in individual departments and units but also are connected with a system-wide team composed of representatives of every role at the facility (Table 5).

Green teams can discuss environmental health concerns, collect and monitor sustainability data on the carbon footprint of the unit or the whole facility, become green champions to improve sustainability culture, make recommendations, develop projects, and become change agents. Specific suggestions for green teams appear in Table 6.

Once green teams have been formed, projects and initiatives can be proposed and facilitated. Areas that green teams can work on, especially in ICUs, include waste reduction, energy use, toxic chemicals, and staff and patient well-being in the unit.⁴  Actions that green teams can take are endless. Ideas and implementation suggestions can be found in the resources listed in previously cited tables. Examples of green team projects appear in Table 7.

Climate change, environmental degradation, toxic chemicals, and microplastics affect the health of patients and the community. The future of human health on the planet is at extreme risk, and the health care system is a major contributor to greenhouse gases that lead to climate change and other environmental harms. Critical care nursing units have one of the highest carbon footprints in health care and generate extensive waste. An ICU patient’s daily energy use is equivalent to the daily use of the average 4-person family in the United States.^3,4,25  The foundations of nursing include maintaining a healing environment, compassion for human life, a commitment to evidence-based practice, and the art of caring. Patient care, especially in the ICU, contributes heavily to the environmental cause of health problems nurses are working to heal, which creates an overwhelming dilemma for nurses who value sustainability and green nursing.^8,11,13 

Historically, nursing has been slow to recognize the connection between environmental and human health, but recently nurses have begun to better understand the role of climate change in human health issues and strive to integrate green practices into patient care. Many nursing workplaces have not yet developed green initiatives or environmental stewardship policies. Nurses also experience multiple barriers to practicing green nursing. The number one barrier is the time and opportunity to become more knowledgeable and involved in policy changes. Nurses have heavy workloads and are rarely paid to participate in green nursing activities. Lack of administrator and leader support, the overwhelming nature of the task of developing green practice changes, and not knowing where to start are also huge barriers.

Change can be made and barriers overcome in the journey to become a green nurse. Nurses can use their voices and influence leaders to engage in sustainability activities, become involved in nursing shared governance, and participate in collaborative green teams. A multitude of strategies can be applied to greening the workplace, including education, networking, and other actionable steps. Buy-in from executive leaders and hospital staff members in all departments is essential. Sustainability programs and initiatives are most likely to succeed if they are based on collaboration with advocacy agencies like Practice Greenhealth that can provide program development ideas, education, and support.

With the support of leadership through funding of relevant programs and paying nurses to participate in environmental stewardship development, nurses can begin formulating nursing practice policies and guidelines. They can start today by accessing resources, engaging in education, and talking to coworkers about potential projects. Climate and environmental action are urgently needed, and mitigation of the effects of environmental harm is clearly within the standards and values of nursing.

If nurses do not have enough bandwidth for major efforts, they can start small. According to Sheila Morovati, founder of the environmental nonprofit organization Habits of Waste, even the smallest action to reduce climate change is crucial.²⁶  Being a perfect green nurse is not the goal, and this mindset can paralyze action. We need millions of imperfect green nurses, doing what they can within their time restraints, for collective action.