The effectiveness of sustainable healthcare education in improving nursing students' knowledge and attitudes has been demonstrated through short-term studies with pre-post test design. However, there is a need to study long-term retention of students' knowledge and attitudes, also their skills in achieving sustainable healthcare from the use to disposal of healthcare resources by providing a hands-on learning experience via simulation.

This study investigated the effects of sustainable healthcare education using cooperative simulation on nursing baccalaureate students' sustainable nursing knowledge, attitude and skills by comparing the self-directed learning.

This randomized controlled experimental study with pre-post-follow up design was registered under ClinicalTrials.gov with number NCT05504421.

The study was conducted at a nursing faculty in a state university.

The study sample comprised 70 third grade nursing students.

Following narrative-based lectures explaining sustainability in nursing, students were randomly assigned to two study groups; an intervention group using cooperative learning-based NurSusToolkit Project cases and the control group using self-directed learning throughout 4 consecutive weeks. Both groups then performed a high-fidelity simulation practice focusing on sustainable healthcare. Data were collected using the Sustainability Attitudes in Nursing Survey, Sustainable Healthcare Knowledge Form, Skill Checklist and Debriefing Form. Quantitative data were analyzed using t-tests, Friedman test, Fisher's Exact test, intraclass correlation coefficients and Cohen Kappa calculations in IBM SPSS Statistics version 23 software. Qualitative data were analyzed via an inductive approach. Ethical approval and official permission were obtained. The students completed informed consent forms.

In the post-test, no significant differences were determined between the groups in terms of sustainable nursing knowledge (U = 557.5, p = 0.503), motivation (U = 514.5, p = 0.237) and attitudes (U = 610, p = 0.976). In the follow-up test, the sustainable nursing knowledge (U = 221.500), motivation (U = 282.500) and attitudes (U = 191) were significantly higher in the intervention group (p < 0.001). In the simulation practice, the intervention group had higher rates of correct separation of nursing care-related waste (intervention group = 77.77 % for both observers, the control group was 0 % and 11.11 % for observer 1 and 2, respectively, Cohen Kappa = 0.898, p < 0.001). In the debriefing, the intervention group requested more simulation practices (33.33 %) to acquire sustainable nursing skills, while the control group did not.

Sustainable healthcare education using cooperative simulation that has long-term effects can enable future nurses to lead the shift towards climate-smart and sustainable nursing care.

Bioethics scholars have become increasingly interested in moral questions associated with healthcare's environmental harms. Much of this scholarship has remained in the theoretical space, where ethical reasoning is underpinned by certain obligations and the implementation of top-down principles. Drawing on twelve focus groups with members of the UK public, this paper aims to bring a sociological ethics of care approach to these discussions. In fulfilling this aim, we highlight how moral decision-making occurs in the context of interrelationships with others, and not simply according to top-down principles. We show how, in line with an ethics of care approach, participants prioritised caring needs based on those in close relational proximity, meaning that emphasis was placed primarily on themselves and their loved ones, followed by other humans and the NHS, and finally the environment. At the same time, we contribute to the ethics of care scholarship by showing how such relation-based hierarchical caring was affected by various socio-cultural and political factors-what we have called 'contextual caring'. We note four factors: access to healthcare, capability of care work, increasing understanding of the relationship between humans and the environment, and societal norms of environmental citizenship. We stress the importance of considering these socio-cultural and political factors in any examination of how relation-based hierarchical care occurs in practice. We reflect on the implications of our focus group findings for policy measures towards addressing the UK NHS's environmental harms.

Climate change is one of the biggest threats to global health in the 21st century and is responsible for many health complaints and diseases worldwide. The healthcare community is an important contributor to environmental pollution, and the latter has an adverse effect on maternal and fetal health. This paradox needs to be addressed, and healthcare professionals need to take the responsibility for change. The current position statement outlines what is already known about environmental sustainability in obstetric healthcare, and provides recommendations on how to address the problem, based on existing evidence and real-life experiences. To start the transition to a more environmentally sustainable obstetrical healthcare, it is important to establish local dedicated teams, working in collaboration with national or international institutions. Institutional and individual energy-saving behaviours need to be encouraged. Public transportation needs to be promoted, and travel movements reduced, by moving to video appointments, telephone appointments, and telemonitoring, when appropriate. The pharmaceutical impact on the climate also needs to be addressed: inhalation anaesthetics should be avoided, shorter prescriptions should be made, and patients should be educated on how to deal with pharmaceutical waste. It is also important to reconsider the way that certain hospital products are used: surgical trays can be optimised, sterile gowns, gloves and drapes do not always need to be used, and reusable products should be preferred. Finally, the overuse or inadequate use of healthcare services needs to be addressed.

Climate change poses unprecedented challenges to global health, with the healthcare sector itself contributing significantly to greenhouse gas emissions. This perspective presents an innovative, adaptable framework for integrating sustainable and climate-friendly practices into healthcare settings across diverse economic contexts. We examine energy efficiency, waste management, water sustainability, supply chain optimization, telemedicine, and biophilic design in healthcare. The framework provides implementation strategies, cross-cutting climate innovations, and explores interconnections between climate-smart healthcare, health equity, and global sustainability. Our findings suggest that implementing climate-smart healthcare can lead to significant reductions in carbon emissions, enhanced resilience to climate-related health threats, and improved health outcomes globally. We conclude that the healthcare sector can transform from a significant contributor to climate change into a leader in climate mitigation and adaptation, creating a more sustainable, resilient, and equitable global health system.

Endoscopic procedures are the cornerstone of intervention in gastroenterology-from evaluating common illnesses to non-surgically managing complex diseases. Expectedly, these procedures are linked to greenhouse gas (GHG) emissions globally and contribute significantly to the global climate change crisis. Professional gastroenterology societies globally raise awareness of this evolving crisis and suggest specific measures to appropriately measure the burden contributed by endoscopy units and mitigate the environmental impact of this common clinical practice. To the unsuspecting eye, the solution to this crisis is relatively simple: decrease the utilization of endoscopic procedures. However, the dependence of modern medicine on these procedures, both diagnostically and therapeutically, makes it significantly more challenging to reduce their utilization. Instead, a structured approach to systematically consider the specific indications for each procedure, minimize waste generation, promote recycling of waste products, and limit the number of repeat endoscopies until clinically necessary may be more pragmatic to reduce GHG emissions globally. In this narrative review, we discuss the perspectives of global gastroenterology societies on sustainable or "green" endoscopy and summarize their recommendations to aid the day-to-day gastroenterologist in making their contribution to environmental sustainability while providing optimal care to their patients.

Healthcare services contribute 5 to 10% of global carbon emissions and environmental burden on the planet. Sustainability in health care and laboratory medicine is gaining global momentum emphasizing a holistic approach to reduce carbon footprint, improve the delivery and quality of care, while optimizing operational efficiency and effectiveness. Digital transformation has the potential of achieving these goals simultaneously. Clinical laboratories should assess and mitigate their environmental impact through digital technologies. In this article, opportunities and challenges in establishing sustainable quality improvement in the clinical laboratory will be discussed with a focus on the redesign of the total testing process and digital transformation of routine quality assurance activities.

Healthcare systems produce significant greenhouse gas emissions, raising an important question: should healthcare be treated like any other polluter when it comes to reducing its emissions, or is healthcare special because of its essential societal role? On one hand, reducing emissions is critical to combat climate change. On the other, healthcare depends on emissions to deliver vital services. The resulting tension surrounds an idea of healthcare exceptionalism and leads to the question I consider in this paper: to what extent (if any) should the valuable goals of healthcare form an exception to the burdens of reducing greenhouse gas emissions? The goals of this paper are twofold. One is to think about how to address the issue of healthcare exceptionalism. Second is to discuss the extent of healthcare's climatic responsibilities. I examine two perspectives on healthcare exceptionalism. The first treats a responsibility to reduce emissions and the delivery of healthcare as separate issues, each governed by its own principle. I reject this view, proposing instead that we consider healthcare's environmental responsibilities in conjunction with its essential functions. I defend an "inability to pay" principle, suggesting that while healthcare should indeed contribute to mitigating climate change, its obligations should be constrained by the necessity of maintaining its core goals like protecting health and preventing disease. Healthcare should be treated differently from other sectors, but not to the extent that it is entirely exempt from efforts to reduce emissions.

Collective changes in healthcare practices are required to ensure real environmental gains. As patient-centred care is increasingly considered to enhance the ability of health systems to meet the expectations of the population, it is crucial for policymakers and health professionals to account for the preferences of the wider public regarding environmentally friendly healthcare. This article synthesises and appraises evidence from empirical studies to understand how people value environmental concerns when making decisions within medical-related or pharmaceutical sectors.

We conducted electronic searches of the PubMed, Scopus, and Embase literature databases. Studies were eligible if they conducted a quantitative experiment to understand participants' preferences regarding sustainability and green initiatives in the medical sector or for pharmaceuticals.

Of the 1138 documents identified, 32 studies were deemed eligible. More than 60% were published since 2020. Different methods were used to elicit the revealed and/or stated preferences of participants. In most studies, respondents valued the environment positively and were willing to change their behaviour or practices to support sustainability. However, concerns such as disease severity or clinical effectiveness of medicines or medical interventions were often prioritised over environmental considerations. The wide heterogeneity in study participants emphasises the need to involve all stakeholders to achieve the transition to a greener and sustainable healthcare system.

The identified studies used various methods but were consistent in finding broad support for environmental considerations within the healthcare sector.

Human health depends on planetary health, and yet healthcare provision can have unintended consequences for the health of the planet. Emissions from the healthcare sector include greenhouse gases, air pollution and plastic pollution, alongside chemical contamination. Chemical pollution resulting in endocrine disruption has been associated with plastics, which are a source of concerning additives such as phthalates, bisphenols, perfluoroalkyl and polyfluoroalkyl substances, and flame retardants (all routinely found in healthcare products). Many endocrine-disrupting chemicals are persistent and ubiquitous in the environment (including water and food sources), with potential secondary harms for human health, including disrupting reproductive, metabolic and thyroid function. Here we review evidence-based strategies for mitigating environmental effects of healthcare delivery. We focus on what endocrinologists can do, including reducing demand for healthcare services through better preventative health, focusing on high-value care and improving sustainability of medical equipment and pharmaceuticals through adopting circular economy principles (including reduce, reuse and, as a last resort, recycle). The specific issue of endocrine-disrupting chemicals might be mitigated through responsible disposal and processing, alongside advocating for the use of alternative materials and replacing additive chemicals with those that have lower toxicity profiles, as well as tighter regulations. We must work to urgently transition to sustainable models of care provision, minimizing negative effects on human and planetary health.

Among the healthcare sector, hospitals are the most resource-intensive infrastructures, contributing significantly to environmental degradation. As global sustainability imperatives intensify, there is a critical need to integrate environmental sustainability into hospital performance measurement systems. The study objective is to highlight the most recurrent environmental performance for hospital sustainability from the recent scientific literature and identify key performance indicators.

This study employs a scoping review methodology to analyze peer-reviewed recent publications addressing environmental sustainability performance measurement and management in hospitals. The literature search was performed using PubMed, Web of Science and Scopus databases. The search was limited to papers published from 2009. The initial searches resulted in 545 studies. The final sample included 22 papers.

The review identifies 6 key sustainability domains: energy management, waste management, water consumption, greenhouse gases emissions, transportation and mobility, and site sustainability. The results underscore the multidimensional nature of environmental performance in healthcare facilities and reveal significant variability in the scope and specificity of existing metrics across studies.

The findings are synthesized to propose a unified, indicator-based environmental sustainability assessment framework for hospitals with a set of 18 environmental key performance indicators (EKPIs). The results underscore the multidimensional nature of environmental performance in healthcare facilities and reveal significant variability in the scope of existing metrics across studies. The findings highlight the necessity of integrating standardized indicators into hospital performance assessment frameworks to ensure comparability, track progress, and drive improvements. Additionally, the lack of harmonized measurement systems poses challenges for benchmarking and scaling sustainable practices across diverse healthcare settings.

This study contributes to the ongoing debate on sustainable healthcare by proposing a structured framework of EKPIs based on the most recent scientific literature and tailored to hospital environments. The framework offers hospital administrators and policymakers actionable tools to monitor and enhance environmental performance.

Healthcare systems around the world are undergoing a rapid digital transformation in response to mounting challenges, such as aging populations, chronic disease prevalence, workforce shortages, funding limitations, and rising consumer expectations. Significant change management is needed to overcome these challenges. Simply adding more of the same resources, in terms of manpower and facilities, is neither feasible nor achievable. Digital health transformation, powered by artificial intelligence (AI), remote monitoring, and data-driven tools, offers a path forward by improving efficiency, expanding access, and enabling proactive care. Success depends on integrating technology with workforce retraining and updated processes. Embracing these innovations is essential for building a more sustainable, equitable, and patient-centered healthcare system.

The healthcare sector is responsible for between 4.4% and 5.2% of global greenhouse gas emissions, and the operating room accounts for 20-30% of hospital waste. Healthcare personnel have a responsibility to develop sustainable healthcare services that reduce waste and pollutants discharged into the environment. Nurse anaesthetists and operating room nurses can play a key role in ensuring sustainable practice in the operating room. The study's aim was to (1) explore their views and practice regarding climate change, the healthcare sector's carbon footprint, and sustainable practice in the operating room, (2) assess differences in the way in which the two professions regard these issues, and (3) assess factors which potentially are associated with participants' views and practice.

A cross-sectional survey was conducted in three hospital trusts in south-eastern Norway between October 2023 and January 2024. Responses were analysed using descriptive statistics, independent t-tests and Chi-square analyses. Thematic analysis was used for free-text responses.

A total of 110 nurse anaesthetists and 88 operating room nurses participated in the survey (response rate = 31%). Almost all participants (96.9%) agreed that the world is facing a climate change crisis. There were significant differences (p < 0.001) between the two professions' views regarding the individual's responsibility in reducing the healthcare sector's carbon footprint. There was also a significant difference in their views regarding whether the health institution provided training to promote sustainable practice (p < 0.001). Both professions recycled waste materials, but there was a significant difference regarding the perceived need for recycling systems (p = 0.03). Three themes emerged from the free-text responses: 'a need for education and information', 'increasing awareness' and 'lack of organisational measures' regarding participants' perspectives on climate, health and sustainability in the operating room.

Despite certain differences in their views and a perceived lack of awareness, information and organisational measures, this study shows that nurse anaesthetists and operating room nurses are concerned about reducing the operating room's carbon footprint. However, they have the potential to play a more active role in greening the operating room by participating in grassroot strategies that foster sustainability.

Not applicable.

Quality improvement (QI) practices and scholarship are increasingly concerned with environmental sustainability given the negative health outcomes caused by the ecological crisis, as well as the environmental impacts of healthcare delivery itself. A core component of QI activities is measuring change. How sustainability metrics have been used in QI is unclear. We conducted a scoping review of metrics used in published sustainability-focused QI initiatives.

MEDLINE, EMBASE, CINAHL and Scopus from 2000 to 2023.

Published healthcare QI initiatives intended to address environmental sustainability with at least one quantitative sustainability metric.

Publication, study, measurement and QI intervention characteristics were charted from included studies. Data items were synthesised and presented narratively as well as quantitatively.

We screened 6294 studies and included 90 full-text publications. The studies were published from 2000 to 2023, with the majority (61%, 55/90) published since 2020. Publications originated from a wide range of clinical disciplines with most QI projects situated in the inpatient setting (78%, 70/90). Environmental sustainability metrics were subcategorised into activity data and environmental impact indicators. Some papers included more than one category of activity data, with the most common being cost (88%, 79/90), hospital waste (52%, 47/90), anaesthetic gases (49%, 44/90), disposable use (24%, 22/90) and distance travelled (14%, 13/90). Fewer publications included environmental impact indicators, with global warming potential dominating this category (53%, 48/90).

There is a need to align QI efforts with environmental sustainability. However, there is limited guidance specific to healthcare QI on how to measure environmental impacts of these efforts. This review illuminates that sustainability-focused QI efforts to date have used a relatively narrow set of sustainability metrics. QI scholars and practitioners can benefit from further education, measurement frameworks and guidelines to effectively incorporate environmental sustainability metrics into QI efforts.

The healthcare sector contributes approximately 4% to 5% of global greenhouse gas (GHG) emissions, thereby impacting climate change. Various initiatives, including teleworking, have been considered to mitigate GHG emissions, but their environmental impact remains poorly defined in the healthcare sector. This study aims to evaluate the impact of teleworking by hospital pharmacists on GHG emissions reduction by comparing the actual situation at one Canadian hospital, which includes teleworking shifts from home, to a scenario where all working shifts necessitate travel to the hospital.

The study was conducted at the pharmacy department of an academic hospital with 86 pharmacists (75 pharmacist full-time equivalents), between June 1, 2020, and May 31, 2023. Two different online carbon footprint calculators, one developed by the Centres de Gestion des Déplacements (CGD) and one available at the website of Carbon Footprint Ltd., were employed to measure mean GHG emissions in kilograms of carbon dioxide equivalents (CO2eq) for individuals based on their modes of transport and distances traveled between home and work.

During the study period, teleworking resulted in a significant reduction of mean GHG emissions per pharmacist relative to the scenario of all on-site shifts, with a reduction of 134 kg CO2eq (1,160 CO2eq vs 1,026 CO2eq; t = 3.32; P = 0.0007) estimated with the CGD calculator and a reduction of 135 kg CO2eq (1,117 CO2eq vs 982 CO2eq; t = 4.31; P < 0.0001) estimated with the Carbon Footprint calculator. Those figures correspond to a reduction of 11.5% (11,249 kg CO2eq) to 12.1% (11,315 kg CO2eq) of the total quantity of emissions associated with commuting for the 84 pharmacists over 3 years. The median distance from home to the hospital was 10.0 km (interquartile range, 8.1 km), with nearly three-quarters of pharmacists commuting by public or active transport.

Teleworking has a positive environmental impact and could be implemented in other pharmacy departments. The implemented teleworking approach represents an encouraging initial step toward reducing the GHG emissions associated with the travel of employees.

Implementing patient's own medication (POM) and self-administration of medication (SAM) has several benefits for safe and sustainable medication use, including enhanced patient empowerment reduced workload for hospital staff and decreased medication waste. Despite positive attitude of stakeholders, the upscaling of these strategies in hospitals remained limited. This study aimed to (i) identify barriers and facilitators for implementing POM and SAM and (ii) develop implementation strategies to address these.

Semistructured interviews were conducted among healthcare providers involved in the implementation of POM and SAM in 10 Dutch hospitals. The study population encompassed (hospital and outpatient) pharmacists, pharmacy technicians, nurses, and (ward) physicians. The topic guide was based on COM-B model. Barriers and facilitators were identified with thematic content analysis and were categorized to the Consolidated Framework for Implementation Research (CFIR). Implementation strategies were selected based on identified barriers through the CFIR- Expert Recommendations for Implementing Change (ERIC) tool and identified strategies were clustered into predefined focus areas to develop implementation targets.

The 23 participants generally expressed a positive attitude towards implementation of POM and SAM. Themes reflecting facilitators related to (i) multiple benefits for patients, hospital, and society, (ii) a dedicated multidisciplinary implementation team, (iii) an iterative implementation process, whereas barriers related to (iv) substantial and invasive workflow changes, (v) reluctance to change responsibilities of healthcare providers, and (vi) unclear regulations and reimbursement. The CFIR-ERIC tool highlighted 57 implementation strategies in nine key focus areas to support the implementation of POM and SAM.

To implement POM and PAM successfully, strategies relating to involving stakeholders, changing infrastructure, and using an iterative implementation process are required.

Gastroenterology is a specialty that has evolved rapidly over time, especially in terms of advancements in endoscopic procedures. However, these advancements also present challenges, given the substantial resource demands associated with endoscopy procedures. Numerous actions could be taken to develop a resilient healthcare system that consumes as few resources as possible, but recommendations are needed to prioritize which processes could be improved. We aimed to evaluate the environmental footprint of a colonoscopy procedure, and to identify the main contributing impact process categories.

A single-center observational study was conducted at a Dutch university hospital. No clinical patient data were collected, but the colonoscopy procedure was studied. Data were collected during 13 colonoscopies. Life cycle assessment (LCA) was used to calculate environmental impact.

Damage to human health from one colonoscopy was 11.3·10 -5 disability-adjusted life-years, equivalent to 1 hour. A single colonoscopy resulted in emission of 56.4 kg of CO 2 -equivalent (CO 2 eq), equal to driving a car for 255 km or 55 days of emissions for an average European household. Transportation of patients and staff (76.5%) and disposables (13.5%) were the greatest contributors to damage to human health.

Among the 13 colonoscopies studied, the environmental impact was mainly attributable to transportation of patients and staff, and disposables. Therefore, raising awareness about the impact of transportation by car, and reducing resource consumption, particularly of disposable products, should be prioritized. Implementing alternatives to colonoscopy, such as intestinal ultrasound, could reduce the environmental footprint of the healthcare system.

Among the many actions required to avert further intensification of today's social, ecological and health crises is also the improvement of healthcare's environmental sustainability, including in countries particularly vulnerable to such crises. The present study aimed to identify Namibian healthcare professionals' knowledge, attitudes and practices, along with barriers and educational needs, as a foundation for context-relevant interventions. The study used a non-experimental, descriptive quantitative research design with an existing validated cross-sectional questionnaire as its data collection tool. Both purposive and snowball sampling were used to select healthcare professionals (n = 71) to participate in the quantitative online questionnaire. R (version 4.2.1) software was used to analyse the data from the completed questionnaires. The results showed that the Namibian healthcare professionals participating in this study have basic knowledge of and positive attitudes toward environmental sustainability in healthcare. However, various barriers to implementing strategies towards environmental sustainability exist that currently prevent the implementation of relevant practices. These should be overcome by the Namibian health system by providing the necessary frameworks, policies, measures and resources to drive improvements in environmental sustainability. Additionally, future and current healthcare professionals must receive training across all professional education levels to enable implementation in practice and effective advocacy and planetary health promotion.

In light of growing environmental concerns, this article examines the often-overlooked environmental impact of simulation-based education (SBE) within healthcare. We position simulation professionals as agents for environmentally sustainable change and seek to empower achievable, meaningful, measurable action. As a high-value yet resource-intensive pedagogical tool, SBE frequently relies on energy-intensive technologies and single-use materials that contribute to carbon emissions and waste. This article explores the environmental impact of SBE, detailing how it contributes to the healthcare sector's impact on the triple planetary crisis; climate change, pollution, and biodiversity loss.

Within the simulation community, we have observed a high level of motivation to respond to the triple planetary crisis and make sustainable change. However, there is limited information available to simulation educators about practical changes that can be made. We have responded with an article that can help move from rhetoric to action, from inertia to empowerment. Understanding the environmental impact of simulation activities provides a useful starting point. We explain how to estimate a carbon footprint for SBE and how this relates to its wider environmental impact. Recognising the urgent need for change, we then present a comprehensive toolkit of practical strategies that can improve the environmental impact of SBE. Part one of our toolkit focuses on resource management, waste reduction and efficient session delivery. In part two, we highlight how principles of sustainable healthcare can be incorporated into scenario design and local strategy. This more holistic approach shows how SBE can be leveraged beyond immediate educational goals to foster sustainable practice in healthcare. We present evidence for our toolkit, detailing the principles and frameworks on which the suggestions are based. Additionally, we discuss how change can be measured and what risks educators should be aware of.

By embedding sustainability into SBE, educators can not only mitigate their own environmental impact but also model sustainable healthcare practices for learners. Through these steps, the simulation community can play a pivotal role in addressing healthcare's environmental impact and contribute to a healthier planet.

Future doctors will need to adapt to the impact on health caused by the changing climate, whilst developing more sustainable practices to decrease the burden of healthcare on the environment. Planetary Health (PH) is emerging as a crucial subject area in medical education. This systematic review synthesises evidence on integrating PH into medical school curricula globally, focusing on experiences of medical students and educators.

MEDLINE, ERIC, and EMBASE were systematically searched to identify qualitative research studies focusing on experiences of medical students and staff in PH integration into medical school curricula. We included articles published in English and in peer-reviewed journals, from 2010 onwards. Articles were assessed for quality using the CASP checklist for qualitative research. Fourteen studies were identified and synthesised using meta-ethnography.

This review identified a strong consensus on the necessity to incorporate PH into medical school curricula. Three inter-related third-order constructs shaped our synthesis. The first was challenging existing norms, as PH represented atypical scenarios with flattened medical hierarchies and reliance on student and faculty enthusiasm and advocacy. The second was a recognition of a moral dimension, with an ethical obligation to teach PH and a responsibility to manage 'climate anxiety' that can emerge in students. The third was an enthusiasm to innovate and influence, reflecting the importance of embedding PH longitudinally in teaching and assessment.

Whilst some factors that shape PH implementation into medical curricula are consistent with other new subject areas, PH integration also raises unique considerations and dynamics. These include a power and knowledge shift away from staff, and a central notion of ethical justice linked to PH education. Medical education leaders should be mindful of these when embedding and growing PH as a core topic in the medical curriculum.

Background: Increasing carbon dioxide (CO2) in the atmosphere contributes to Earth's warming, which has negative impacts on human health. The health care system is a major contributor to CO2 emissions. Telehealth has the capacity to reduce health-care-related emissions by eliminating patient travel to in-person appointments. Methods: Data were obtained from Nebraska Medicine's (NM) electronic medical record. Parameters included patient zip code, provider location, calendar year of visit, and provider specialty. Euclidean distance from centroid zip code to clinic location was calculated. Environmental Protection Agency estimates were used to convert mileage to CO2 saved. Results: During the period January 1, 2019, to January 31, 2022, the NM health care system completed 214,241 telemedicine visits for patients whose home zip code is within Nebraska, resulting in greater than 2,600 metric tons of CO2 avoided. Telehealth appointments increased by more than 22,000% from 2019 to 2020. An average of 12.38 kg of CO2 was avoided with each telehealth visit. Medical specialties that avoided the most CO2 included family medicine, endocrinology, and infectious disease. Conclusion: This study demonstrates the capability of the NM health care system to rapidly adjust to an emergency pandemic by drastically increasing the use of telehealth, which also avoided thousands of tons of transportation-associated CO2 emissions. Telehealth appointments increased during the height of the pandemic by more than 22,000%. Telehealth is an effective CO2 emission-reducing strategy and a worthy avenue to further explore reduced health-care-related emissions.

Climate change is considered one of the greatest threats to environmental sustainability, human health and social well-being worldwide. The healthcare sector is one of the main actors with a strong negative environmental footprint, being responsible for about 4% of global emissions, and is also considered one of the costliest sectors, with healthcare spending absorbing about 10% of global economic output. This article examines the environmental costs of the healthcare system in Greece, with a focus on public hospitals. The data analysis methodology was based on linear ordinary regression (OLS) models to calculate environmental costs related to energy consumption, waste management and water consumption. Data was collected through the Ministry of Health's platform (BI Health) and analyzed using Stata software. The main findings suggest that environmental costs are a significant part of total operating costs, particularly in university and specialist hospitals. Factors such as the number of beds, the existence of special units (e.g. ICU) and the use of natural gas have a significant impact on environmental costs. The study offers a mathematical model for predicting environmental costs, which can help hospital administrators to make decisions about sustainable practices. This model could provide an important opportunity for practical application to make targeted decisions such as investing in sustainable technologies, improving energy efficiency and enhancing waste management, leading to cost-effective and environmentally sustainable practices.

The MJA-Lancet Countdown on health and climate change in Australia was established in 2017 and produced its first national assessment in 2018 and annual updates in 2019, 2020, 2021, 2022 and 2023. It examines five broad domains: health hazards, exposures and impacts; adaptation, planning and resilience for health; mitigation actions and health co-benefits; economics and finance; and public and political engagement. In this, the seventh report of the MJA-Lancet Countdown, we track progress on an extensive suite of indicators across these five domains, accessing and presenting the latest data and further refining and developing our analyses. We also examine selected indicators of trends in health and climate change in New Zealand. Our analyses show the exposure to heatwaves is growing in Australia, increasing the risk of heat stress and other health threats such as bushfires and drought. Our analyses also highlight continuing deficiencies in Australia's response to the health and climate change threat. A key component of Australia's capacity to respond to bushfires, its number of firefighting volunteers, is in decline, dropping by 38 442 people (17%) in just seven years. Australia's total energy supply remains dominated by fossil fuels (coal, oil and natural gas), and although energy from coal decreased from 2021 to 2023, energy from oil increased, and transport energy from petrol grew substantially in 2021-22 (the most recent year for which data are available). Greenhouse gas emissions from Australia's health care sector in 2021 rose to their highest level since 2010. In other areas some progress is being made. The Australian Government completed the first pass of the National Climate Risk Assessment, which included health and social support as one of the eleven priority risks, based in part on the assessed severity of impact. Renewable sources such as wind and solar now provide almost 40% of Australia's electricity, with growth in both large-scale and small-scale (eg, household) renewable generation and battery storage systems. The sale of electric vehicles reached an all-time high in 2023 of 98 436, accounting for 8.47% of all new vehicle sales. Although Australia had a reprieve from major catastrophic climate events in 2023, New Zealand experienced cyclone Gabrielle and unprecedented floods, which contributed to the highest displacement of people and insured economic losses over the period of our analyses (ie, since the year 2010 and 2000 respectively). Nationally, regionally and globally, the next five years are pivotal in reducing greenhouse gas emissions and transitioning energy production to renewables. Australia is now making progress in this direction. This progress must continue and accelerate, and the remaining deficiencies in Australia's response to the health and climate change threat must be addressed. There are strong signs that Australians are increasingly engaged and acting on health and climate change, and our new indicator on health and climate change litigation in Australia demonstrates the legal system is active on this issue in this country. Our 2022 and 2023 reports signalled our intentions to introduce indicators on Aboriginal and Torres Strait Islander health and climate change, and mental health and climate change in Australia. Although the development of appropriate indicators is challenging, these are key areas and we expect our reporting on them will commence in our next report.

The health care sector contributes notably to environmental harms, impacting human and ecosystem health. Hence, countries increasingly set ambitions to transition to environmentally sustainable health care, focusing on resource use, energy consumption, and patient travel. Telemedicine is often considered a promising solution to reduce travel-related carbon emissions. However, underlying environmental impact assessments lack important components such as staff travel and fail to adhere to standardized conduct and reporting. Moreover, assessments of telemedicine use in primary care are scarce.

This study aims to quantify and compare the environmental impact of physical visits and telemedicine visits in the context of domiciliary care and home nursing.

We conducted a life cycle assessment following international ISO-14040/44 standards of all resources required per individual patient visit, either in person at the patient's home or via video calling with a dedicated user-friendly tablet. We collected anonymous user data in collaboration with a telemedicine service company, complemented by consulting staff members of four nursing organizations. Telemedicine visits were elementary in nature, such as supporting patients in taking their medication or structuring their daily agenda. We quantified average environmental impacts from cradle to grave, using the Environmental Footprint method, and verified the robustness of the comparison via uncertainty analysis. The variability of environmental impacts in different settings was explored using scenario analyses for the available minimum to maximum ranges.

Compared to a single physical visit in the studied setting, a telemedicine visit contributed less to global warming (0.1 vs 0.3 kg of carbon dioxide equivalents [kgCO2eq]; -60%), particulate matter formation (6.2 * 10-9 vs 1.8 * 10-8 disease incidence; -60%), and fossil resource use (1.8 vs 4.4 megajoules; -60%). Mineral/metal resource use was higher for telemedicine than for physical visits (1.1 * 10-5 vs 4.0 * 10-6 kg antimony equivalent; +180%). Only water use was not consistently different in the uncertainty analysis. Scenario analyses indicated that telemedicine's environmental impact could become similar to physical visits only in urban settings (1-3 km of travel distance) with 50%-100% car commuting (0.1-0.4 vs 0.2-0.7 kgCO2eq). In rural settings (5-15 km of travel distance, 80%-100% car commute), physical visits' environmental impact was higher (1.0-3.5 kgCO2eq), mostly even for mineral/metal resource use.

Using telemedicine for domiciliary care and home nursing mostly reduces its environmental impact compared to physical visits. Benefits are larger in rural settings, where travel distances between patients are larger, and apply to multiple environmental impacts but not always to mineral/metal resource use. In urban settings, factors that influence the degree to which telemedicine is environmentally beneficial are whether staff are working from home versus at the office, commuting to the office by bicycle versus by car, and reusing video-calling devices. Accordingly, considerate application of telemedicine is important to support care for both human and planetary health.

This study aimed to implement green endoscopy through the microbiological assessment of gowning techniques during endoscopy to reduce carbon emissions and separate medical waste.

Twenty-five patients who performed esophagogastroduodenoscopy from March to May 2024 were included in this study. Four sections of the isolation gowns (anterior, posterior, right, and left) were cut into 2 cm2 after endoscopy, and the rate of microbial contamination was examined using the stamp method.

The endoscopic examination time was 8 min (6-12), and endoscopy was performed by 10 expert endoscopists, six endoscopists, and nine residents. The overall isolation gown contamination rate was 56%, with 25%, 20.8%, 20.8%, and 33.3% in the front, back, as well as right and left arms, respectively. The rates of isolation gown contamination rates in the expert endoscopists, endoscopists, and residents groups were 30%, 50%, and 77.8%, respectively, with a higher rate in the residents group. Regardless of the physician's performance, bacterial detection was consistently higher in the left arm (42.9% vs. 40% vs. 25%; p = 0.093). The detected bacteria comprised 58% Gram-positive and 42% Gram-negative organisms, including those from tap water used for endoscopy bacteria and obtained from the participant's skin or mouth. No pathogenic organisms were detected.

The bacteria detected in disposable gowns after gastrointestinal endoscopy were non-pathogenic. Thus, our findings suggest that changing all personal protective equipment of respective endoscopes might not be essential. We advocate for green endoscopy to achieve sustainable development goals and reduce medical waste.

Intensive care medicine is an area with a particularly high consumption of resources. This review presents important new findings relating to the environmental sustainability of intensive care medicine. For example, the drugs used in intensive care medicine can end up in the environment and cause relevant ecotoxicity. The consumption of material items is very high in intensive care medicine and the increasing replacement of reusable items by disposable items is a major problem. Simple measures can reduce the ecological footprint of materials and introduce the recycling of waste in intensive care units. The high energy consumption of air conditioning, lighting and medical technology varies between facilities but in most cases is substantial and can be significantly reduced through appropriate measures. Ideally, the consumption should be measured and analyzed in detail. In the future, support from artificial intelligence is conceivable in this aspect. Sustainability must be given a much higher priority in the training, continued and advanced education in intensive care medicine than it has been to date and in intensive care research sustainability aspects should be given equal consideration alongside economic aspects when it comes to assessing otherwise equivalent treatments. It is particularly important to avoid the misuse and overuse of intensive care. It brings no benefit to patients and hinders needs-based treatment that is oriented towards the patient's well-being. In addition, misuse and overuse increases costs and drives up the consumption of resources and thus the ecological footprint. Sustainability in the intensive care unit can only be achieved as a team. Various approaches are presented on how a networked Green Team can promote sustainability in the intensive care unit.

Intensive care units (ICUs) are the primary producers of greenhouse gas emissions within hospitals, due to the use of several invasive materials. Nurses represent a large portion of the healthcare workforce and can be pivotal in promoting sustainability practices. Several international reports have suggested that nursing can help achieve the sustainable development objectives set by the United Nations.

The purpose is to explore behaviour related to environmental sustainability in intensive care nurses.

A qualitative content analysis comprised of in-depth interviews involving 27 ICU nurses, who were each asked the same open-ended question. The transcripts collected were then analyzed and organized by a team of independently-working researchers. The analysis of the extrapolated concepts was carried out following the Neem M. (2022) method. The study is supported by a grant from the Centre of Excellence for Nursing Scholarship, Rome, July 2024.

The main recurring themes are as follows: (1) concepts of environmental sustainability in ICUs, (2) critical issues related to sustainable intervention in the ICUs (3) proactive environmental sustainability attitudes in ICUs. Time to know, define criticality, and improve is the conceptualization of sustainable behaviors experienced by ICU nurses.

Taking the time to know and define the critical issues for implementing sustainable behaviours in the ICU, turned out to be the key to enforce the mindset of green nursing thinking.

Sustainability behaviours need to be proposed and verified by ICU managers by creating sustainability teams and promoting a good working environment, founding the progression to green ICUs by focusing on health impact education and mindfulness.

This short communication presents an audit of anesthetic gas usage at National Taiwan University Hospital from 2018 to 2023. Using descriptive statistics and trend analysis, the data reveals trends in the consumption of sevoflurane and desflurane, associated costs, and their corresponding carbon emissions. A significant decrease in desflurane usage contributed to a 42.4% reduction in carbon dioxide equivalent (CO2e) emissions per general anesthesia case from 2018 to 2023. The findings underscore the importance of sustainable practices in anesthesia to align with global efforts to reduce carbon emissions.

Cardiovascular disease is the leading cause of morbidity and mortality worldwide, with a substantial amount of health-care resources targeted towards its diagnosis and management. Environmental sustainability in cardiovascular care can have an important role in reducing greenhouse gas emissions and pollution and could be beneficial for improving health metrics and societal well-being and minimizing the cost of health care. In this Review, we discuss the motivations and frameworks for sustainable cardiovascular care with an emphasis on the reduction of the climate-related and environmental effects of cardiovascular care. We also provide an overview of greenhouse gas emissions related to the provision of health care, including their measurement and quantification, carbon accounting, carbon disclosures and climate effects. The principles of life-cycle assessment, waste prevention and circular economics in health care are discussed, and the emissions associated with various sectors of cardiovascular care as well as the rationale for prevention as a powerful approach to reduce these emissions are presented. Finally, we highlight the challenges in environmental sustainability and future directions as applicable to cardiovascular practice.

Climate change is having a major impact on public health. The healthcare system is responsible for around 8% of greenhouse gas emissions in France. Infectious diseases (ID) lie at the heart of these consequences.

The primary aim of this study was to assess the expectations of French ID specialists in terms of a sustainable healthcare transition. Secondary objectives included the assessment of awareness regarding this subject, perceptions, adopted attitudes and opportunities for actions.

A survey on sustainable healthcare transition was sent to all the French Society for ID members.

Of the 860 physicians approached, 220 responded. More than 78% of respondents responded correctly to questions concerning the impact of climate change on public health. The environmental impact of the healthcare system was less well understood. A higher level of environmental anxiety was associated with a higher rate of declaration of concrete actions. People under 40 years of age declared themselves to be more active. Regarding attitudes towards the roles of different stakeholders in a sustainable healthcare transition, the role of medical societies is prominent. Respondents' main expectations and suggestions are the following: (1) creation of a cross functional group dedicated to a sustainable healthcare transition, (2) creation of a training program, to meet the training needs of 94% of respondents, (3) continuation of the French Society for ID's lobbying for the relocation of antibiotic production in Europe, research on life-cycle analysis of anti-infective drugs, single-dose packaging for antibiotics, (4) reflection on the concept of "sustainably designed healthcare" in ID, (5) continued exploration of the "One Health" concept and (6) development of recommendations for sustainably designed hygiene practice.

This national survey of French ID specialists is a prerequisite for the implementation of actions within the French Society for ID.

This discussion paper proposes four new nursing leadership roles to address planetary health challenges.

Nurses are essential in reducing healthcare's greenhouse emissions. The Planetary Health Education Framework (PHEF) supports integrating planetary health concepts into sustainable healthcare practice. Nurse educators with planetary health expertise should teach the PHEF, while nurse climate advocates promote it to health professionals, with nurse-led planetary health researchers undertaking climate-change research and Planetary Health Nurse Practitioners practicing sustainable healthcare.

Discussion paper.

A PICO framework was used to identify relevant articles: In nursing (P) should new roles be introduced (I) compared to no new roles (C) to understand climate change impacts on both nursing and planetary health (O).

Barriers to sustainable healthcare include denial, group-think, and ignorance. National and International organisation enablers highlight the importance of climate change in nurse education. The Australian College of Nursing recommends government funding for nurse-led planetary health research.

Educators should focus on curricula development, nurse climate advocates on education and policy, researchers on supporting planetary health research, and PHNPs on climate justice, environmental protection, and emissions reduction.

An urgent need for societal transformation exists to reduce the environmental impact of humanity, because environmental health affects human health. Health care causes ~5% of global greenhouse gas emissions and other substantial and ongoing environmental harms. Thus, health-care professionals and managers must lead ongoing efforts to improve the environmental performance of health systems. Life-cycle assessment (LCA) is a methodology that enables estimation of environmental impacts of products and processes. It models environmental effects from 'cradle' (raw material extraction) to 'grave' (end of useful life) and conventionally reports a range of different impact categories. LCA is a valuable tool when used appropriately. Maximizing its utility requires rational assumptions alongside careful consideration of system boundaries and data sources. Well-executed LCAs are detailed and transparently reported, enabling findings to be adapted or generalized to different settings. Attention should be given to modelling mitigation solutions in LCAs. This important step can guide health-care systems towards new and innovative solutions that embed progress towards international climate agreements. Many urological conditions are common, recurrent or chronic, requiring resource-intensive management with large associated environmental impacts. LCAs in urology have predominantly focussed on greenhouse gas emissions and have enabled identification of modifiable 'hotspots' including electricity use, travel, single-use items, irrigation, reprocessing and waste incineration. However, the methodological and reporting quality of published urology LCAs generally requires improvement and standardization. Health-care evaluation and commissioning frameworks that value LCA findings alongside clinical outcomes and cost could accelerate sustainable innovations. Rapid implementation strategies for known environmentally sustainable solutions are also needed.

The European Kidney Health Alliance's 2023 annual Policy Forum brought together relevant stakeholder groups and examined the impact of the environment on kidney health and of kidney replacement therapies on the environment; the environmental footprint of kidney care; and the role of the European Union (EU) in facilitating the transition to sustainable healthcare. Interventions made by nephrologists, patient representatives, renal nurses, scientists, civil society representatives, medical technology specialists, and EU policymakers and administrators considered themes that included the burden of chronic kidney disease (CKD) in the EU, the link between kidney health and environment, waste production and resource use, organ transplantation, technological innovation, and the role that the EU has to play in addressing the burden of kidney disease and fostering more sustainable healthcare practices. The 2023 European Kidney Forum illustrated the broad consensus among diverse stakeholders operating within the kidney health landscape on the critical need to adopt a more sustainable approach to kidney care in the EU. The Forum also highlighted the cruciality of EU policymakers' commitment to improving the sustainability of the healthcare sector through EU policies, tools and initiatives. Panel discussions pointed to the strong consensus between different stakeholders in the kidney health domain on the need for action to better prevent chronic kidney disease; improve the EU's organ donation and transplantation landscape; and recognise and address the substantial environmental impact linked to the management and treatment of CKD.

The healthcare sector significantly contributes to global environmental impacts. While efforts are underway to reduce emissions, this article explores ecotherapy as an innovative approach to treatment and public health that could further mitigate emissions while enhancing health outcomes. Ecotherapy involves nature-based interventions that reconnect individuals with the environment, offering mental and physical health benefits. Evidence indicates that ecotherapy can improve conditions like depression and anxiety, promote social cohesion, and encourage pro-environmental worldviews. Despite its potential, barriers such as cultural perceptions and accessibility issues hinder widespread adoption. The article emphasizes the need for trained practitioners and standardized evaluations to integrate ecotherapy into mainstream health and social care, providing co-benefits for both human and planetary health.

The triple planetary crisis of climate change, environmental pollution, and biodiversity loss is increasingly driving poor health outcomes worldwide. Healthcare systems and services are often not environmentally sustainable and compound the problem, while healthcare professionals are also recognised as key leaders in advancing sustainable healthcare. To adopt this leadership position, healthcare professionals' knowledge, attitudes, and practices regarding environmental sustainability in healthcare must be established. This article reports the development and validation of a new instrument for this purpose that corresponds to the specificities of the Southern African context.

Questionnaire development followed a seven-stage process. Information was obtained from a 2021 study titled 'South African Healthcare Professionals' Knowledge, Attitudes, and Practices Regarding Environmental Sustainability in Healthcare: A Mixed-Methods Study' to develop the instrument. Information was also sourced from the literature regarding environmental sustainability and healthcare to generate the first questionnaire with 29 items. The following stages included two rounds of expert input, separated by a pilot study with the target population to receive feedback regarding the instrument's structure, relevance, and length. Content validity was determined through statistical analysis.

Feedback was received from nine experts in stage two and 13 pilot-study participants in stage four and incorporated to improve the questionnaire. In stage six, the questionnaire was rated by seven experts. The content validity index of the questionnaire was calculated at two different stages, after which the indices were compared. Following a final edit, the questionnaire has 24 questionnaire items. The closing analysis calculated the scale content validity index average (S-CVI/Ave) of 0,922; this indicates that the final questionnaire has excellent content validity.

A questionnaire that assesses the knowledge, attitudes and practices of healthcare professionals regarding environmental sustainability in Southern Africa has been developed and validated. This questionnaire can now be used for further studies in Southern Africa.

Due to the significant environmental impact of healthcare, there is an urgent need to accelerate its circular transition. We provide an overview of the ESCH-R project study design and methodology for accelerating the transition from a linear to a circular healthcare sector through the development and implementation of circular interventions in the Netherlands. Using a transdisciplinary approach, we will apply the 10-R ladder framework for a circular economy to hospitals. Methods are presented to analyze current clinical practices, policies and requirements for sustainable behavioral change, from material flows and operations to policy and regulations. We describe methods for the development of circular interventions, including business models, contract templates, and product redesigns. Finally, our approach to dissemination and education is presented. The described study design and methods can be used by other hospital (settings) to identify environmental hotspots for circular interventions in their own healthcare practice and for the cross-transfer of knowledge and anticipated challenges in implementing circular strategies. Ultimately, the ESCH-R project will deliver innovative, scalable approaches for hospitals to reduce procurement of raw materials, retain value of medical products, and reduce waste streams, CO2 emissions and pollution.