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Environments and Health

Nurses and Climate Action

Cook, Cara MS, RN, AHN-BC; Demorest, Shanda L. DNP, RN-BC, PHN; Schenk, Elizabeth PhD, MHI, RN-BC, FAAN

Author Information
AJN, American Journal of Nursing: April 2019 - Volume 119 - Issue 4 - p 54-60
doi: 10.1097/01.NAJ.0000554551.46769.49
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In Brief

Members of the Alliance of Nurses for Healthy Environments at a rally at the White House in 2017. Photo courtesy of the Alliance of Nurses for Healthy Environments.

There is a growing body of concerning evidence regarding changes in Earth's climatic patterns and subsequent health effects. The Lancet Countdown, an international research collaboration that provides an independent overview of the connections between climate change and health, estimates there's been a tripling in the amount of scientific reports on this topic in the past decade.1 Although climate change can directly affect health, it's more commonly the environmental, ecological, and social consequences of an altered climate that harm human health.2 Climate change as a health threat manifests as changes in food, water, and air quality; an increased risk of vector-borne illnesses, such as Zika and Lyme infection; a rise in temperature-related illnesses; and mental health effects owing to community displacement and disruption.1, 3, 4 Certain populations—including children and the elderly, those who have chronic health conditions, some communities of color, and people who have fewer resources—are more vulnerable to these health risks. Climate change also serves as a threat multiplier, exacerbating existing health inequities and barriers.

In October 2018, the United Nations Intergovernmental Panel on Climate Change released a report emphasizing the need for accelerated decarbonization to limit global warming to 1.5°C higher than preindustrial levels.5 The report, Global Warming of 1.5°C, evaluates the difference in climate-related risks at this temperature and at 2°C above preindustrial levels. The authors identified an increase in the risk of health effects—including vector-borne disease, premature deaths from air pollution, and heat-related illness and death—as temperatures rise.5 Although the full severity of health threats and the pace of change remain unknown, the need to reduce the impact of climate change by limiting the emissions of greenhouse gases—compounds that trap heat in Earth's atmosphere—and to prepare communities for anticipated changes is clear. Because human activity is considered to be the predominant cause of global warming since 1950, altering human behavior can help to slow the trajectory of climate change.3 Various civil society organizations (for example, nongovernmental organizations, community groups, and faith-based organizations), businesses, and government agencies are taking steps to avoid catastrophic changes. In addition, countries and cities are assessing their unique vulnerabilities to climate change and developing disaster response and adaptation plans in which they identify interventions and actions that will prepare their communities for the social, economic, and health consequences of climate change.1

Beyond this societal and governmental response, the health sector—including health departments, systems, and facilities—also has a responsibility to address climate change. The health industry is resource-intensive and as such is a significant contributor to greenhouse gas emissions. Health care organizations must reduce their emissions—most importantly emissions of carbon dioxide, methane, and nitrous oxide—and account in their strategic planning for the anticipated impact of climate change on individuals and communities. Health care professionals, especially nurses, will play an important role in these efforts and are ideally situated to help reduce the burden of the health effects of climate change in various practice settings. To follow is a closer look at the way the health industry contributes to pollution and the practical actions nurses can take to help mitigate the resulting health risks.


Although health care organizations help patients to be healthier and recover from illness and injury, they also put people at risk with polluting practices, processes, and products. Global health programs have addressed health care–associated harm for decades6, 7; however, there has been less focus on the risks caused by health care pollution.

Estimates show that the health care sector contributes nearly 10% of greenhouse gas emissions in the United States.8 Hospitals use a lot of energy: they are two-and-a-half times as energy intensive as office buildings.9 They use significant amounts of energy in their highly technical processes, including through the use of heating and cooling systems. Most of the available energy nationwide is from coal or natural gas, which are fossil fuels whose use leads to greenhouse gas emissions.10 Through their use of these energy sources, hospitals are contributing to climate change. Further, unlike many office buildings, they are open every day. Hospitals can reduce their pollution in two primary ways: (1) they can conserve energy through more efficient operations, automatic heating and cooling processes, the use of light-emitting diode (LED) lighting, and other interventions; and (2) they can use renewable energy sources, such as solar, wind, and low-impact hydropower. As detailed in a World Health Organization report, significant health benefits can be realized as a result of reducing carbon emissions.4

Numerous toxic chemicals can be found in hospitals. These include pharmaceuticals, potent germicides in cleaning products, phthalates in medical devices, and pesticides or herbicides.11 Many less toxic choices are available, and hospital leaders should choose safer options when possible. Moreover, hospitals provide food for patients, families, staff, and the public, giving them a twofold opportunity: to serve highly nutritious food and to purchase products that create less pollution when grown, shipped, prepared, and disposed of. More sustainable options include using food that is locally grown, produced using fewer toxic chemicals, and requiring less packaging.

Hospitals create an exorbitant amount of waste, both regulated (chemical, nuclear, infectious, pharmaceutical, and narcotic) and nonregulated (landfill, composting, and recycling).11-13 These waste streams contribute to pollution in several ways. Regulated waste, for instance, contributes to chemical pollution if not managed properly. Waste in landfills produces methane gas, which contributes to climate change.14, 15 The excessive amount of waste produced at hospitals—it's estimated that 29 pounds of waste is produced per staffed bed per day—points to an overuse of resources that is not sustainable.16 The harmful effects of hospital waste can be reduced by using recycling systems and ensuring the proper segregation of hazardous, pharmaceutical, narcotic, and infectious waste.

Many organizations have been focused on the health care industry's effect on the environment. Health Care Without Harm (, an international nonprofit founded in 1996 to help health care organizations reduce their environmental footprint, provides resources, networks, and leadership. Its partner, Practice Greenhealth (, a U.S.-based membership organization, promotes environmental stewardship among health care facilities. However, additional action is needed by health care professionals, especially nurses.


Nurses have long understood the connection between environmental factors and health outcomes. Since the era of Florence Nightingale, they have been at the forefront of addressing the complex issues that influence public health, such as the need for clean air to breathe, clean water to drink, and a safe place to live and work. As frontline caregivers, today's nurses are witnessing and being challenged to respond to the effects of a changing climate. From increases in global temperature to more frequent and intense extreme weather events to air quality deterioration, the consequences of climate change are creating health risks that nurses are seeing in all practice settings. Nurses must be a part of efforts by the health sector and communities to prepare for further changes.

Health professionals, including nurses, have reported a lack of knowledge regarding the connection between climate change and health, and they've identified a need for further resources to foster an adequate response by the health sector.17 The results of a survey assessing nurses’ knowledge, attitudes, and perceptions revealed that public health nurses viewed climate change as a distant issue that affected health globally rather than locally, and they reported having minimal knowledge of its effect on health.18 A Swedish study exploring nurses’ perceptions of climate change and the environment found a lack of congruity between these issues and nurses’ daily work.19 Respondents identified several barriers to understanding and engaging in climate or environmental sustainability actions, including feeling overwhelmed by the issue, a lack of inclusion of sustainability or climate change information in the nursing curriculum, time restrictions and competing workplace priorities, and a lack of institutional support.19 Adding to nurses’ misunderstanding and lack of awareness of the way climate change affects health is the historical framing of this as an environmental issue. Research indicates that focusing on the health benefits of addressing climate change and framing it as a public health issue may serve to aid understanding and build public support for solutions.20, 21 An improvement in awareness among nurses and other health professionals has the potential to advance the widespread adoption of interventions that reduce carbon emissions and subsequently improve health.

ANHE and the Nursing Collaborative on Climate Change and Health

Recognizing that nurses represent the largest portion of the health care workforce and as such have a vital role in leading the health sector in responding to climate change, the Alliance of Nurses for Healthy Environments (ANHE) is working to improve nursing awareness and engagement (for more information, see ANHE and the Nursing Collaborative on Climate Change and Health). In addition, other professional nursing associations have shown leadership by publicly recognizing climate change as a health threat and as a concern that necessitates nursing advocacy.22, 23 Widespread nursing engagement with climate change as a health threat is crucial, especially at the institutional level.

Nurses are in key positions to address the environmental impact of health care facilities by influencing decisions to help reduce greenhouse gases and other pollutants in hospitals. Most practicing nurses in the United States work in acute care settings, where the most pollutants are generated.24 In addition, Standard 17 of the American Nurses Association's Standards of Professional Nursing Practice highlights environmental responsibilities: “The registered nurse practices in an environmentally safe and healthy manner.”25 Yet, it remains unclear how aware nurses are of health care pollution, or how many nurses participate in activities to reduce it.26 Few health care organizations have nursing-specific green teams, in which nurses work together to decrease health care pollution, or shared governance councils, which focus on reducing pollution. Such teams provide an excellent avenue for nurses to become engaged and apply their clinical expertise to decreasing pollution caused by nursing practice.


The WHAM Grid: Work–Home–Adaptation–Mitigation

Despite the ANHE's recent work to integrate climate change education into curricula and practice, few nursing programs or practice settings include information about health care–generated pollution or climate change. To help address this gap, the ANHE and Health Care Without Harm collaborated to create the Nurses Climate Challenge, which was launched in 2018 to motivate nurses to learn and teach about climate change and health. In a separate 2018 initiative, the ANHE worked with researchers to develop the Climate, Health, and Nursing Tool (CHANT), a mechanism for measuring the perceptions, motivations, and behaviors of nurses. That same year, the ANHE developed a third resource, the WHAM Grid, which describes actions nurses can take at work and home to address climate change (see The WHAM Grid: Work–Home–Adaptation–Mitigation).

The Nurses Climate Challenge. In this campaign, nurses aim to educate 5,000 health professionals on the effects of climate change on human health. Although nurses have not heretofore been widespread leaders in taking climate action, the Nurses Climate Challenge provides those in various specialties with an opportunity to educate and engage their colleagues in climate conversations using an expertly produced online toolkit (see With the aim of building a cohort of nurse educators (called “nurse climate champions”), the Nurses Climate Challenge serves as an innovative model for launching a movement of health professionals committed to climate solutions in care and educational settings and at home.

Signing up to be a nurse climate champion is simple. Anyone who has nursing credentials or is in nursing school can create an account on the Nurses Climate Challenge website. After becoming a champion, nurses have access to a robust collection of online resources to deliver climate change and health education to audiences of health professionals and students. The toolkit includes the following downloadable resources:

  • suggested steps and a timeline for educating others
  • an e-mail template to engage leadership to establish initial buy-in
  • customizable posters to promote educational events
  • slides for 10- and 15-minute presentations, which can be used during staff meetings and grand rounds, describing how climate change affects health
  • an optional survey to collect postpresentation feedback
  • a template for a sticker that says “Ask me about climate and health” that nurse climate champions can print and wear as identifiers
  • talking tips and strategies for having potentially difficult conversations with other health professionals about the impact of climate change on health
  • a list of the most effective actions to take in care, education, and home settings

As with other emerging research and projects centered on nursing and climate change, metrics are critical. The Nurses Climate Challenge relies on its champions to report, via the website, the number of audience members they've educated. After champions report their successes, an innovative web platform provides a publicly viewable tally of progress on the Nurses Climate Challenge's homepage. The website also includes an interactive map showing the location of each nurse climate champion. Within nine months of launching, the campaign had more than 430 nurse climate champions across five continents who had educated more than 4,750 health professionals and students on climate change and health.

CHANT was developed to provide a tool for the ongoing measurement of nurses’ awareness of and engagement with climate change as a health issue. This 10-minute survey asks nurses about climate change and health in terms of the following: awareness, experience, concern, motivation, urgency, and behavior. It's available for use by individuals, health care organizations, and schools and is being used to better understand changes in awareness, motivation, and behaviors over time. This knowledge can help to guide educators, nursing policymakers, risk planners, and others. A better understanding of nurses’ engagement with this serious health challenge will also help the profession to meet its environmental health standard of practice. To take the survey and learn more about CHANT, visit

It's essential that nurses understand the causes and health implications of climate change. The Nurses Climate Challenge and CHANT will help to advance knowledge across the profession and enable nurses to meet the needs of individuals, families, and communities affected by the current and expected health consequences of climate change.


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