Association Between Climate Change and Patient Health Outcomes: a Mixed-methods Systematic Review

Association Between Climate Change and Patient Health Outcomes: a Mixed-methods Systematic Review | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Systematic Review Association Between Climate Change and Patient Health Outcomes: a Mixed-methods Systematic Review Jana Turzáková, Dominika Kohanová, Andrea Solgajová, Tomáš Sollár This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-4346650/v1 This work is licensed under a CC BY 4.0 License Status: Posted Version 1 posted You are reading this latest preprint version Abstract Introduction: Climate change poses significant threats to the environment, biodiversity, and socioeconomic stability worldwide. Its impact on human health, particularly within healthcare systems, is growing in concern. Nurses, as front-line healthcare workers, play a crucial role in addressing climate-related health risks. However, there is a gap in understanding nursing perspectives on climate change and its implications for patient health outcomes. Aim: To synthesize empirical evidence on the association between climate change and patient health outcomes from a nursing perspective. Methods: A mixed-methods systematic review was conducted following the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA). The search was carried out in January 2023 in six scientific databases including CINAHL, PubMed, Scopus, ProQuest, Web of Science, and OVID Nursing. Studies focusing on climate change and patient health outcomes from a nursing perspective were included. Data extraction, quality appraisal, and synthesis were performed systematically. Results: The systematic review included 18 studies of a mainly quantitative nature. Three main themes emerged as follows: Climate Healthcare Interplay ; Future Nurses as Agents of Change ; and Navigating Sustainability Challenges in Nursing . These themes highlighted nurses' awareness of the interrelation between climate and health, the need for environmental education in nursing, and the challenges that hinder sustainable nursing practices. Conclusion: This review underscores the importance of integrating climate change topics into nursing education and fostering organizational support for sustainable nursing practices. Addressing these challenges is essential for nurses to mitigate the health risks posed by climate change effectively. Nursing climate change environment nurses nursing students patient health outcomes Figures Figure 1 Figure 2 INTRODUCTION Climate change is a pressing global issue that demands urgent attention and action from individuals, communities, governments, and businesses around the world [ 1 ]. Its importance cannot be overstated, as it poses significant threats to the environment, biodiversity, and socioeconomic stability [ 2 ]. According to the World Health Organization [ 3 ], the Earth has warmed every decade due to the increasing concentration of greenhouse gases, resulting in more variable hydrological events (general floods, flash floods, coastal flooding, melting glaciers, heavy precipitation) and meteorological events (sea level rise, tropical storms, cyclones, and hurricanes). There is widespread scientific consensus that the world’s climate is changing [ 4 ]. Global documents on climate change, for example, Global Climate 2011–2020: A decade of acceleration, 2023; Special Report on Climate Change and Land, 2019; State of Climate Services, 2023; Yearbook of Global Climate Action, 2023: Marrakech Partnership for Global Change Action, 2023 [ 2 , 5 – 7 ] emphasize the urgent need for action to mitigate its impacts and adapt to changing environmental conditions. Similarly, they emphasize the scientific consensus on human-induced climate change and its harmful effects on ecosystems, economies, and societies, particularly those affecting vulnerable populations. These documents set targets to reduce greenhouse gas emissions, move to renewable energy, increase resilience to climate disasters, and encourage sustainable development. They underscore the need for global cooperation, financial aid to developing countries, and the participation of governments, businesses, and civil society. Concerning human health, climate change affects the environment, natural systems, and societal conditions, including health systems. It exacerbates risks, potentially reversing progress in public health [ 3 ]. Climate changes have the potential to negatively impact population health worldwide, while the effects vary between geographic regions and populations [ 4 , 8 , 9 ]. Furthermore, climate change undermines the health workforce and infrastructure, reducing the capacity for universal health coverage [ 10 ]. Delaying action on climate change escalates health risks, undermines global health progress, and violates our commitment to universal health rights [ 3 , 10 ]. Climate changes underscore the need for emergency preparedness for climate-related disasters, sustainable health systems that can withstand these challenges, and a broader understanding of the links between climate and health. Health professionals must perceive environmental health as an integral part of human health and must strive to influence it at the individual, collective, and political levels [ 8 ]. Currently, nursing is beginning its journey toward addressing climate change. Nursing is one of the most trusted professions in the world, and the number of nurses is approximately 60% of all health professionals worldwide [ 11 ]. Therefore, nurses can be crucial in achieving the goals of sustainable development, environmental sustainability, and human well-being [ 12 ]. Generally, it is essential to talk about the important role of nurses as front-line workers in the fight against climate change. Their role can be important directly in the disaster area or, for example, in providing care to the increased number of emergency department visits due to climate-related incidents and events [ 13 ]. At the same time, nurses should lobby for public health planning to address the anticipated health consequences of climate change and measures to slow climate change [ 14 ]. However, nurses overwhelmingly feel that they are still underprepared to take action on climate change, which appears to represent a moral imperative for the health of the planet within their profession. However, to address this issue, nurses must be confident that they can participate in coordinated and cooperative pathways within their nursing practice [ 15 ]. Inclusion in nursing education could support the response of the nursing profession to this new and important aspect of health care [ 16 ]. By proactively addressing climate-related health risks, nurses can improve patient care, promote public health, and strengthen healthcare systems. They should address the impact of climate change on health outcomes, as it directly affects patient well-being and community health. However, there are literature gaps in nursing perspectives on the health consequences of climate change. Currently, there are several reviews in the literature focusing on health impacts in general [ 17 , 18 ] or from the perspective of other healthcare professionals than nursing [ 19 ]. Thus, this systematic review aimed to investigate the effects of climate change on patient outcomes and care from a nursing point of view. AIM The mixed-method systematic review aimed to synthesize existing empirical evidence on the association between climate change and patient health outcomes. A specific review question was formulated: What is the impact of climate change on patient health outcomes from a nursing perspective? METHODS Design A mixed-methods systematic review with a data-based convergent design was chosen [ 20 ], with the inclusion criterion that the reviewed studies focus mainly on climate change and its association with patient health outcomes. Search Methods This review adhered to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) [ 21 ]. The SPIDER tool (sample, phenomenon of interest, design, evaluation, type of research) accompanied by the time frame and language was used to formulate the search terms, ensuring alignment with the research question (Table 1 ) [ 22 ]. Table 1 SPIDER tool terms Criteria Inclusion Exclusion Sample Nursing professionals (e.g., nurses, nursing students, nurse aids, nurse managers…) Other healthcare professionals (e.g., physicians, midwifery…) Phenomenon of interest Association between climate change and patient health outcomes No association between climate change and patient health outcomes Design All designs None Evaluation Questionnaires, surveys, interviews, focus groups, etc. None Research type Empirical research (quantitative, qualitative, mixed method) Reviews, discussion articles, study protocols, editorials, commentaries, case studies, conference abstracts Time frame From the earliest published study up to January 2024 After January 2024 Language English Languages other than English The search was carried out in January 2024 in six scientific databases, including CINAHL, PubMed, Scopus, ProQuest, Web of Science, and OVID Nursing. The search was carried out using both Boolean operators (AND, OR) and different combinations of keywords that referred to climate change and patient health outcomes (Table 2 ). The search was limited to language (English); however, no time limits were determined. Table 2 The search process in the scientific databases CINAHL, PubMed, Scopus, ProQuest, Web of Science, and OVID Nursing Search words Hits ("Nursing" [Mesh] OR "Nurses" [Mesh]) AND ("Attitude" [Mesh] OR "Opinions" [Mesh] OR "Knowledge" [Mesh] OR "Perception" [Mesh] OR "Awareness" [Mesh] OR "Feelings" [Mesh] OR "Viewpoint" [Mesh] OR "experience*" OR "sense*" OR "view*" OR "impression*" OR "belief*" OR "concern*" OR "understanding" OR "cognition" OR "value*" OR "action*" OR "response*" OR "behavio*") AND ("Climate Change" [Mesh] OR "Greenhouse Effect" [Mesh] OR "global warming" OR "climate crisis" OR "climate warming" OR "climate issue*" OR "climate vulnerability*" OR "climate emergenc*" OR "climate action*" OR "climate control*" OR "environmental change" OR "planetary health") AND ("outcome*" OR "consequence*" OR "effect*" OR "impact*" OR "challenge*" OR "Association" [Mesh]) AND ("Patient care" [Mesh] OR "Nursing care" [Mesh] OR "Delivery of Health Care" [Mesh] OR "Health Care Delivery" [Mesh] OR "Inpatient care" [Mesh] OR "Outpatient care" [Mesh] OR "Health service" [Mesh] OR "Urgent care" [Mesh] OR "Clinic visit" [Mesh] OR "Ambulatory care" [Mesh] OR "health care" OR "emergency care" OR "hospital care") PubMed: 62 ("nurse*" OR "nursing") AND ("experience*" OR "attitude*" OR "knowledge" OR "perception*" OR "awareness" OR "sense*" OR "feeling*" OR "opinion*" OR "viewpoint*" OR "view*" OR "impression*" OR "belief*" OR "concern*" OR "understanding" OR "cognition" OR "value*" OR "action*" OR "response*" OR "behavio*") AND ("climate change*" OR "global warming" OR "climate crisis" OR "climate warming" OR "climate issue*" OR "climate vulnerability*" OR "climate emergenc*" OR "greenhouse effect*" OR "climate action*" OR "climate control*" OR "environmental change*" OR "planetary health*") AND ("outcome*" OR "consequence*" OR "effect*" OR "association*" OR "impact*" OR "challenge*") AND ("patient care" OR "care delivery" OR "health care" OR "care provision" OR "nursing care" OR "inpatient care" OR "outpatient care" OR "health service*" OR "urgent care" OR "emergency care" OR "clinic visit*" OR "ambulatory care" OR "hospital care") Scopus: 90 CINAHL: 103 ProQuest: 528 Web of Science: 418 OVID Nursing: 56 Total 1257 Inclusion and Exclusion Criteria Inclusion and exclusion criteria were stated, following the SPIDER tool. The study was included if it: a) was an empirical study (quantitative, qualitative, mixed-method); b) was published in a peer-reviewed journal; c) was published in the English language; d) was focused on the topic of interest (climate change and patient health outcomes); e) reflected nursing perspective (e.g., nurses, nursing students, nursing assistants, nursing aids). On the contrary, the study was not included if it: a) involved other than a nursing perspective (e.g., physician, midwifery); b) was a review study, discussion article, case study, conference abstract, study protocol, editorial, or commentary. Study Retrieval Based on predefined criteria, the data were systematically retrieved by two independent researchers (AS, DK) within two retrieval phases. The search and retrieval process was reflected in the PRISMA flow diagram (Fig. 1 ) [ 21 ]. The Rayyan QCRI® program [ 23 ] was used to retrieve studies effectively in both retrieval phases. The search produced 1,257 studies (CINAHL = 103, PubMed = 62, ProQuest = 528, Scopus = 90, Web of Science = 418, OVID Nursing = 56). After removing duplicates (n = 345), 912 studies were analyzed by title and abstract and examined against inclusion and exclusion criteria. In this phase, 893 studies were excluded because they did not directly relate to the stated objective of the study. In the second retrieval phase, 19 studies were examined by reading full texts. The second phase resulted in 18 studies included in further analysis. One study was excluded from the final analysis based on the evaluation that it did not relate to the nursing perspective. Quality Appraisal of the Studies For the evaluation of the methodological quality of 18 retrieved studies, the specific Mixed Method Appraisal Tool (MMAT) was used in our review [ 24 ], which is designed for quantitative (n = 9), qualitative (n = 6), and mixed-method study (n = 3) assessments. The evaluation of the methodological quality of the studies was carried out by two independent researchers (DK, JT), and any differences were discussed until a consensus was reached. Most of the quantitative studies did not meet the requirements of an adequate sampling strategy and a representative sample, and none of them could prove that the risk of non-response bias was low. On the other hand, almost all employed precise measurements and statistical analysis appropriate to answer the research question. All six qualitative studies were assessed as adequately fulfilling all the criteria specified by MMAT, that is a clear congruity between the research objectives and the methodological approach, as represented by the data collection method, the data analysis procedure, and the interpretation appropriately grounded in the data. The mixed-method studies failed to fulfill one [ 25 ], two [ 26 ], and, respectively, four[ 27 ] of a total of five criteria evaluated. A significant terminological ambiguity was identified, e.g. study title indicated a different research design from what the authors conducted and what the study reported. Based on the MMAT, none of the studies was excluded from the review due to low methodological quality. The comprehensive results are shown in Additional File 1. Data Extraction Data extraction of studies included in the systematic review was performed by two independent researchers (JT, DK). Data were extracted using a spreadsheet in Microsoft Excel, which included the following information: author, year, country, study design, sampling methods, sample size (including targeted respondents), data collection, data analysis, and perspective (nurses, nursing students). Study Risk of Bias Assessment To mitigate potential bias, the study employed the following strategies: (a) all researchers actively participated in the refining of the study protocol; (b) the literature search was conducted independently by two researchers (DK, AS); (c) two researchers independently performed data extraction (JT, DK) under the supervision of the senior researcher (TS); (d) two researchers independently evaluated the methodological quality of the studies (DK, JT); and (e) collective decision-making accompanied each stage, with a meeting held to determine progress to the next stage. Data Synthesis Data were analyzed using the convergent integrated approach. Both quantitative data and qualitative evidence were combined through thematic synthesis, involving coding and the development of descriptive themes to produce a comprehensive summary of the study findings [ 20 ]. Each article was reviewed for expressions and statements reflecting the association between climate change and patient health outcomes. These expressions and statements were categorized into subthemes and further organized into overarching themes, named on the basis of their content. The expressions and language used by the study participants and the study authors were used in the analysis to reduce interpretation. The results were presented narratively and in tables to address the defined research questions. The research team discussed condensed and charted data in tables and double-checked precision (10% of the material). RESULTS Given the rather broad scope of this review, the included studies were conducted in various settings of nursing practice and education, employed a wide range of designs, and aimed to address various research objectives (Additional File 2). In general, the review included mainly quantitative studies (n = 9). Most of the studies were conducted in the United States (n = 6), followed by Spain (n = 2), Turkey (n = 2) and China (n = 2), and one study each in the United Kingdom, Canada, the Republic of Korea, and Peru. Two studies analyzed data from more than 1 country [ 28 , 29 ]. Regarding the sample, most of the studies included practicing nurses (n = 8) and nursing students (n = 6). The sample size ranged from 20 to 733 respondents. The method most frequently used in data collection was a questionnaire (n = 9), followed by interviews or focus groups (n = 4). The most reported methods used in data analysis were combinations of descriptive and inferential statistics (n = 8). Review findings The findings were extracted and synthesized into three themes that were further specified by seven subthemes (Fig. 2 ). In studies in which the sample comprised of nurses and other healthcare professionals[ 26 , 30 , 31 ] or members of the public [ 32 ], only the results from the nursing perspective were included in the analysis and synthesis. Theme 1: Climate Healthcare Interplay The first theme is related to the interrelation of the environment and healthcare and represents the context, in which healthcare is provided. The findings suggest that nurses are aware of this context – climate change poses a significant risk to human health, and on the other hand, the healthcare industry contributes through its energy and resources requirements, greenhouse gas emissions, and waste production to this critical state. This theme was synthesized from two subthemes (The environment as a factor of health; Healthcare as an unsustainable industry), as described below. Subtheme 1: The environment as a factor of health The first subtheme included three codes (Nurses are aware that the environment is an important determinant of health; Climate change poses new healthcare needs; The health impacts of climate change are geographically dependent). As was evident in several studies [ 29 – 31 , 33 , 34 ], the environment appeared to be an important determinant of health, as reported by practicing nurses, nursing students, as well as faculty. Furthermore, they understand the risks to human health in relation to climate change [ 30 , 31 , 33 , 34 ]. Given the traditional emphasis of nursing on addressing social inequalities, nurses recognize that communities are disproportionately affected, resulting in climate injustice – groups of people who have the least power in society (e.g., indigenous people, people with low income) are more vulnerable to climate change impacts [ 29 ]. Furthermore, based on the studies analyzed, we identified that nurses understand that climate change poses new healthcare needs [ 25 , 26 , 33 , 35 ]. Students [ 25 , 35 ] and nurses [ 26 , 33 ] recognize the health impacts of climate change through newly emerging diseases and infections, such as respiratory diseases, cardiovascular diseases, infectious diseases, mental health issues, cancer, fetal malformations, premature births, increased incidence of chronic diseases in children, and new healthcare needs (e.g., epidemics related to seasonal changes) that arise due to extreme weather conditions and place a burden on the health system. These conditions may include heat or cold waves, temperature changes, natural disasters, and drought. In this context, various regions of the world face various health impacts of changing climate that were explored in four studies included in this review [ 25 , 26 , 33 , 36 ]. For example, in the United States, some symptoms associated with climate change were experienced by nurses themselves, their families, and patients (respiratory diseases and mental health issues), and some were indirectly experienced by reading or hearing (vector-borne diseases, heat illness, and trauma) [ 33 ]. Similarly, Turkish students listed their own experience with respiratory diseases, while water-borne diseases, and deaths due to malnutrition as impacts of climate change were experienced indirectly [ 25 ]. On the other hand, heat illness and vector-borne diseases in China were reported as local health impacts of climate change [ 26 , 36 ]. Subtheme 2: Healthcare as an unsustainable industry The second subtheme included three codes (Nursing as a profession must address the climate change topic; The healthcare sector is a significant contributor to climate change; Years of practice may raise awareness and action). The review findings highlighted the need to address the topic of climate change from the nursing perspective [ 29 – 31 ]. Nurses believe that they have a professional obligation to address this issue within their practice. This professional obligation is related to the holistic perspective of nursing – if the health of individuals is to be preserved, the environment as a crucial determinant of health should be protected [ 29 ]. In this context, nurses raised another important issue of the healthcare system being a significant contributor to climate change in the included studies [ 29 , 31 , 34 , 35 , 37 ]. Nurses are concerned that the healthcare sector produces too much waste and generates a considerable climate footprint [ 29 , 34 ]. Once students enter clinical practice, they find out how much waste is produced, how healthcare material is overused, and how waste is or is not managed, recycled, and disposed of. They become concerned about the excessive use of healthcare equipment and proper disposal of materials and understand the need for balance between overuse and patient health [ 31 , 35 , 37 ]. However, their scores of awareness, concern, motivation, and change behavior at home and work are lower than those of practicing nurses and faculty [ 33 ], therefore, immediate action regarding education is needed. Nurses with more years of clinical practice had a slightly higher tendency to adopt appropriate environmental practices (e.g. energy use and waste management) [ 38 ]. Theme 2: Future nurses as agents of change The second theme outlines key areas related to environmental education in nursing in terms of student awareness, the effect of sustainability education, and challenges related to curriculum integration. It highlights how nursing students are aware of the impacts of climate change and advocate for more education on environmental health. Additionally, it discusses the effectiveness of sustainability education in improving students' knowledge and behavior, as well as the challenges in integrating climate change topics into the curriculum. This theme was synthesized from three subthemes (Readiness to address climate change; Sustainability education; Curriculum integration of climate change topics), as described below. Subtheme 1: Readiness to address climate change The first subtheme included two codes (Aware generation; Students are ready to address the climate change issues). The findings of this review suggested that although many students did not receive formal education on environmental issues, they know about climate change and are aware of its impacts on many aspects of their private and future professional lives, primarily due to media exposure. Additionally, nurse educators can build on students’ awareness [ 25 , 30 , 31 , 39 ]. In this context, the review findings also highlighted that nursing students enter the profession with the expectation that nursing as a profession has the responsibility and influence needed to address the topic of climate change. Students believe that modern nursing roles include being a researcher, educator, and leader in climate change actions [ 25 ]. Furthermore, they believe that environmental awareness needs to be increased [ 35 , 37 ] and demand more education on the influence of the environment on health and the environmental impact of healthcare [ 25 , 31 , 35 ]. Subtheme 2: Sustainability education The second subtheme included two codes (Sustainability education may raise knowledge and behavior; Extracurricular activities count). In three studies [ 28 , 35 , 37 ], the emphasis was placed on sustainability education, which can support students to challenge unsustainable practices and implement change, e.g. waste management, and use of resources [ 37 ], has improved the competencies of nursing students and increased their awareness of sustainable care [ 35 ] and has improved students' knowledge, attitude and behavior regarding sustainability development [ 28 ]. Additionally, awareness of global climate change was related to environmental literacy and higher in students who have previously participated in meetings on environmental problems [ 39 ], or environmental voluntary activities and watched environmental documentaries [ 25 ]. Subtheme 3: Curriculum integration of climate change topics The third subtheme included two codes (The curriculum needs to address climate change topics; Curriculum integration of climate change topics is difficult). Three studies specifically addressed the topic of climate change and its integration into the nursing curriculum [ 25 , 30 , 40 ]. However, this topic was not generally included in the nursing curriculum in the analyzed studies conducted in the USA or Turkey. Additionally, other studies analyzed did not reflect the topic of curriculum integration of climate change. Nurse practitioner program directors, faculty, and nursing students believe that there should be greater emphasis on environmental health in their programs. Nevertheless, the integration of the topic of climate change into the nursing curriculum is difficult, mainly due to serious barriers related to overcrowded curricula, with dense content that it already needs to cover, lack of faculty expertise in the area, and lack of access to information resources related to environmental health [ 30 , 40 ]. Theme 3: Navigating sustainability challenges in nursing The third and last theme explores challenges that hinder sustainable nursing practices, focusing on patient-centered care and lack of support. Nurses prioritize patient needs over environmental concerns due to busy clinical settings, which leads to minimal attention to environmental issues. Additionally, the lack of organizational support and barriers faced by students contribute to the challenge. The narrative highlights the importance of education, awareness, and leadership in promoting sustainable practices and advocating for environmental stewardship within the nursing profession. This theme was synthesized from two subthemes (Patient-centered care; Lack of support), as described below. Subtheme 1: Patient-centered care The first subtheme included two codes (Patient care is a priority; Some issues are more relevant to nursing, and some are less). Based on nurses´ reports, the environmental aspect of healthcare is understood and present in the way nurses think about climatic change and nursing, but in busy clinical settings, it is less likely to impact the quality of care. When deciding between the needs of the patients and the environmental perspective, the patient is the priority. Nurses must deal with competing priorities and prioritize patient care/safety over the environment [ 41 ]. Authors [ 33 ]found that although nurses scored high on the awareness scale, awareness alone did not lead to behavior change, because nurses feel overwhelmed. However, they strongly believe that their actions can significantly impact the area of waste management. The impact in the areas of sustainable food, chemical reduction, and sustainable transportation is moderate, and the impact in the areas of energy and water use is minimal [ 34 ]. Nevertheless, regarding environmental aspects, patients may benefit from meteorological information utilization, e.g. warnings regarding heat waves. However, it is not the primary patient care issue – it would be difficult to provide additional information beyond that indispensable in busy healthcare settings. Patients must receive and remember essential information on check-ups and medication, and too much information can cause overwhelming at discharge [ 32 ]. Subtheme 2: Lack of support The second subtheme included three codes (Workplace culture and organizational policy do not support environmentally responsible practices; Future nurses face even more barriers; Education, awareness, and leadership are crucial for success). The review findings highlighted that hospitals prioritize patient safety and budget. Nurses perceive a lack of organizational support, they believe that the management should implement the change, not individuals (e.g., recycle bins, use of single-use vs. reusable products, more plant-based options in food services, low-emission transportation) [ 41 ]. Nurses report more sustainable behavior at home than at work, because at home they have more control over the context and do not need to follow regulations and guidelines [ 33 ]. Insufficient support was perceived by nurses who participate in environmental activism, too. Nurses who feel a professional duty to address climate change experience strong emotions such as anger, fear, and sadness. They are frustrated by the lack of recognition of environmental care in nursing and may feel isolated and overwhelmed. Environmental activism adds emotional labor beyond patient care. US nurses feel more supported in activism than UK nurses [ 29 ]. In addition, nursing students perceived several barriers to providing sustainable care to patients during their clinical placements, as reported in two studies [ 35 , 37 ]. These barriers included a lack of confidence due to an imbalance of power and lack of knowledge, resistance to change in practice, lack of time, and lack of facilities [ 37 ]. What students may perceive as a lack of environmental awareness on the part of the healthcare staff with whom they work during their clinical placements [ 35 ], may be the result of competing priorities in busy clinical settings, prioritizing patient needs and safe care, and lack of organizational support that prevents nurses from acting sustainable [ 41 ]. The lack of support was also evident regarding insufficient education about environmental stewardship, as reported by nurses in two studies [ 25 , 34 ]. Nurses believe that once educated, they can have an impact on public health – educate patients, families, and communities about environmental health. Furthermore, continuing education for practicing nurses is needed, especially in developing countries [ 38 ] and for emergencies related to extreme weather events, e.g., heat illness [ 36 ]. DISCUSSION The systematic review aimed to synthesize the existing evidence on the links between climate change and patient health outcomes from a nursing perspective. The findings were synthesized into three main themes. The findings of the first theme, "Climate Healthcare Interplay", shed light on the intricate relationship between the environment and healthcare delivery. Nurses, as frontline healthcare providers, recognize the significant impact of climate change on human health firsthand, either through personal experiences or indirectly through patient care. The health impacts of climate change and the emergence of new diseases were the main nursing outcomes on this theme. Furthermore, nurses in the analyzed studies recognized that the environment is an important determinant of health and health outcomes [ 30 , 31 , 33 , 34 ]. Climate-related shocks such as temperature fluctuations, precipitation changes, and rising sea levels degrade environmental and social factors that influence health [ 3 , 42 ]. All aspects of health, from air and water quality to food systems, are impacted [ 3 ]. According to the WHO, climate change may be responsible for 250,000 additional deaths per year between 2030 and 2050 [ 43 ]. The impact of climate change is increasing the severity and frequency, and health problems that did not exist before arise [ 44 ]. More specifically, climate change introduces new healthcare needs, with emerging diseases and infections becoming more prevalent due to extreme weather conditions, such as heat waves, floods, and storm intensity [ 45 , 46 ], or they can result from subsequent changes in environmental conditions that lead to an increase in waterborne diseases [ 47 ], foodborne diseases [ 48 , 49 ], vector-borne diseases [ 50 ], and nutritional insecurity [ 51 ]. Mental health can also be affected by the impacts of climate change [ 45 , 46 ]. Problems related to climate anxiety, ecological anxiety, climate sadness, and solastalgia are also described as the health consequences of climate change [ 52 ]. Posttraumatic stress disorder is a direct consequence of acute weather events [ 53 ], and traumatic exposure to major storms is a predictor of multiple mental health outcomes, including substance use and addiction [ 54 ], especially among people who already belong to marginalized groups [ 55 ]. This was also reflected in our systematic review, while findings highlighted that with climate change and the emergence of new diseases, new healthcare needs arise [ 25 , 26 , 33 , 35 ], which were recognized not only by nurses [ 26 , 33 ] but also by nursing students [ 25 , 35 ]. The findings of this systematic review highlighted the important role and responsibility of nurses in managing climate change and its impact on patient care, health, and patient outcomes. Furthermore, nurses represent the largest global healthcare resource to contribute to disaster preparedness efforts for climate change-related water disasters and work to mitigate environmental toxins that can threaten human health [ 56 ]. The role of nurses is also to minimize the effects of climate change on mental health among vulnerable population groups through evaluation, preventive education, and care [ 57 ]. In particular, advanced practice nurses (APNs) are pivotal in tackling climate change's health challenges. They educate on climate-related risks, offer preventive care, manage acute and chronic conditions exacerbated by climate change, and advocate for sustainable policies [ 13 , 14 ]. APNs play a vital role in promoting resilience and protecting public health from climate-related threats. Their specific competencies should include identifying people with increased vulnerability – young, old, people with chronic health conditions and marginalized groups living in poverty, with lack of health care coverage, immigration status, language barriers, homelessness, or mental illness – and providing advanced education about these risks together with identifying available community health services [ 13 , 14 ]. Despite the indisputable advantages and importance of advanced practice, the tasks and roles of these nurses have not been clearly defined, which significantly limits their implementation in the current healthcare system, especially when addressing climate change impacts[ 58 ]. Similarly to APNs, community nurses and public health nurses are considered key stakeholders when it comes to addressing climate change. They are defined as professionals who are supposed to lead as influencers of climate action and strengthen communities, for the active involvement of all individuals in achieving socio-political change [ 59 ]. In the context of addressing climate change, the nursing perspective is essential, especially in terms of the healthcare sector, as discussed in all included studies in this review [ 29 , 31 , 33 – 35 , 37 ]. More specifically, nursing professionals recognize the healthcare sector as a significant contributor to climate change, primarily due to excessive waste production and energy consumption [ 29 – 31 , 34 ]. When providing health care, policymakers in several countries recommend the use of disposable medical devices, which increases waste in the health sector. A recent example is the excessive use of medical gloves and masks due to the outbreak of the COVID-19 pandemic, which has significantly worsened this problem [ 60 ]. Medical waste also includes syringes, scalpels, linen contaminated with biological material and body parts [ 61 ], and hazardous toxic and radioactive materials [ 62 ]. Improper healthcare waste management practices can exacerbate the problem in developing countries, which can negatively affect the sustainability of the environment and public health [ 63 ]. The link between the increase in waste in the healthcare delivery system also exists in connection with the global increase in population and the aging population [ 64 ], with the occurrence of chronic diseases and comorbidities [ 65 ], and with the increase in infectious diseases [ 66 ]. Overall, the entire healthcare sector needs to address its carbon footprint, which means that healthcare professionals, managers, and nursing leaders must be involved in addressing increased energy costs, stressed health services [ 13 ], increased plastic waste, and personal protective equipment as one of the environmental side effects of the recent COVID-19 pandemic [ 67 ]. The issue of increased medical waste was also highlighted in the analyzed studies from the perspective of nursing students and their education, while emphasis was placed on the topic of correct understanding of the use of medical equipment [ 31 , 35 , 37 ] and support of motivation to change behavior with greater responsibility towards the environment. Better preparation is already required during the education of nurses, as many nursing students are not sufficiently prepared for the health impacts of climate change and the response of the nursing profession [ 16 ]. The findings of the second theme, "Future Nurses as Agents of Change", highlight the role of nursing students in environmental education, their awareness of climate change impacts, the effectiveness of sustainability education, and challenges in curriculum integration. Education appears to be important in knowing and understanding the relationships between climate change and patient health outcomes. Nursing students enter the profession with the expectation that nursing as a profession has a responsibility in influencing climate change with the need to continuously raise awareness of this topic [ 35 , 37 ]. The findings of our systematic review suggested that students received limited education about environmental and climate change issues in their formal university education. Although students are informed about these topics primarily through the media (including social networks), they would request more education, especially on environmental impact on health, as well as environmental impact and waste generation within the provision of healthcare [ 25 , 31 , 35 ]. As part of achieving the 2030 Sustainable Development Goals, specifically Goal 13, and Goal 3: "Improving environmental education and awareness", education must equip nursing students with the knowledge and skills they need to sustainably promote the health and well-being of current and future generations [ 68 ]. A necessary step to achieve transformational change is the inclusion of planetary health education in the curriculum [ 69 ] and the explanation of nurses' competencies to strengthen the sustainability of the support of people's health and well-being, as well as the health of the planet [ 70 ]. Furthermore, there is evidence of the impact of education on the sustainability of environmental resources, on promoting the competencies of nursing students, and on increasing their awareness of this topic [ 28 , 35 , 37 ]. Among the extracurricular activities that appeared to be useful in raising awareness of global climate change, the discussions about environmental problems [ 39 ], environmental voluntary activities, and watching environmental documentaries [ 25 ] were crucial and discussed across the analyzed studies. Efforts to integrate climate change topics into the curriculum in nursing education were also discussed [ 25 , 30 , 40 ]. Environmental topics are currently absent in the curriculum, and some barriers limit its integration. This is mainly a consequence of the overcrowded and demanding curriculum and a lack of professional competence in environmental health [ 30 , 40 ]. The findings of the third and last theme, "Navigating Sustainability Challenges in Nursing," shed light on the obstacles to sustainable nursing practices, focusing on patient-centered care and the lack of organizational support. Areas that hinder sustainable nursing practices have been identified. These calls are mainly directed at management and policymakers. When providing nursing care in terms of quality and safety, nurses prioritize the needs of the patient. When deciding between patient needs and environmental needs, the patient is the priority [ 41 ]. On the other hand, it should be emphasized that nurses are aware that their actions can significantly affect waste areas and impact the environment [ 34 ]. The main reason for their actions is the lack of support from hospital management [ 41 ]. The findings of this review highlighted that hospitals prioritize patient safety and budget. Nursing students already perceived several obstacles in providing sustainable care to patients within clinical education [ 35 , 37 , 41 ]. They felt that their lecturers during clinical education did not address awareness of environmental aspects [ 35 ] not only because they prioritized the needs of patients in terms of quality and safety, but also due to demands and rush in providing care in the clinical environment, and due to insufficient management support [ 41 ]. On the other hand, rather low nursing competence to support sustainable practice is a result of insufficient education in this area [ 25 , 34 , 36 , 38 ]. The important challenge here arises: How can nurses deal with climate change within the healthcare sector? The solution can be found in education and training that addresses the impact of climate change on health, as well as strategies to mitigate or adapt to these impacts [ 71 ]. Another important area is the integration of sustainability practices, which involves encouraging healthcare facilities to adopt practices such as reducing energy, minimizing energy consumption and waste generation, and using environmentally friendly products [ 72 ]. Nurses must advocate for policies and initiatives that promote environmental sustainability in healthcare delivery at the local, national, and international levels [ 73 ]. Policy support is particularly associated with providing evidence from best practices for nurses to address climate change issues, with research and development of evidence-based interventions as essential activities [ 74 ]. Collaboration and networking among nurses and other healthcare professionals, environmental organizations, and community groups are of great importance in promoting environmental sustainability in healthcare [ 75 ]. Nurses feel their professional duty to support environmental care, as well as the need for greater environmental activism to achieve change [ 29 ]. All these actions can help nurses play a key role in mitigating the impacts of climate change on patient outcomes and promoting sustainability in healthcare. Implications for the international audience The present review has highlighted several methodological weaknesses in the reviewed studies. One of the most significant challenges was related to sampling. Most studies employed convenience sampling in specific regions or only one institution with rather small sample sizes which were not diverse enough, and with limited response rates, which may raise questions about the representativeness of the sample and generalizability of the findings. With current technological possibilities for global research integration, comparative studies may seem a promising direction, with special regard to communities more vulnerable to experiencing impacts of climate change due to their health status or geographical, demographic, and social characteristics. However, it is important to continue to address specific research objectives through qualitative or mixed–method studies, which provide useful perspectives to explore the lived experience of all actors who participate in the interplay of climate change and nursing. As the review findings suggest, students seem to be ready to implement sustainable practices in clinical settings, but organizational policy and workplace culture often do not support their motivation. It is crucial to explore the settings where the change was successfully implemented and to verify the factors that facilitate it. Lastly, it is essential to look for ways to raise environmental awareness of practicing nurses, especially in developing countries, and explore how to empower them to adopt sustainable practices that will not represent another burden on their already busy work pace but will integrate quality patient care with low environmental impact. There is a growing body of evidence suggesting that various forms of sustainability education and integrating the issue of climate change and health in the curriculum may increase the levels of knowledge, awareness, and motivation to act sustainably in students. The challenges we identified need to be addressed – competing curricular priorities and lack of expertise and resources on the part of faculty. Once educators have enough support, they can start to perceive these issues as clinically relevant and find a way to integrate them into the curriculum. Limitations Only studies published in English were included possibly resulting in omitting relevant research published in non-English studies. The authors come from different backgrounds and there was some discrepancy in evaluations of the methodological quality of the studies at the beginning, however, several discussions took place until the agreement in the team was achieved. CONCLUSION The purpose of the present systematic review was to critically examine empirical studies on the impact of climate change on patient health outcomes from the nursing perspective and to synthesize the evidence reported in quantitative, qualitative, and mixed-method studies available through all relevant databases searches. If a shift to sustainable healthcare and introducing climate change-related topics into the curriculum is to be made, it is crucial to understand the nursing perspective, the most numerous and most influential and trusted healthcare workforce, who is expected to implement changes in practice. Although the reviewed studies have some methodological limitations, provide promising findings on nursing education and practice. Nurses, who work hard to find the balance between quality patient care and low environmental impact healthcare, are faced with barriers related to organizational policy and workplace culture. Sustainability education seems to improve the environmental awareness of nursing students; however, the curriculum is already too extensive, and the same barriers present in clinical settings prevent students from implementing the changes. In conclusion, competing priorities in both educational and clinical settings, although they seem legitimate, need to be solved to effectively address the challenge of climate change and nursing. Declarations Ethics approval and consent to participate Not applicable. Consent for publication Not applicable. Availability of data and materials All data generated or analyzed in this study are included within this article and its additional files. Competing interests The authors declare they have no competing interests. Funding The authors declare this study received no external funding. Authors' contributions The authors confirm their contribution to the paper as follows: study conception and design: JT, DK, AS, TS; data collection: DK, AS; analysis and interpretation of results: JT, DK; draft manuscript preparation JT, DK, AS, TS. All authors read and approved the final version of the manuscript. Acknowledgments Not applicable. References Feliciano D, Recha J, Ambaw G, MacSween K, Solomon D, Wollenberg E. Assessment of agricultural emissions, climate change mitigation and adaptation practices in Ethiopia. Clim Policy. 2022;22(4):427–44. http://dx.doi.org/10.1080/14693062.2022.2028597 World Meteorological Organization. The Global Climate 2011-2020: A decade of acceleration [Internet]. Geneva: WMO. 2023 [cited 2024 Apr 18]. Available from: https://wmo.int/publication-series/global-climate-2011-2020-decade-of-acceleration World Health Organization. Climate change [Internet]. Geneva: WHO. 2023 [cited 2024 Feb 16]. Available from: https://www.who.int/news-room/fact-sheets/detail/climate-change-and-health Crimmins A, Balbus J, Gamble JL, Beard CB, Bell JE, Dodgen D, et al. The Impacts of Climate Change on Human Health in the United States: A Scientific Assessment. [Internet]. Washington, DC: US Global Change Research Program; 2016; 312 pp. [cited 2024 Feb 16]. Available from: http://dx.doi.org/10.7930/J0R49NQX The Intergovernmental Panel on Climate Change. Special Report on Climate Change and Land [Internet]. Geneva: WMO; 2019 [cited 2024 Feb 16]. Available from: https://www.ipcc.ch/srccl/ United Nations. Yearbook of Global Climate Action, 2023: Marrakech Partnership for Global Change Action [Internet]. Bonn: UNFCCC; 2023 [cited 2024 Feb 16]. Available from: https://unfccc.int/documents/632342 World Meteorological Organization (WMO). 2023 State of Climate Services for Health [Internet]. 2023 [cited 2024 Feb 16]. Available from: https://wmo.int/publication-series/2023-state-of-climate-services-health Norman I, Griffiths P. Nurses save the planet. Int J Nurs Stud. 2021;123(104061):104061. http://dx.doi.org/10.1016/j.ijnurstu.2021.104061 Watts N, Amann M, Ayeb-Karlsson S, Belesova K, Bouley T, Boykoff M, et al. The Lancet Countdown on health and climate change: from 25 years of inaction to a global transformation for public health. Lancet. 2018;391(10120):581–630. http://dx.doi.org/10.1016/s0140-6736(17)32464-9 Lugten E, Hariharan N. Strengthening health systems for climate adaptation and health security: Key considerations for policy and programming. Health Secur. 2022;20(5):435–9. http://dx.doi.org/10.1089/hs.2022.0050 Butterfield P, Leffers J, Vásquez MD. Nursing’s pivotal role in global climate action. BMJ. 2021;n1049. http://dx.doi.org/10.1136/bmj.n1049 Álvarez-Nieto C, Álvarez-García C, Parra-Anguita L, Sanz-Martos S, López-Medina IM. Effectiveness of scenario-based learning and augmented reality for nursing students’ attitudes and awareness toward climate change and sustainability. BMC Nurs. 2022;21(1):245. http://dx.doi.org/10.1186/s12912-022-01023-9 Sayre L, Rhazi N, Carpenter H, Hughes NL. Climate change and human health: the role of nurses in confronting the issue. Nurs Adm Q. 2010;34(4):334–42. http://dx.doi.org/10.1097/NAQ.0b013e3181f60df9 Allen PJ. Climate Change: A Review of Potential Health Consequences. Prim Health Care. 2015;5(1):1000183. 10.4172/2167-1079.1000183 Vold L, Meszaros M. Rhizomatic assemblages: Connecting climate change to nursing action. Witness: Can J Crit Nurs Discourse. 2021;3(2):18–35. http://dx.doi.org/10.25071/2291-5796.113 Leffers J, Levy RM, Nicholas PK, Sweeney CF. Mandate for the nursing profession to address climate change through nursing education. J Nurs Scholarsh. 2017;49(6):679–87. http://dx.doi.org/10.1111/jnu.12331 Harper SL, Cunsolo A, Babujee A, Coggins S, Aguilar MD, Wright CJ. Climate change and health in North America: literature review protocol. Syst Rev. 2021;10(1):3. http://dx.doi.org/10.1186/s13643-020-01543-y Rocque RJ, Beaudoin C, Ndjaboue R, Cameron L, Poirier-Bergeron L, Poulin-Rheault R-A, et al. Health effects of climate change: an overview of systematic reviews. BMJ Open. 2021;11(6):e046333. http://dx.doi.org/10.1136/bmjopen-2020-046333 Hathaway J, Maibach EW. Health implications of climate change: A review of the literature about the perception of the public and health professionals. Curr Environ Health Rep. 2018;5. http://dx.doi.org/10.1007/s40572-018-0190-3 Hong QN, Pluye P, Bujold M, Wassef M. Convergent and sequential synthesis designs: implications for conducting and reporting systematic reviews of qualitative and quantitative evidence. Syst Rev. 2017;6(1). http://dx.doi.org/10.1186/s13643-017-0454-2 Page MJ, McKenzie JE, Bossuyt PM, Boutron I, Hoffmann TC, Mulrow CD, et al. The PRISMA 2020 statement: an updated guideline for reporting systematic reviews. BMJ. 2021;372:n71. http://dx.doi.org/10.1136/bmj.n71 Cooke A, Smith D, Booth A. Beyond PICO: the SPIDER tool for qualitative evidence synthesis: The SPIDER tool for qualitative evidence synthesis. Qual Health Res. 2012;22(10):1435–43. http://dx.doi.org/10.1177/1049732312452938 Ouzzani M, Hammady H, Fedorowicz Z, Elmagarmid A. Rayyan—a web and mobile app for systematic reviews. Syst Rev. 2016;5(1). http://dx.doi.org/10.1186/s13643-016-0384-4 Hong QN, Pluye P, Fabregues S, Bartlett G, Boardman F, Cargo M. Mixed Methods Appraisal Tool (MMAT), version. BMJ Open. 2018; Ergin E, Altinel B, Aktas E. A mixed method study on global warming, climate change and the role of public health nurses from the perspective of nursing students. Nurse Educ Today. 2021;107(105144):105144. http://dx.doi.org/10.1016/j.nedt.2021.105144 Yang L, Liu C, Bi P, Vardoulakis S, Huang C. Local actions to health risks of heatwaves and dengue fever under climate change: Strategies and barriers among primary healthcare professionals in southern China. Environ Res. 2020;187(109688):109688. http://dx.doi.org/10.1016/j.envres.2020.109688 Luque-Alcaraz OM, Gomera A, Ruíz Á, Aparicio-Martinez P, Vaquero-Abellan M. Validation of the Spanish version of the questionnaire on environmental awareness in nursing (NEAT). Healthcare (Basel). 2022;10(8):1420. http://dx.doi.org/10.3390/healthcare10081420 Saleh M, Elsabahy MS. Integrating sustainability development education program in nursing to challenge practice among nursing interns in health care. J Nurs Manag. 2022;30(8):4419–29. https://doi.org/10.1111/jonm.13869 Terry L, Bowman K. Outrage and the emotional labour associated with environmental activism among nurses. J Adv Nurs. 2020;76(3):867–77. http://dx.doi.org/10.1111/jan.14282 Breakey S, Starodub R, Nicholas PK, Wong J. A cross-sectional study to assess faculty and student knowledge of climate change and health: Readiness for curricular integration. J Adv Nurs. 2023;79(12):4716–31. http://dx.doi.org/10.1111/jan.15729 Ryan EC, Dubrow R, Sherman JD. Medical, nursing, and physician assistant student knowledge and attitudes toward climate change, pollution, and resource conservation in health care. BMC Med Educ. 2020;20(1):200. http://dx.doi.org/10.1186/s12909-020-02099-0 Ock M, Choi EY, Oh I, Yun SH, Kim Y-K, Kim H, et al. Perceptions regarding utilization of meteorological information in healthcare in Korea: a qualitative study. Ann Occup Environ Med. 2018;30(1). http://dx.doi.org/10.1186/s40557-018-0214-3 Schenk EC, Cook C, Demorest S, Burduli E. Climate, Health, and Nursing Tool (CHANT): Initial survey results. Public Health Nurs. 2021;38(2):152–9. http://dx.doi.org/10.1111/phn.12864 Schenk E, Johnson S. Nurse-sensitive environmental indicators: A qualitative study. J Nurs Manag. 2022;30(8):4378–86. http://dx.doi.org/10.1111/jonm.13861 López-Medina IM, Álvarez-García C, Parra-Anguita L, Sanz-Martos S, Álvarez-Nieto C. Perceptions and concerns about sustainable healthcare of nursing students trained in sustainability and health: A cohort study. Nurse Educ Pract. 2022;65(103489):103489. http://dx.doi.org/10.1016/j.nepr.2022.103489 Zhao L, Lin X, Zang Y. Emergency preparedness for heat illness in China: A cross-sectional observational study. Int Emerg Nurs. 2021;54(100957):100957. http://dx.doi.org/10.1016/j.ienj.2020.100957 Aronsson J, Clarke D, Grose J, Richardson J. Student nurses exposed to sustainability education can challenge practice: A cohort study. Nurs Health Sci. 2020;22(3):803–11. http://dx.doi.org/10.1111/nhs.12734 Rojas-Perez HL, Díaz-Vásquez MA, Díaz-Manchay RJ, Zeña-Ñañez S, Failoc-Rojas VE, Smith D. Nurses’ environmental practices in northern Peruvian hospitals. Workplace Health Saf. 2023;21650799231163130. http://dx.doi.org/10.1177/21650799231163130 Incesu O, Yas MA. The relationship between nursing students' environmental literacy and awareness of Global Climate Change. Public Health Nurs. 2024;41(1):67-76. https://doi.org/10.1111/phn.13255 Bellack JP, Musham C, Hainer A, Graber DR, Holmes D. Environmental health competencies: a survey of nurse practitioner programs. AAOHN J. 1996;44(7):337–44. Kalogirou MR, Dahlke S, Davidson S, Yamamoto S. How the hospital context influences nurses’ environmentally responsible practice: A focused ethnography. J Adv Nurs. 2021;77(9):3806–19. http://dx.doi.org/10.1111/jan.14936 Conrad K. The era of climate change medicine-challenges to health care systems. Ochsner J. 2023 Spring;23(1):7–8. http://dx.doi.org/10.31486/toj.23.5033 Watts N, Adger WN, Agnolucci P, Blackstock J, Byass P, Cai W, et al. Health and climate change: policy responses to protect public health. Lancet. 2015;386(10006):1861–914. http://dx.doi.org/10.1016/S0140-6736(15)60854-6 Kim EJ. U.S. global change research program: The impacts of climate change on human health in the United States: A scientific assessment: (2016). Washington, DC: Author. 312 pages. https://health2016.globalchange.gov/downloads. J Am Plann Assoc. 2016;82(4):418–9. http://dx.doi.org/10.1080/01944363.2016.1218736 Rataj E, Kunzweiler K, Garthus-Niegel S. Extreme weather events in developing countries and related injuries and mental health disorders - a systematic review. BMC Public Health. 2016;16(1):1020. http://dx.doi.org/10.1186/s12889-016-3692-7 Cunsolo A, Ellis NR. Ecological grief as a mental health response to climate change-related loss. Nat Clim Chang. 2018;8(4):275–81. http://dx.doi.org/10.1038/s41558-018-0092-2 Levy K, Woster AP, Goldstein RS, Carlton EJ. Untangling the impacts of climate change on waterborne diseases: A systematic review of relationships between diarrheal diseases and temperature, rainfall, flooding, and drought. Environ Sci Technol. 2016;50(10):4905–22. http://dx.doi.org/10.1021/acs.est.5b06186 Park MS, Park KH, Bahk GJ. Interrelationships between multiple climatic factors and incidence of foodborne diseases. Int J Environ Res Public Health. 2018;15(11):2482. http://dx.doi.org/10.3390/ijerph15112482 Lake IR, Barker GC. Climate Change, Foodborne Pathogens and Illness in Higher-Income Countries. Curr Environ Health Rep. 2018;5(1):187-196. https://doi.org/10.1007/s40572-018-0189-9 Mordecai EA, Caldwell JM, Grossman MK, Lippi CA, Johnson LR, Neira M, et al. Thermal biology of mosquito-borne disease. Ecol Lett. 2019;22(10):1690–708. http://dx.doi.org/10.1111/ele.13335 Springmann M, Mason-D’Croz D, Robinson S, Garnett T, Godfray HCJ, Gollin D, et al. Global and regional health effects of future food production under climate change: a modelling study. Lancet. 2016;387(10031):1937–46. http://dx.doi.org/10.1016/S0140-6736(15)01156-3 Galway LP, Beery T, Jones-Casey K, Tasala K. Mapping the solastalgia literature: A scoping review study. Int J Environ Res Public Health. 2019;16(15):2662. http://dx.doi.org/10.3390/ijerph16152662 Berry HL, Bowen K, Kjellstrom T. Climate change and mental health: a causal pathways framework. Int J Public Health. 2010;55(2):123–32. http://dx.doi.org/10.1007/s00038-009-0112-0 Pollack AA, Weiss B, Trung LT. Mental health, life functioning and risk factors among people exposed to frequent natural disasters and chronic poverty in Vietnam. BJPsych Open. 2016;2(3):221–32. http://dx.doi.org/10.1192/bjpo.bp.115.002170 Matthews V, Longman J, Berry HL, Passey M, Bennett-Levy J, Morgan GG, et al. Differential mental health impact six months after extensive river flooding in rural Australia: A cross-sectional analysis through an equity lens. Front Public Health. 2019;7:367. http://dx.doi.org/10.3389/fpubh.2019.00367 Veenema TG, Thornton CP, Lavin RP, Bender AK, Seal S, Corley A. Climate change-related water disasters’ impact on population health: Climate change disasters health impact. J Nurs Scholarsh. 2017;49(6):625–34. http://dx.doi.org/10.1111/jnu.12328 White BP, Breakey S, Brown MJ, Smith JR, Tarbet A, Nicholas PK, et al. Mental health impacts of climate change among vulnerable populations globally: An integrative review. Ann Glob Health [Internet]. 2023;89(1):66. Available from: http://dx.doi.org/10.5334/aogh.4105 Cadet MJ. Integrating climate change concepts into advanced practice registered nurses curricula with the application of the National Organization of Nurse Practitioner Faculties competencies. J Prof Nurs. 2022;41:157–65. http://dx.doi.org/10.1016/j.profnurs.2022.05.006 Polivka BJ, Chaudry RV, Mac Crawford J. Public health nurses’ knowledge and attitudes regarding climate change. Environ Health Perspect. 2012;120(3):321–5. http://dx.doi.org/10.1289/ehp.1104025 Chen C, Chen J, Fang R, Ye F, Yang Z, Wang Z, et al. What medical waste management system may cope With COVID-19 pandemic: Lessons from Wuhan. Resour Conserv Recycl. 2021;170(105600):105600. http://dx.doi.org/10.1016/j.resconrec.2021.105600 Chauhan A, Singh SP. Selection of healthcare waste disposal firms using a multi-method approach. J Environ Manage. 2021;295(113117):113117. http://dx.doi.org/10.1016/j.jenvman.2021.113117 World Health Organization (WHO). Health-care waste [Internet]. 2018 [cited 2024 Apr 7]. Available from: https://www.who.int/news-room/fact-sheets/detail/health-care-waste Görçün ÖF, Aytekin A, Korucuk S, Tirkolaee EB. Evaluating and selecting sustainable logistics service providers for medical waste disposal treatment in the healthcare industry. J Clean Prod. 2023;408(137194):137194. http://dx.doi.org/10.1016/j.jclepro.2023.137194 McPhail S. Multimorbidity in chronic disease: impact on health care resources and costs. Risk Manag Healthc Policy. 2016;9:143–56. http://dx.doi.org/10.2147/rmhp.s97248 Raghupathi W, Raghupathi V. An empirical study of chronic diseases in the United States: A visual analytics approach to public health. Int J Environ Res Public Health. 2018;15(3):431. http://dx.doi.org/10.3390/ijerph15030431 Peng J, Wu X, Wang R, Li C, Zhang Q, Wei D. Medical waste management practice during the 2019-2020 novel coronavirus pandemic: Experience in a general hospital. Am J Infect Control. 2020;48(8):918–21. http://dx.doi.org/10.1016/j.ajic.2020.05.035 Seif F, Noorimotlagh Z, Mirzaee SA, Kalantar M, Barati B, Fard ME, Fard NK. The SARS-CoV-2 (COVID-19) pandemic in hospital: An insight into environmental surfaces contamination, disinfectants' efficiency, and estimation of plastic waste production. Environ Res. 2021;202:111809. https://doi.org/10.1016/j.envres.2021.111809 Shaw E, Walpole S, McLean M, Alvarez-Nieto C, Barna S, Bazin K, et al. AMEE Consensus Statement: Planetary health and education for sustainable healthcare. Med Teach. 2021;43(3):272–86. http://dx.doi.org/10.1080/0142159X.2020.1860207 Rosa WE, Kurth AE, Sullivan-Marx E, Shamian J, Shaw HK, Wilson LL, et al. Nursing and midwifery advocacy to lead the United Nations Sustainable Development Agenda. Nurs Outlook. 2019;67(6):628–41. http://dx.doi.org/10.1016/j.outlook.2019.06.013 Kelly T, Lazenby M. Developing and validating learning domains, competencies, and evaluation items for global health clinical immersion practicums for graduate-level nursing programs. J Adv Nurs. 2019;75(1):234–52. http://dx.doi.org/10.1111/jan.13851 Gaudreau C, Guillaumie L, Jobin É, Diallo TA. Nurses and Climate Change: A Narrative Review of Nursing Associations' Recommendations for Integrating Climate Change Mitigation Strategies. Can J Nurs Res. 2024;19:8445621241229932. https://doi.org/10.1177/08445621241229932 Vallée A. Green hospitals face to climate change: Between sobriety and resilience. Heliyon. 2024;10(2):e24769. http://dx.doi.org/10.1016/j.heliyon.2024.e24769 Harris OO, Bialous SA, Muench U, Chapman S, Dawson-Rose C. Climate change, Public Health, health policy, and nurses training. Am J Public Health. 2022;112(S3):S321–7. http://dx.doi.org/10.2105/AJPH.2022.306826 Salvador Costa S, Melo MJ, Azeiteiro P, Carvalho U, Ryan S. Nursing Interventions to Reduce Health Risks from Climate Change Impact in Urban Areas: A Scoping Review Protocol. Nurs Rep. 2023;13:496–505. https://doi.org/10.3390/nursrep13010045 Crowder SJ, Tanner AL, Dawson MA, Felsman IC, Hassmiller SB, Miller LC, et al. Better together: Coalitions committed to advancing health equity. Nurs Outlook. 2022;70(6):S48–58. http://dx.doi.org/10.1016/j.outlook.2022.02.013 Additional Declarations The authors declare no competing interests. Supplementary Files AdditionalFile1Qualityappraisal.docx Additional file 1 Quality assessment of the included studies AdditionalFile2Characteristicsofreviewedstudies.docx Additional file 2 Characteristics of the reviewed studies Cite Share Download PDF Status: Posted Version 1 posted You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. As a division of Research Square Company, we’re committed to making research communication faster, fairer, and more useful. We do this by developing innovative software and high quality services for the global research community. Our growing team is made up of researchers and industry professionals working together to solve the most critical problems facing scientific publishing. Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-4346650","acceptedTermsAndConditions":true,"allowDirectSubmit":true,"archivedVersions":[],"articleType":"Systematic Review","associatedPublications":[],"authors":[{"id":297050873,"identity":"22b68209-d3b5-41b0-8acf-88017065ef4c","order_by":0,"name":"Jana Turzáková","email":"data:image/png;base64,iVBORw0KGgoAAAANSUhEUgAAAZAAAAAyAQMAAABI0h/eAAAABlBMVEX///8AAABVwtN+AAAACXBIWXMAAA7EAAAOxAGVKw4bAAAAyklEQVRIiWNgGAWjYBACxgYwlQDEzAcYG2wYGCQIammDa2FLYGxII0ILAxtcC48BcVqY5/eYffxRkyZncPzMN8kZCQz2kg0EHcZjPEPiWI6xwZncbZIbEhgSZxOyBaSFwYCtInFmA1DLwx8MCXJEaUn4B9TS/+aZ5AOgw4jTcrAtJ7FfIocN5DBGIhyWVszY2JdmzC/xzNhyRoIE0IUEtBg2H97M+ONbshwbf/LDmz0JNvYSBwhpQTOTcEQyyBNWMgpGwSgYBSMeAADi9TtaNV5BygAAAABJRU5ErkJggg==","orcid":"https://orcid.org/0000-0001-8483-8588","institution":"Constantine the Philosopher University in Nitra","correspondingAuthor":true,"prefix":"","firstName":"Jana","middleName":"","lastName":"Turzáková","suffix":""},{"id":297051927,"identity":"859be7e4-f7e3-4d87-9386-aa0e6124750e","order_by":1,"name":"Dominika Kohanová","email":"","orcid":"https://orcid.org/0000-0003-3396-3519","institution":"Constantine the Philosopher University in Nitra","correspondingAuthor":false,"prefix":"","firstName":"Dominika","middleName":"","lastName":"Kohanová","suffix":""},{"id":297052301,"identity":"b9b9f2c4-1a95-4ca4-a78e-83bd954164b5","order_by":2,"name":"Andrea Solgajová","email":"","orcid":"https://orcid.org/0000-0002-6174-4797","institution":"Constantine the Philosopher University in Nitra","correspondingAuthor":false,"prefix":"","firstName":"Andrea","middleName":"","lastName":"Solgajová","suffix":""},{"id":297052302,"identity":"4a79777d-6704-4024-b662-d3ae1f81b3c0","order_by":3,"name":"Tomáš Sollár","email":"","orcid":"https://orcid.org/0000-0002-8214-896X","institution":"Constantine the Philosopher University in Nitra","correspondingAuthor":false,"prefix":"","firstName":"Tomáš","middleName":"","lastName":"Sollár","suffix":""}],"badges":[],"createdAt":"2024-04-30 06:20:22","currentVersionCode":1,"declarations":{"humanSubjects":false,"vertebrateSubjects":false,"conflictsOfInterestStatement":false,"humanSubjectEthicalGuidelines":false,"humanSubjectConsent":false,"humanSubjectClinicalTrial":false,"humanSubjectCaseReport":false,"vertebrateSubjectEthicalGuidelines":false},"doi":"10.21203/rs.3.rs-4346650/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-4346650/v1","draftVersion":[],"editorialEvents":[],"editorialNote":"","failedWorkflow":false,"files":[{"id":55817730,"identity":"422dcf43-4e8d-4b4a-b76b-3ba87be362a3","added_by":"auto","created_at":"2024-05-03 20:50:38","extension":"png","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":55027,"visible":true,"origin":"","legend":"\u003cp\u003e\u003cstrong\u003ePRISMA flow diagram\u003c/strong\u003e\u003c/p\u003e","description":"","filename":"1.png","url":"https://assets-eu.researchsquare.com/files/rs-4346650/v1/f270a655238904893a5e0e2b.png"},{"id":55817731,"identity":"e03631ac-d2c8-4ac5-b7d2-59e31b5a01c2","added_by":"auto","created_at":"2024-05-03 20:50:38","extension":"png","order_by":2,"title":"Figure 2","display":"","copyAsset":false,"role":"figure","size":54896,"visible":true,"origin":"","legend":"\u003cp\u003e\u003cstrong\u003eMain themes and subthemes reflecting the association between climate change and patient health outcomes\u003c/strong\u003e\u003c/p\u003e","description":"","filename":"2.png","url":"https://assets-eu.researchsquare.com/files/rs-4346650/v1/2de26c0b04e01b93d7667e13.png"},{"id":55818363,"identity":"e0d2147b-6f27-4c24-8b0d-9add73370d34","added_by":"auto","created_at":"2024-05-03 20:58:39","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":865136,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-4346650/v1/a8464d93-0d00-416e-b111-05f53282e875.pdf"},{"id":55817732,"identity":"fd4de687-f363-427a-a891-26125e5e24f0","added_by":"auto","created_at":"2024-05-03 20:50:38","extension":"docx","order_by":1,"title":"","display":"","copyAsset":false,"role":"supplement","size":17070,"visible":true,"origin":"","legend":"\u003cp\u003eAdditional file 1 Quality assessment of the included studies\u003c/p\u003e","description":"","filename":"AdditionalFile1Qualityappraisal.docx","url":"https://assets-eu.researchsquare.com/files/rs-4346650/v1/9ec64cf0fe3bb11f966eb0f3.docx"},{"id":55817733,"identity":"1b3cdb81-e245-414d-8105-b94051c0f495","added_by":"auto","created_at":"2024-05-03 20:50:38","extension":"docx","order_by":2,"title":"","display":"","copyAsset":false,"role":"supplement","size":20104,"visible":true,"origin":"","legend":"\u003cp\u003eAdditional file 2 Characteristics of the reviewed studies\u003c/p\u003e","description":"","filename":"AdditionalFile2Characteristicsofreviewedstudies.docx","url":"https://assets-eu.researchsquare.com/files/rs-4346650/v1/d0c8539e18491e35a96dfad2.docx"}],"financialInterests":"The authors declare no competing interests.","formattedTitle":"\u003cp\u003e\u003cstrong\u003eAssociation Between Climate Change and Patient Health Outcomes: a Mixed-methods Systematic Review\u003c/strong\u003e\u003c/p\u003e","fulltext":[{"header":"INTRODUCTION","content":"\u003cp\u003eClimate change is a pressing global issue that demands urgent attention and action from individuals, communities, governments, and businesses around the world [\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e]. Its importance cannot be overstated, as it poses significant threats to the environment, biodiversity, and socioeconomic stability [\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eAccording to the World Health Organization [\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e], the Earth has warmed every decade due to the increasing concentration of greenhouse gases, resulting in more variable hydrological events (general floods, flash floods, coastal flooding, melting glaciers, heavy precipitation) and meteorological events (sea level rise, tropical storms, cyclones, and hurricanes). There is widespread scientific consensus that the world\u0026rsquo;s climate is changing [\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e]. Global documents on climate change, for example, Global Climate 2011\u0026ndash;2020: A decade of acceleration, 2023; Special Report on Climate Change and Land, 2019; State of Climate Services, 2023; Yearbook of Global Climate Action, 2023: Marrakech Partnership for Global Change Action, 2023 [\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e, \u003cspan additionalcitationids=\"CR6\" citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e] emphasize the urgent need for action to mitigate its impacts and adapt to changing environmental conditions. Similarly, they emphasize the scientific consensus on human-induced climate change and its harmful effects on ecosystems, economies, and societies, particularly those affecting vulnerable populations. These documents set targets to reduce greenhouse gas emissions, move to renewable energy, increase resilience to climate disasters, and encourage sustainable development. They underscore the need for global cooperation, financial aid to developing countries, and the participation of governments, businesses, and civil society.\u003c/p\u003e \u003cp\u003eConcerning human health, climate change affects the environment, natural systems, and societal conditions, including health systems. It exacerbates risks, potentially reversing progress in public health [\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e]. Climate changes have the potential to negatively impact population health worldwide, while the effects vary between geographic regions and populations [\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e, \u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e, \u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e]. Furthermore, climate change undermines the health workforce and infrastructure, reducing the capacity for universal health coverage [\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e]. Delaying action on climate change escalates health risks, undermines global health progress, and violates our commitment to universal health rights [\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e, \u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eClimate changes underscore the need for emergency preparedness for climate-related disasters, sustainable health systems that can withstand these challenges, and a broader understanding of the links between climate and health. Health professionals must perceive environmental health as an integral part of human health and must strive to influence it at the individual, collective, and political levels [\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e]. Currently, nursing is beginning its journey toward addressing climate change. Nursing is one of the most trusted professions in the world, and the number of nurses is approximately 60% of all health professionals worldwide [\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e]. Therefore, nurses can be crucial in achieving the goals of sustainable development, environmental sustainability, and human well-being [\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eGenerally, it is essential to talk about the important role of nurses as front-line workers in the fight against climate change. Their role can be important directly in the disaster area or, for example, in providing care to the increased number of emergency department visits due to climate-related incidents and events [\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e]. At the same time, nurses should lobby for public health planning to address the anticipated health consequences of climate change and measures to slow climate change [\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e]. However, nurses overwhelmingly feel that they are still underprepared to take action on climate change, which appears to represent a moral imperative for the health of the planet within their profession. However, to address this issue, nurses must be confident that they can participate in coordinated and cooperative pathways within their nursing practice [\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e]. Inclusion in nursing education could support the response of the nursing profession to this new and important aspect of health care [\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eBy proactively addressing climate-related health risks, nurses can improve patient care, promote public health, and strengthen healthcare systems. They should address the impact of climate change on health outcomes, as it directly affects patient well-being and community health. However, there are literature gaps in nursing perspectives on the health consequences of climate change. Currently, there are several reviews in the literature focusing on health impacts in general [\u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e, \u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e] or from the perspective of other healthcare professionals than nursing [\u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e]. Thus, this systematic review aimed to investigate the effects of climate change on patient outcomes and care from a nursing point of view.\u003c/p\u003e\n\u003ch3\u003eAIM\u003c/h3\u003e\n\u003cp\u003eThe mixed-method systematic review aimed to synthesize existing empirical evidence on the association between climate change and patient health outcomes. A specific review question was formulated: What is the impact of climate change on patient health outcomes from a nursing perspective?\u003c/p\u003e"},{"header":"METHODS","content":"\u003cdiv id=\"Sec4\" class=\"Section2\"\u003e \u003ch2\u003eDesign\u003c/h2\u003e \u003cp\u003eA mixed-methods systematic review with a data-based convergent design was chosen [\u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e], with the inclusion criterion that the reviewed studies focus mainly on climate change and its association with patient health outcomes.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec5\" class=\"Section2\"\u003e \u003ch2\u003eSearch Methods\u003c/h2\u003e \u003cp\u003eThis review adhered to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) [\u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e]. The SPIDER tool (sample, phenomenon of interest, design, evaluation, type of research) accompanied by the time frame and language was used to formulate the search terms, ensuring alignment with the research question (Table\u0026nbsp;\u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e1\u003c/span\u003e) [\u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e].\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab1\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 1\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eSPIDER tool terms\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"3\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eCriteria\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eInclusion\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003eExclusion\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eSample\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eNursing professionals (e.g., nurses, nursing students, nurse aids, nurse managers\u0026hellip;)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eOther healthcare professionals (e.g., physicians, midwifery\u0026hellip;)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003ePhenomenon of interest\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eAssociation between climate change and patient health outcomes\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eNo association between climate change and patient health outcomes\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eDesign\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eAll designs\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eNone\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eEvaluation\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eQuestionnaires, surveys, interviews, focus groups, etc.\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eNone\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eResearch type\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eEmpirical research (quantitative, qualitative, mixed method)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eReviews, discussion articles, study protocols, editorials, commentaries, case studies, conference abstracts\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eTime frame\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eFrom the earliest published study up to January 2024\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eAfter January 2024\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eLanguage\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eEnglish\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eLanguages other than English\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003eThe search was carried out in January 2024 in six scientific databases, including CINAHL, PubMed, Scopus, ProQuest, Web of Science, and OVID Nursing. The search was carried out using both Boolean operators (AND, OR) and different combinations of keywords that referred to climate change and patient health outcomes (Table\u0026nbsp;\u003cspan refid=\"Tab2\" class=\"InternalRef\"\u003e2\u003c/span\u003e). The search was limited to language (English); however, no time limits were determined.\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab2\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 2\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eThe search process in the scientific databases CINAHL, PubMed, Scopus, ProQuest, Web of Science, and OVID Nursing\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"2\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eSearch words\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eHits\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e(\"Nursing\" [Mesh] OR \"Nurses\" [Mesh]) AND (\"Attitude\" [Mesh] OR \"Opinions\" [Mesh] OR \"Knowledge\" [Mesh] OR \"Perception\" [Mesh] OR \"Awareness\" [Mesh] OR \"Feelings\" [Mesh] OR \"Viewpoint\" [Mesh] OR \"experience*\" OR \"sense*\" OR \"view*\" OR \"impression*\" OR \"belief*\" OR \"concern*\" OR \"understanding\" OR \"cognition\" OR \"value*\" OR \"action*\" OR \"response*\" OR \"behavio*\") AND (\"Climate Change\" [Mesh] OR \"Greenhouse Effect\" [Mesh] OR \"global warming\" OR \"climate crisis\" OR \"climate warming\" OR \"climate issue*\" OR \"climate vulnerability*\" OR \"climate emergenc*\" OR \"climate action*\" OR \"climate control*\" OR \"environmental change\" OR \"planetary health\") AND (\"outcome*\" OR \"consequence*\" OR \"effect*\" OR \"impact*\" OR \"challenge*\" OR \"Association\" [Mesh]) AND (\"Patient care\" [Mesh] OR \"Nursing care\" [Mesh] OR \"Delivery of Health Care\" [Mesh] OR \"Health Care Delivery\" [Mesh] OR \"Inpatient care\" [Mesh] OR \"Outpatient care\" [Mesh] OR \"Health service\" [Mesh] OR \"Urgent care\" [Mesh] OR \"Clinic visit\" [Mesh] OR \"Ambulatory care\" [Mesh] OR \"health care\" OR \"emergency care\" OR \"hospital care\")\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003ePubMed: 62\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e(\"nurse*\" OR \"nursing\") AND (\"experience*\" OR \"attitude*\" OR \"knowledge\" OR \"perception*\" OR \"awareness\" OR \"sense*\" OR \"feeling*\" OR \"opinion*\" OR \"viewpoint*\" OR \"view*\" OR \"impression*\" OR \"belief*\" OR \"concern*\" OR \"understanding\" OR \"cognition\" OR \"value*\" OR \"action*\" OR \"response*\" OR \"behavio*\") AND (\"climate change*\" OR \"global warming\" OR \"climate crisis\" OR \"climate warming\" OR \"climate issue*\" OR \"climate vulnerability*\" OR \"climate emergenc*\" OR \"greenhouse effect*\" OR \"climate action*\" OR \"climate control*\" OR \"environmental change*\" OR \"planetary health*\") AND (\"outcome*\" OR \"consequence*\" OR \"effect*\" OR \"association*\" OR \"impact*\" OR \"challenge*\") AND (\"patient care\" OR \"care delivery\" OR \"health care\" OR \"care provision\" OR \"nursing care\" OR \"inpatient care\" OR \"outpatient care\" OR \"health service*\" OR \"urgent care\" OR \"emergency care\" OR \"clinic visit*\" OR \"ambulatory care\" OR \"hospital care\")\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eScopus: 90\u003c/p\u003e \u003cp\u003eCINAHL: 103\u003c/p\u003e \u003cp\u003eProQuest: 528\u003c/p\u003e \u003cp\u003eWeb of Science: 418\u003c/p\u003e \u003cp\u003eOVID Nursing: 56\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eTotal\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u003cb\u003e1257\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec6\" class=\"Section2\"\u003e \u003ch2\u003eInclusion and Exclusion Criteria\u003c/h2\u003e \u003cp\u003eInclusion and exclusion criteria were stated, following the SPIDER tool. The study was included if it: a) was an empirical study (quantitative, qualitative, mixed-method); b) was published in a peer-reviewed journal; c) was published in the English language; d) was focused on the topic of interest (climate change and patient health outcomes); e) reflected nursing perspective (e.g., nurses, nursing students, nursing assistants, nursing aids). On the contrary, the study was not included if it: a) involved other than a nursing perspective (e.g., physician, midwifery); b) was a review study, discussion article, case study, conference abstract, study protocol, editorial, or commentary.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec7\" class=\"Section2\"\u003e \u003ch2\u003eStudy Retrieval\u003c/h2\u003e \u003cp\u003eBased on predefined criteria, the data were systematically retrieved by two independent researchers (AS, DK) within two retrieval phases. The search and retrieval process was reflected in the PRISMA flow diagram (Fig.\u0026nbsp;\u003cspan refid=\"Fig1\" class=\"InternalRef\"\u003e1\u003c/span\u003e) [\u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e]. The Rayyan QCRI\u0026reg; program [\u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e23\u003c/span\u003e] was used to retrieve studies effectively in both retrieval phases. The search produced 1,257 studies (CINAHL\u0026thinsp;=\u0026thinsp;103, PubMed\u0026thinsp;=\u0026thinsp;62, ProQuest\u0026thinsp;=\u0026thinsp;528, Scopus\u0026thinsp;=\u0026thinsp;90, Web of Science\u0026thinsp;=\u0026thinsp;418, OVID Nursing\u0026thinsp;=\u0026thinsp;56). After removing duplicates (n\u0026thinsp;=\u0026thinsp;345), 912 studies were analyzed by title and abstract and examined against inclusion and exclusion criteria. In this phase, 893 studies were excluded because they did not directly relate to the stated objective of the study. In the second retrieval phase, 19 studies were examined by reading full texts. The second phase resulted in 18 studies included in further analysis. One study was excluded from the final analysis based on the evaluation that it did not relate to the nursing perspective.\u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec8\" class=\"Section2\"\u003e \u003ch2\u003eQuality Appraisal of the Studies\u003c/h2\u003e \u003cp\u003eFor the evaluation of the methodological quality of 18 retrieved studies, the specific Mixed Method Appraisal Tool (MMAT) was used in our review [\u003cspan citationid=\"CR24\" class=\"CitationRef\"\u003e24\u003c/span\u003e], which is designed for quantitative (n\u0026thinsp;=\u0026thinsp;9), qualitative (n\u0026thinsp;=\u0026thinsp;6), and mixed-method study (n\u0026thinsp;=\u0026thinsp;3) assessments. The evaluation of the methodological quality of the studies was carried out by two independent researchers (DK, JT), and any differences were discussed until a consensus was reached. Most of the quantitative studies did not meet the requirements of an adequate sampling strategy and a representative sample, and none of them could prove that the risk of non-response bias was low. On the other hand, almost all employed precise measurements and statistical analysis appropriate to answer the research question. All six qualitative studies were assessed as adequately fulfilling all the criteria specified by MMAT, that is a clear congruity between the research objectives and the methodological approach, as represented by the data collection method, the data analysis procedure, and the interpretation appropriately grounded in the data. The mixed-method studies failed to fulfill one [\u003cspan citationid=\"CR25\" class=\"CitationRef\"\u003e25\u003c/span\u003e], two [\u003cspan citationid=\"CR26\" class=\"CitationRef\"\u003e26\u003c/span\u003e], and, respectively, four[\u003cspan citationid=\"CR27\" class=\"CitationRef\"\u003e27\u003c/span\u003e] of a total of five criteria evaluated. A significant terminological ambiguity was identified, e.g. study title indicated a different research design from what the authors conducted and what the study reported. Based on the MMAT, none of the studies was excluded from the review due to low methodological quality. The comprehensive results are shown in Additional File 1.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec9\" class=\"Section2\"\u003e \u003ch2\u003eData Extraction\u003c/h2\u003e \u003cp\u003eData extraction of studies included in the systematic review was performed by two independent researchers (JT, DK). Data were extracted using a spreadsheet in Microsoft Excel, which included the following information: author, year, country, study design, sampling methods, sample size (including targeted respondents), data collection, data analysis, and perspective (nurses, nursing students).\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec10\" class=\"Section2\"\u003e \u003ch2\u003eStudy Risk of Bias Assessment\u003c/h2\u003e \u003cp\u003eTo mitigate potential bias, the study employed the following strategies: (a) all researchers actively participated in the refining of the study protocol; (b) the literature search was conducted independently by two researchers (DK, AS); (c) two researchers independently performed data extraction (JT, DK) under the supervision of the senior researcher (TS); (d) two researchers independently evaluated the methodological quality of the studies (DK, JT); and (e) collective decision-making accompanied each stage, with a meeting held to determine progress to the next stage.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec11\" class=\"Section2\"\u003e \u003ch2\u003eData Synthesis\u003c/h2\u003e \u003cp\u003eData were analyzed using the convergent integrated approach. Both quantitative data and qualitative evidence were combined through thematic synthesis, involving coding and the development of descriptive themes to produce a comprehensive summary of the study findings [\u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e]. Each article was reviewed for expressions and statements reflecting the association between climate change and patient health outcomes. These expressions and statements were categorized into subthemes and further organized into overarching themes, named on the basis of their content. The expressions and language used by the study participants and the study authors were used in the analysis to reduce interpretation. The results were presented narratively and in tables to address the defined research questions. The research team discussed condensed and charted data in tables and double-checked precision (10% of the material).\u003c/p\u003e \u003c/div\u003e"},{"header":"RESULTS","content":"\u003cp\u003eGiven the rather broad scope of this review, the included studies were conducted in various settings of nursing practice and education, employed a wide range of designs, and aimed to address various research objectives (Additional File 2). In general, the review included mainly quantitative studies (n\u0026thinsp;=\u0026thinsp;9). Most of the studies were conducted in the United States (n\u0026thinsp;=\u0026thinsp;6), followed by Spain (n\u0026thinsp;=\u0026thinsp;2), Turkey (n\u0026thinsp;=\u0026thinsp;2) and China (n\u0026thinsp;=\u0026thinsp;2), and one study each in the United Kingdom, Canada, the Republic of Korea, and Peru. Two studies analyzed data from more than 1 country [\u003cspan citationid=\"CR28\" class=\"CitationRef\"\u003e28\u003c/span\u003e, \u003cspan citationid=\"CR29\" class=\"CitationRef\"\u003e29\u003c/span\u003e]. Regarding the sample, most of the studies included practicing nurses (n\u0026thinsp;=\u0026thinsp;8) and nursing students (n\u0026thinsp;=\u0026thinsp;6). The sample size ranged from 20 to 733 respondents. The method most frequently used in data collection was a questionnaire (n\u0026thinsp;=\u0026thinsp;9), followed by interviews or focus groups (n\u0026thinsp;=\u0026thinsp;4). The most reported methods used in data analysis were combinations of descriptive and inferential statistics (n\u0026thinsp;=\u0026thinsp;8).\u003c/p\u003e \u003cdiv id=\"Sec13\" class=\"Section2\"\u003e \u003ch2\u003eReview findings\u003c/h2\u003e \u003cp\u003eThe findings were extracted and synthesized into three themes that were further specified by seven subthemes (Fig.\u0026nbsp;\u003cspan refid=\"Fig2\" class=\"InternalRef\"\u003e2\u003c/span\u003e). In studies in which the sample comprised of nurses and other healthcare professionals[\u003cspan citationid=\"CR26\" class=\"CitationRef\"\u003e26\u003c/span\u003e, \u003cspan citationid=\"CR30\" class=\"CitationRef\"\u003e30\u003c/span\u003e, \u003cspan citationid=\"CR31\" class=\"CitationRef\"\u003e31\u003c/span\u003e] or members of the public [\u003cspan citationid=\"CR32\" class=\"CitationRef\"\u003e32\u003c/span\u003e], only the results from the nursing perspective were included in the analysis and synthesis.\u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec14\" class=\"Section2\"\u003e \u003ch2\u003eTheme 1: Climate Healthcare Interplay\u003c/h2\u003e \u003cp\u003eThe first theme is related to the interrelation of the environment and healthcare and represents the context, in which healthcare is provided. The findings suggest that nurses are aware of this context \u0026ndash; climate change poses a significant risk to human health, and on the other hand, the healthcare industry contributes through its energy and resources requirements, greenhouse gas emissions, and waste production to this critical state. This theme was synthesized from two subthemes (The environment as a factor of health; Healthcare as an unsustainable industry), as described below.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec15\" class=\"Section2\"\u003e \u003ch2\u003eSubtheme 1: The environment as a factor of health\u003c/h2\u003e \u003cp\u003eThe first subtheme included three codes (Nurses are aware that the environment is an important determinant of health; Climate change poses new healthcare needs; The health impacts of climate change are geographically dependent).\u003c/p\u003e \u003cp\u003eAs was evident in several studies [\u003cspan additionalcitationids=\"CR30\" citationid=\"CR29\" class=\"CitationRef\"\u003e29\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR31\" class=\"CitationRef\"\u003e31\u003c/span\u003e, \u003cspan citationid=\"CR33\" class=\"CitationRef\"\u003e33\u003c/span\u003e, \u003cspan citationid=\"CR34\" class=\"CitationRef\"\u003e34\u003c/span\u003e], the environment appeared to be an important determinant of health, as reported by practicing nurses, nursing students, as well as faculty. Furthermore, they understand the risks to human health in relation to climate change [\u003cspan citationid=\"CR30\" class=\"CitationRef\"\u003e30\u003c/span\u003e, \u003cspan citationid=\"CR31\" class=\"CitationRef\"\u003e31\u003c/span\u003e, \u003cspan citationid=\"CR33\" class=\"CitationRef\"\u003e33\u003c/span\u003e, \u003cspan citationid=\"CR34\" class=\"CitationRef\"\u003e34\u003c/span\u003e]. Given the traditional emphasis of nursing on addressing social inequalities, nurses recognize that communities are disproportionately affected, resulting in climate injustice \u0026ndash; groups of people who have the least power in society (e.g., indigenous people, people with low income) are more vulnerable to climate change impacts [\u003cspan citationid=\"CR29\" class=\"CitationRef\"\u003e29\u003c/span\u003e]. Furthermore, based on the studies analyzed, we identified that nurses understand that climate change poses new healthcare needs [\u003cspan citationid=\"CR25\" class=\"CitationRef\"\u003e25\u003c/span\u003e, \u003cspan citationid=\"CR26\" class=\"CitationRef\"\u003e26\u003c/span\u003e, \u003cspan citationid=\"CR33\" class=\"CitationRef\"\u003e33\u003c/span\u003e, \u003cspan citationid=\"CR35\" class=\"CitationRef\"\u003e35\u003c/span\u003e]. Students [\u003cspan citationid=\"CR25\" class=\"CitationRef\"\u003e25\u003c/span\u003e, \u003cspan citationid=\"CR35\" class=\"CitationRef\"\u003e35\u003c/span\u003e] and nurses [\u003cspan citationid=\"CR26\" class=\"CitationRef\"\u003e26\u003c/span\u003e, \u003cspan citationid=\"CR33\" class=\"CitationRef\"\u003e33\u003c/span\u003e] recognize the health impacts of climate change through newly emerging diseases and infections, such as respiratory diseases, cardiovascular diseases, infectious diseases, mental health issues, cancer, fetal malformations, premature births, increased incidence of chronic diseases in children, and new healthcare needs (e.g., epidemics related to seasonal changes) that arise due to extreme weather conditions and place a burden on the health system. These conditions may include heat or cold waves, temperature changes, natural disasters, and drought. In this context, various regions of the world face various health impacts of changing climate that were explored in four studies included in this review [\u003cspan citationid=\"CR25\" class=\"CitationRef\"\u003e25\u003c/span\u003e, \u003cspan citationid=\"CR26\" class=\"CitationRef\"\u003e26\u003c/span\u003e, \u003cspan citationid=\"CR33\" class=\"CitationRef\"\u003e33\u003c/span\u003e, \u003cspan citationid=\"CR36\" class=\"CitationRef\"\u003e36\u003c/span\u003e]. For example, in the United States, some symptoms associated with climate change were experienced by nurses themselves, their families, and patients (respiratory diseases and mental health issues), and some were indirectly experienced by reading or hearing (vector-borne diseases, heat illness, and trauma) [\u003cspan citationid=\"CR33\" class=\"CitationRef\"\u003e33\u003c/span\u003e]. Similarly, Turkish students listed their own experience with respiratory diseases, while water-borne diseases, and deaths due to malnutrition as impacts of climate change were experienced indirectly [\u003cspan citationid=\"CR25\" class=\"CitationRef\"\u003e25\u003c/span\u003e]. On the other hand, heat illness and vector-borne diseases in China were reported as local health impacts of climate change [\u003cspan citationid=\"CR26\" class=\"CitationRef\"\u003e26\u003c/span\u003e, \u003cspan citationid=\"CR36\" class=\"CitationRef\"\u003e36\u003c/span\u003e].\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec16\" class=\"Section2\"\u003e \u003ch2\u003eSubtheme 2: Healthcare as an unsustainable industry\u003c/h2\u003e \u003cp\u003eThe second subtheme included three codes (Nursing as a profession must address the climate change topic; The healthcare sector is a significant contributor to climate change; Years of practice may raise awareness and action).\u003c/p\u003e \u003cp\u003eThe review findings highlighted the need to address the topic of climate change from the nursing perspective [\u003cspan additionalcitationids=\"CR30\" citationid=\"CR29\" class=\"CitationRef\"\u003e29\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR31\" class=\"CitationRef\"\u003e31\u003c/span\u003e]. Nurses believe that they have a professional obligation to address this issue within their practice. This professional obligation is related to the holistic perspective of nursing \u0026ndash; if the health of individuals is to be preserved, the environment as a crucial determinant of health should be protected [\u003cspan citationid=\"CR29\" class=\"CitationRef\"\u003e29\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eIn this context, nurses raised another important issue of the healthcare system being a significant contributor to climate change in the included studies [\u003cspan citationid=\"CR29\" class=\"CitationRef\"\u003e29\u003c/span\u003e, \u003cspan citationid=\"CR31\" class=\"CitationRef\"\u003e31\u003c/span\u003e, \u003cspan citationid=\"CR34\" class=\"CitationRef\"\u003e34\u003c/span\u003e, \u003cspan citationid=\"CR35\" class=\"CitationRef\"\u003e35\u003c/span\u003e, \u003cspan citationid=\"CR37\" class=\"CitationRef\"\u003e37\u003c/span\u003e]. Nurses are concerned that the healthcare sector produces too much waste and generates a considerable climate footprint [\u003cspan citationid=\"CR29\" class=\"CitationRef\"\u003e29\u003c/span\u003e, \u003cspan citationid=\"CR34\" class=\"CitationRef\"\u003e34\u003c/span\u003e]. Once students enter clinical practice, they find out how much waste is produced, how healthcare material is overused, and how waste is or is not managed, recycled, and disposed of. They become concerned about the excessive use of healthcare equipment and proper disposal of materials and understand the need for balance between overuse and patient health [\u003cspan citationid=\"CR31\" class=\"CitationRef\"\u003e31\u003c/span\u003e, \u003cspan citationid=\"CR35\" class=\"CitationRef\"\u003e35\u003c/span\u003e, \u003cspan citationid=\"CR37\" class=\"CitationRef\"\u003e37\u003c/span\u003e]. However, their scores of awareness, concern, motivation, and change behavior at home and work are lower than those of practicing nurses and faculty [\u003cspan citationid=\"CR33\" class=\"CitationRef\"\u003e33\u003c/span\u003e], therefore, immediate action regarding education is needed. Nurses with more years of clinical practice had a slightly higher tendency to adopt appropriate environmental practices (e.g. energy use and waste management) [\u003cspan citationid=\"CR38\" class=\"CitationRef\"\u003e38\u003c/span\u003e].\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec17\" class=\"Section2\"\u003e \u003ch2\u003eTheme 2: Future nurses as agents of change\u003c/h2\u003e \u003cp\u003eThe second theme outlines key areas related to environmental education in nursing in terms of student awareness, the effect of sustainability education, and challenges related to curriculum integration. It highlights how nursing students are aware of the impacts of climate change and advocate for more education on environmental health. Additionally, it discusses the effectiveness of sustainability education in improving students' knowledge and behavior, as well as the challenges in integrating climate change topics into the curriculum. This theme was synthesized from three subthemes (Readiness to address climate change; Sustainability education; Curriculum integration of climate change topics), as described below.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec18\" class=\"Section2\"\u003e \u003ch2\u003eSubtheme 1: Readiness to address climate change\u003c/h2\u003e \u003cp\u003eThe first subtheme included two codes (Aware generation; Students are ready to address the climate change issues).\u003c/p\u003e \u003cp\u003eThe findings of this review suggested that although many students did not receive formal education on environmental issues, they know about climate change and are aware of its impacts on many aspects of their private and future professional lives, primarily due to media exposure. Additionally, nurse educators can build on students\u0026rsquo; awareness [\u003cspan citationid=\"CR25\" class=\"CitationRef\"\u003e25\u003c/span\u003e, \u003cspan citationid=\"CR30\" class=\"CitationRef\"\u003e30\u003c/span\u003e, \u003cspan citationid=\"CR31\" class=\"CitationRef\"\u003e31\u003c/span\u003e, \u003cspan citationid=\"CR39\" class=\"CitationRef\"\u003e39\u003c/span\u003e]. In this context, the review findings also highlighted that nursing students enter the profession with the expectation that nursing as a profession has the responsibility and influence needed to address the topic of climate change. Students believe that modern nursing roles include being a researcher, educator, and leader in climate change actions [\u003cspan citationid=\"CR25\" class=\"CitationRef\"\u003e25\u003c/span\u003e]. Furthermore, they believe that environmental awareness needs to be increased [\u003cspan citationid=\"CR35\" class=\"CitationRef\"\u003e35\u003c/span\u003e, \u003cspan citationid=\"CR37\" class=\"CitationRef\"\u003e37\u003c/span\u003e] and demand more education on the influence of the environment on health and the environmental impact of healthcare [\u003cspan citationid=\"CR25\" class=\"CitationRef\"\u003e25\u003c/span\u003e, \u003cspan citationid=\"CR31\" class=\"CitationRef\"\u003e31\u003c/span\u003e, \u003cspan citationid=\"CR35\" class=\"CitationRef\"\u003e35\u003c/span\u003e].\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec19\" class=\"Section2\"\u003e \u003ch2\u003eSubtheme 2: Sustainability education\u003c/h2\u003e \u003cp\u003eThe second subtheme included two codes (Sustainability education may raise knowledge and behavior; Extracurricular activities count).\u003c/p\u003e \u003cp\u003eIn three studies [\u003cspan citationid=\"CR28\" class=\"CitationRef\"\u003e28\u003c/span\u003e, \u003cspan citationid=\"CR35\" class=\"CitationRef\"\u003e35\u003c/span\u003e, \u003cspan citationid=\"CR37\" class=\"CitationRef\"\u003e37\u003c/span\u003e], the emphasis was placed on sustainability education, which can support students to challenge unsustainable practices and implement change, e.g. waste management, and use of resources [\u003cspan citationid=\"CR37\" class=\"CitationRef\"\u003e37\u003c/span\u003e], has improved the competencies of nursing students and increased their awareness of sustainable care [\u003cspan citationid=\"CR35\" class=\"CitationRef\"\u003e35\u003c/span\u003e] and has improved students' knowledge, attitude and behavior regarding sustainability development [\u003cspan citationid=\"CR28\" class=\"CitationRef\"\u003e28\u003c/span\u003e]. Additionally, awareness of global climate change was related to environmental literacy and higher in students who have previously participated in meetings on environmental problems [\u003cspan citationid=\"CR39\" class=\"CitationRef\"\u003e39\u003c/span\u003e], or environmental voluntary activities and watched environmental documentaries [\u003cspan citationid=\"CR25\" class=\"CitationRef\"\u003e25\u003c/span\u003e].\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec20\" class=\"Section2\"\u003e \u003ch2\u003eSubtheme 3: Curriculum integration of climate change topics\u003c/h2\u003e \u003cp\u003eThe third subtheme included two codes (The curriculum needs to address climate change topics; Curriculum integration of climate change topics is difficult).\u003c/p\u003e \u003cp\u003eThree studies specifically addressed the topic of climate change and its integration into the nursing curriculum [\u003cspan citationid=\"CR25\" class=\"CitationRef\"\u003e25\u003c/span\u003e, \u003cspan citationid=\"CR30\" class=\"CitationRef\"\u003e30\u003c/span\u003e, \u003cspan citationid=\"CR40\" class=\"CitationRef\"\u003e40\u003c/span\u003e]. However, this topic was not generally included in the nursing curriculum in the analyzed studies conducted in the USA or Turkey. Additionally, other studies analyzed did not reflect the topic of curriculum integration of climate change. Nurse practitioner program directors, faculty, and nursing students believe that there should be greater emphasis on environmental health in their programs. Nevertheless, the integration of the topic of climate change into the nursing curriculum is difficult, mainly due to serious barriers related to overcrowded curricula, with dense content that it already needs to cover, lack of faculty expertise in the area, and lack of access to information resources related to environmental health [\u003cspan citationid=\"CR30\" class=\"CitationRef\"\u003e30\u003c/span\u003e, \u003cspan citationid=\"CR40\" class=\"CitationRef\"\u003e40\u003c/span\u003e].\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec21\" class=\"Section2\"\u003e \u003ch2\u003eTheme 3: Navigating sustainability challenges in nursing\u003c/h2\u003e \u003cp\u003eThe third and last theme explores challenges that hinder sustainable nursing practices, focusing on patient-centered care and lack of support. Nurses prioritize patient needs over environmental concerns due to busy clinical settings, which leads to minimal attention to environmental issues. Additionally, the lack of organizational support and barriers faced by students contribute to the challenge. The narrative highlights the importance of education, awareness, and leadership in promoting sustainable practices and advocating for environmental stewardship within the nursing profession. This theme was synthesized from two subthemes (Patient-centered care; Lack of support), as described below.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec22\" class=\"Section2\"\u003e \u003ch2\u003eSubtheme 1: Patient-centered care\u003c/h2\u003e \u003cp\u003eThe first subtheme included two codes (Patient care is a priority; Some issues are more relevant to nursing, and some are less).\u003c/p\u003e \u003cp\u003eBased on nurses\u0026acute; reports, the environmental aspect of healthcare is understood and present in the way nurses think about climatic change and nursing, but in busy clinical settings, it is less likely to impact the quality of care. When deciding between the needs of the patients and the environmental perspective, the patient is the priority. Nurses must deal with competing priorities and prioritize patient care/safety over the environment [\u003cspan citationid=\"CR41\" class=\"CitationRef\"\u003e41\u003c/span\u003e]. Authors [\u003cspan citationid=\"CR33\" class=\"CitationRef\"\u003e33\u003c/span\u003e]found that although nurses scored high on the awareness scale, awareness alone did not lead to behavior change, because nurses feel overwhelmed. However, they strongly believe that their actions can significantly impact the area of waste management. The impact in the areas of sustainable food, chemical reduction, and sustainable transportation is moderate, and the impact in the areas of energy and water use is minimal [\u003cspan citationid=\"CR34\" class=\"CitationRef\"\u003e34\u003c/span\u003e]. Nevertheless, regarding environmental aspects, patients may benefit from meteorological information utilization, e.g. warnings regarding heat waves. However, it is not the primary patient care issue \u0026ndash; it would be difficult to provide additional information beyond that indispensable in busy healthcare settings. Patients must receive and remember essential information on check-ups and medication, and too much information can cause overwhelming at discharge [\u003cspan citationid=\"CR32\" class=\"CitationRef\"\u003e32\u003c/span\u003e].\u003c/p\u003e \u003cdiv id=\"Sec23\" class=\"Section3\"\u003e \u003ch2\u003eSubtheme 2: Lack of support\u003c/h2\u003e \u003cp\u003eThe second subtheme included three codes (Workplace culture and organizational policy do not support environmentally responsible practices; Future nurses face even more barriers; Education, awareness, and leadership are crucial for success).\u003c/p\u003e \u003cp\u003eThe review findings highlighted that hospitals prioritize patient safety and budget. Nurses perceive a lack of organizational support, they believe that the management should implement the change, not individuals (e.g., recycle bins, use of single-use vs. reusable products, more plant-based options in food services, low-emission transportation) [\u003cspan citationid=\"CR41\" class=\"CitationRef\"\u003e41\u003c/span\u003e]. Nurses report more sustainable behavior at home than at work, because at home they have more control over the context and do not need to follow regulations and guidelines [\u003cspan citationid=\"CR33\" class=\"CitationRef\"\u003e33\u003c/span\u003e]. Insufficient support was perceived by nurses who participate in environmental activism, too. Nurses who feel a professional duty to address climate change experience strong emotions such as anger, fear, and sadness. They are frustrated by the lack of recognition of environmental care in nursing and may feel isolated and overwhelmed. Environmental activism adds emotional labor beyond patient care. US nurses feel more supported in activism than UK nurses [\u003cspan citationid=\"CR29\" class=\"CitationRef\"\u003e29\u003c/span\u003e]. In addition, nursing students perceived several barriers to providing sustainable care to patients during their clinical placements, as reported in two studies [\u003cspan citationid=\"CR35\" class=\"CitationRef\"\u003e35\u003c/span\u003e, \u003cspan citationid=\"CR37\" class=\"CitationRef\"\u003e37\u003c/span\u003e]. These barriers included a lack of confidence due to an imbalance of power and lack of knowledge, resistance to change in practice, lack of time, and lack of facilities [\u003cspan citationid=\"CR37\" class=\"CitationRef\"\u003e37\u003c/span\u003e]. What students may perceive as a lack of environmental awareness on the part of the healthcare staff with whom they work during their clinical placements [\u003cspan citationid=\"CR35\" class=\"CitationRef\"\u003e35\u003c/span\u003e], may be the result of competing priorities in busy clinical settings, prioritizing patient needs and safe care, and lack of organizational support that prevents nurses from acting sustainable [\u003cspan citationid=\"CR41\" class=\"CitationRef\"\u003e41\u003c/span\u003e]. The lack of support was also evident regarding insufficient education about environmental stewardship, as reported by nurses in two studies [\u003cspan citationid=\"CR25\" class=\"CitationRef\"\u003e25\u003c/span\u003e, \u003cspan citationid=\"CR34\" class=\"CitationRef\"\u003e34\u003c/span\u003e]. Nurses believe that once educated, they can have an impact on public health \u0026ndash; educate patients, families, and communities about environmental health. Furthermore, continuing education for practicing nurses is needed, especially in developing countries [\u003cspan citationid=\"CR38\" class=\"CitationRef\"\u003e38\u003c/span\u003e] and for emergencies related to extreme weather events, e.g., heat illness [\u003cspan citationid=\"CR36\" class=\"CitationRef\"\u003e36\u003c/span\u003e].\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e"},{"header":"DISCUSSION","content":"\u003cp\u003eThe systematic review aimed to synthesize the existing evidence on the links between climate change and patient health outcomes from a nursing perspective. The findings were synthesized into three main themes.\u003c/p\u003e \u003cp\u003eThe findings of the first theme, \"Climate Healthcare Interplay\", shed light on the intricate relationship between the environment and healthcare delivery. Nurses, as frontline healthcare providers, recognize the significant impact of climate change on human health firsthand, either through personal experiences or indirectly through patient care. The health impacts of climate change and the emergence of new diseases were the main nursing outcomes on this theme. Furthermore, nurses in the analyzed studies recognized that the environment is an important determinant of health and health outcomes [\u003cspan citationid=\"CR30\" class=\"CitationRef\"\u003e30\u003c/span\u003e, \u003cspan citationid=\"CR31\" class=\"CitationRef\"\u003e31\u003c/span\u003e, \u003cspan citationid=\"CR33\" class=\"CitationRef\"\u003e33\u003c/span\u003e, \u003cspan citationid=\"CR34\" class=\"CitationRef\"\u003e34\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eClimate-related shocks such as temperature fluctuations, precipitation changes, and rising sea levels degrade environmental and social factors that influence health [\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e, \u003cspan citationid=\"CR42\" class=\"CitationRef\"\u003e42\u003c/span\u003e]. All aspects of health, from air and water quality to food systems, are impacted [\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e]. According to the WHO, climate change may be responsible for 250,000 additional deaths per year between 2030 and 2050 [\u003cspan citationid=\"CR43\" class=\"CitationRef\"\u003e43\u003c/span\u003e]. The impact of climate change is increasing the severity and frequency, and health problems that did not exist before arise [\u003cspan citationid=\"CR44\" class=\"CitationRef\"\u003e44\u003c/span\u003e]. More specifically, climate change introduces new healthcare needs, with emerging diseases and infections becoming more prevalent due to extreme weather conditions, such as heat waves, floods, and storm intensity [\u003cspan citationid=\"CR45\" class=\"CitationRef\"\u003e45\u003c/span\u003e, \u003cspan citationid=\"CR46\" class=\"CitationRef\"\u003e46\u003c/span\u003e], or they can result from subsequent changes in environmental conditions that lead to an increase in waterborne diseases [\u003cspan citationid=\"CR47\" class=\"CitationRef\"\u003e47\u003c/span\u003e], foodborne diseases [\u003cspan citationid=\"CR48\" class=\"CitationRef\"\u003e48\u003c/span\u003e, \u003cspan citationid=\"CR49\" class=\"CitationRef\"\u003e49\u003c/span\u003e], vector-borne diseases [\u003cspan citationid=\"CR50\" class=\"CitationRef\"\u003e50\u003c/span\u003e], and nutritional insecurity [\u003cspan citationid=\"CR51\" class=\"CitationRef\"\u003e51\u003c/span\u003e]. Mental health can also be affected by the impacts of climate change [\u003cspan citationid=\"CR45\" class=\"CitationRef\"\u003e45\u003c/span\u003e, \u003cspan citationid=\"CR46\" class=\"CitationRef\"\u003e46\u003c/span\u003e]. Problems related to climate anxiety, ecological anxiety, climate sadness, and solastalgia are also described as the health consequences of climate change [\u003cspan citationid=\"CR52\" class=\"CitationRef\"\u003e52\u003c/span\u003e]. Posttraumatic stress disorder is a direct consequence of acute weather events [\u003cspan citationid=\"CR53\" class=\"CitationRef\"\u003e53\u003c/span\u003e], and traumatic exposure to major storms is a predictor of multiple mental health outcomes, including substance use and addiction [\u003cspan citationid=\"CR54\" class=\"CitationRef\"\u003e54\u003c/span\u003e], especially among people who already belong to marginalized groups [\u003cspan citationid=\"CR55\" class=\"CitationRef\"\u003e55\u003c/span\u003e]. This was also reflected in our systematic review, while findings highlighted that with climate change and the emergence of new diseases, new healthcare needs arise [\u003cspan citationid=\"CR25\" class=\"CitationRef\"\u003e25\u003c/span\u003e, \u003cspan citationid=\"CR26\" class=\"CitationRef\"\u003e26\u003c/span\u003e, \u003cspan citationid=\"CR33\" class=\"CitationRef\"\u003e33\u003c/span\u003e, \u003cspan citationid=\"CR35\" class=\"CitationRef\"\u003e35\u003c/span\u003e], which were recognized not only by nurses [\u003cspan citationid=\"CR26\" class=\"CitationRef\"\u003e26\u003c/span\u003e, \u003cspan citationid=\"CR33\" class=\"CitationRef\"\u003e33\u003c/span\u003e] but also by nursing students [\u003cspan citationid=\"CR25\" class=\"CitationRef\"\u003e25\u003c/span\u003e, \u003cspan citationid=\"CR35\" class=\"CitationRef\"\u003e35\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eThe findings of this systematic review highlighted the important role and responsibility of nurses in managing climate change and its impact on patient care, health, and patient outcomes. Furthermore, nurses represent the largest global healthcare resource to contribute to disaster preparedness efforts for climate change-related water disasters and work to mitigate environmental toxins that can threaten human health [\u003cspan citationid=\"CR56\" class=\"CitationRef\"\u003e56\u003c/span\u003e]. The role of nurses is also to minimize the effects of climate change on mental health among vulnerable population groups through evaluation, preventive education, and care [\u003cspan citationid=\"CR57\" class=\"CitationRef\"\u003e57\u003c/span\u003e]. In particular, advanced practice nurses (APNs) are pivotal in tackling climate change's health challenges. They educate on climate-related risks, offer preventive care, manage acute and chronic conditions exacerbated by climate change, and advocate for sustainable policies [\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e, \u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e]. APNs play a vital role in promoting resilience and protecting public health from climate-related threats. Their specific competencies should include identifying people with increased vulnerability \u0026ndash; young, old, people with chronic health conditions and marginalized groups living in poverty, with lack of health care coverage, immigration status, language barriers, homelessness, or mental illness \u0026ndash; and providing advanced education about these risks together with identifying available community health services [\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e, \u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e]. Despite the indisputable advantages and importance of advanced practice, the tasks and roles of these nurses have not been clearly defined, which significantly limits their implementation in the current healthcare system, especially when addressing climate change impacts[\u003cspan citationid=\"CR58\" class=\"CitationRef\"\u003e58\u003c/span\u003e]. Similarly to APNs, community nurses and public health nurses are considered key stakeholders when it comes to addressing climate change. They are defined as professionals who are supposed to lead as influencers of climate action and strengthen communities, for the active involvement of all individuals in achieving socio-political change [\u003cspan citationid=\"CR59\" class=\"CitationRef\"\u003e59\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eIn the context of addressing climate change, the nursing perspective is essential, especially in terms of the healthcare sector, as discussed in all included studies in this review [\u003cspan citationid=\"CR29\" class=\"CitationRef\"\u003e29\u003c/span\u003e, \u003cspan citationid=\"CR31\" class=\"CitationRef\"\u003e31\u003c/span\u003e, \u003cspan additionalcitationids=\"CR34\" citationid=\"CR33\" class=\"CitationRef\"\u003e33\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR35\" class=\"CitationRef\"\u003e35\u003c/span\u003e, \u003cspan citationid=\"CR37\" class=\"CitationRef\"\u003e37\u003c/span\u003e]. More specifically, nursing professionals recognize the healthcare sector as a significant contributor to climate change, primarily due to excessive waste production and energy consumption [\u003cspan additionalcitationids=\"CR30\" citationid=\"CR29\" class=\"CitationRef\"\u003e29\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR31\" class=\"CitationRef\"\u003e31\u003c/span\u003e, \u003cspan citationid=\"CR34\" class=\"CitationRef\"\u003e34\u003c/span\u003e]. When providing health care, policymakers in several countries recommend the use of disposable medical devices, which increases waste in the health sector. A recent example is the excessive use of medical gloves and masks due to the outbreak of the COVID-19 pandemic, which has significantly worsened this problem [\u003cspan citationid=\"CR60\" class=\"CitationRef\"\u003e60\u003c/span\u003e]. Medical waste also includes syringes, scalpels, linen contaminated with biological material and body parts [\u003cspan citationid=\"CR61\" class=\"CitationRef\"\u003e61\u003c/span\u003e], and hazardous toxic and radioactive materials [\u003cspan citationid=\"CR62\" class=\"CitationRef\"\u003e62\u003c/span\u003e]. Improper healthcare waste management practices can exacerbate the problem in developing countries, which can negatively affect the sustainability of the environment and public health [\u003cspan citationid=\"CR63\" class=\"CitationRef\"\u003e63\u003c/span\u003e]. The link between the increase in waste in the healthcare delivery system also exists in connection with the global increase in population and the aging population [\u003cspan citationid=\"CR64\" class=\"CitationRef\"\u003e64\u003c/span\u003e], with the occurrence of chronic diseases and comorbidities [\u003cspan citationid=\"CR65\" class=\"CitationRef\"\u003e65\u003c/span\u003e], and with the increase in infectious diseases [\u003cspan citationid=\"CR66\" class=\"CitationRef\"\u003e66\u003c/span\u003e]. Overall, the entire healthcare sector needs to address its carbon footprint, which means that healthcare professionals, managers, and nursing leaders must be involved in addressing increased energy costs, stressed health services [\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e], increased plastic waste, and personal protective equipment as one of the environmental side effects of the recent COVID-19 pandemic [\u003cspan citationid=\"CR67\" class=\"CitationRef\"\u003e67\u003c/span\u003e]. The issue of increased medical waste was also highlighted in the analyzed studies from the perspective of nursing students and their education, while emphasis was placed on the topic of correct understanding of the use of medical equipment [\u003cspan citationid=\"CR31\" class=\"CitationRef\"\u003e31\u003c/span\u003e, \u003cspan citationid=\"CR35\" class=\"CitationRef\"\u003e35\u003c/span\u003e, \u003cspan citationid=\"CR37\" class=\"CitationRef\"\u003e37\u003c/span\u003e] and support of motivation to change behavior with greater responsibility towards the environment. Better preparation is already required during the education of nurses, as many nursing students are not sufficiently prepared for the health impacts of climate change and the response of the nursing profession [\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eThe findings of the second theme, \"Future Nurses as Agents of Change\", highlight the role of nursing students in environmental education, their awareness of climate change impacts, the effectiveness of sustainability education, and challenges in curriculum integration.\u003c/p\u003e \u003cp\u003eEducation appears to be important in knowing and understanding the relationships between climate change and patient health outcomes. Nursing students enter the profession with the expectation that nursing as a profession has a responsibility in influencing climate change with the need to continuously raise awareness of this topic [\u003cspan citationid=\"CR35\" class=\"CitationRef\"\u003e35\u003c/span\u003e, \u003cspan citationid=\"CR37\" class=\"CitationRef\"\u003e37\u003c/span\u003e]. The findings of our systematic review suggested that students received limited education about environmental and climate change issues in their formal university education. Although students are informed about these topics primarily through the media (including social networks), they would request more education, especially on environmental impact on health, as well as environmental impact and waste generation within the provision of healthcare [\u003cspan citationid=\"CR25\" class=\"CitationRef\"\u003e25\u003c/span\u003e, \u003cspan citationid=\"CR31\" class=\"CitationRef\"\u003e31\u003c/span\u003e, \u003cspan citationid=\"CR35\" class=\"CitationRef\"\u003e35\u003c/span\u003e]. As part of achieving the 2030 Sustainable Development Goals, specifically Goal 13, and Goal 3: \"Improving environmental education and awareness\", education must equip nursing students with the knowledge and skills they need to sustainably promote the health and well-being of current and future generations [\u003cspan citationid=\"CR68\" class=\"CitationRef\"\u003e68\u003c/span\u003e]. A necessary step to achieve transformational change is the inclusion of planetary health education in the curriculum [\u003cspan citationid=\"CR69\" class=\"CitationRef\"\u003e69\u003c/span\u003e] and the explanation of nurses' competencies to strengthen the sustainability of the support of people's health and well-being, as well as the health of the planet [\u003cspan citationid=\"CR70\" class=\"CitationRef\"\u003e70\u003c/span\u003e]. Furthermore, there is evidence of the impact of education on the sustainability of environmental resources, on promoting the competencies of nursing students, and on increasing their awareness of this topic [\u003cspan citationid=\"CR28\" class=\"CitationRef\"\u003e28\u003c/span\u003e, \u003cspan citationid=\"CR35\" class=\"CitationRef\"\u003e35\u003c/span\u003e, \u003cspan citationid=\"CR37\" class=\"CitationRef\"\u003e37\u003c/span\u003e]. Among the extracurricular activities that appeared to be useful in raising awareness of global climate change, the discussions about environmental problems [\u003cspan citationid=\"CR39\" class=\"CitationRef\"\u003e39\u003c/span\u003e], environmental voluntary activities, and watching environmental documentaries [\u003cspan citationid=\"CR25\" class=\"CitationRef\"\u003e25\u003c/span\u003e] were crucial and discussed across the analyzed studies. Efforts to integrate climate change topics into the curriculum in nursing education were also discussed [\u003cspan citationid=\"CR25\" class=\"CitationRef\"\u003e25\u003c/span\u003e, \u003cspan citationid=\"CR30\" class=\"CitationRef\"\u003e30\u003c/span\u003e, \u003cspan citationid=\"CR40\" class=\"CitationRef\"\u003e40\u003c/span\u003e]. Environmental topics are currently absent in the curriculum, and some barriers limit its integration. This is mainly a consequence of the overcrowded and demanding curriculum and a lack of professional competence in environmental health [\u003cspan citationid=\"CR30\" class=\"CitationRef\"\u003e30\u003c/span\u003e, \u003cspan citationid=\"CR40\" class=\"CitationRef\"\u003e40\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eThe findings of the third and last theme, \"Navigating Sustainability Challenges in Nursing,\" shed light on the obstacles to sustainable nursing practices, focusing on patient-centered care and the lack of organizational support. Areas that hinder sustainable nursing practices have been identified. These calls are mainly directed at management and policymakers. When providing nursing care in terms of quality and safety, nurses prioritize the needs of the patient. When deciding between patient needs and environmental needs, the patient is the priority [\u003cspan citationid=\"CR41\" class=\"CitationRef\"\u003e41\u003c/span\u003e]. On the other hand, it should be emphasized that nurses are aware that their actions can significantly affect waste areas and impact the environment [\u003cspan citationid=\"CR34\" class=\"CitationRef\"\u003e34\u003c/span\u003e]. The main reason for their actions is the lack of support from hospital management [\u003cspan citationid=\"CR41\" class=\"CitationRef\"\u003e41\u003c/span\u003e]. The findings of this review highlighted that hospitals prioritize patient safety and budget. Nursing students already perceived several obstacles in providing sustainable care to patients within clinical education [\u003cspan citationid=\"CR35\" class=\"CitationRef\"\u003e35\u003c/span\u003e, \u003cspan citationid=\"CR37\" class=\"CitationRef\"\u003e37\u003c/span\u003e, \u003cspan citationid=\"CR41\" class=\"CitationRef\"\u003e41\u003c/span\u003e]. They felt that their lecturers during clinical education did not address awareness of environmental aspects [\u003cspan citationid=\"CR35\" class=\"CitationRef\"\u003e35\u003c/span\u003e] not only because they prioritized the needs of patients in terms of quality and safety, but also due to demands and rush in providing care in the clinical environment, and due to insufficient management support [\u003cspan citationid=\"CR41\" class=\"CitationRef\"\u003e41\u003c/span\u003e]. On the other hand, rather low nursing competence to support sustainable practice is a result of insufficient education in this area [\u003cspan citationid=\"CR25\" class=\"CitationRef\"\u003e25\u003c/span\u003e, \u003cspan citationid=\"CR34\" class=\"CitationRef\"\u003e34\u003c/span\u003e, \u003cspan citationid=\"CR36\" class=\"CitationRef\"\u003e36\u003c/span\u003e, \u003cspan citationid=\"CR38\" class=\"CitationRef\"\u003e38\u003c/span\u003e]. The important challenge here arises: How can nurses deal with climate change within the healthcare sector? The solution can be found in education and training that addresses the impact of climate change on health, as well as strategies to mitigate or adapt to these impacts [\u003cspan citationid=\"CR71\" class=\"CitationRef\"\u003e71\u003c/span\u003e]. Another important area is the integration of sustainability practices, which involves encouraging healthcare facilities to adopt practices such as reducing energy, minimizing energy consumption and waste generation, and using environmentally friendly products [\u003cspan citationid=\"CR72\" class=\"CitationRef\"\u003e72\u003c/span\u003e]. Nurses must advocate for policies and initiatives that promote environmental sustainability in healthcare delivery at the local, national, and international levels [\u003cspan citationid=\"CR73\" class=\"CitationRef\"\u003e73\u003c/span\u003e]. Policy support is particularly associated with providing evidence from best practices for nurses to address climate change issues, with research and development of evidence-based interventions as essential activities [\u003cspan citationid=\"CR74\" class=\"CitationRef\"\u003e74\u003c/span\u003e]. Collaboration and networking among nurses and other healthcare professionals, environmental organizations, and community groups are of great importance in promoting environmental sustainability in healthcare [\u003cspan citationid=\"CR75\" class=\"CitationRef\"\u003e75\u003c/span\u003e]. Nurses feel their professional duty to support environmental care, as well as the need for greater environmental activism to achieve change [\u003cspan citationid=\"CR29\" class=\"CitationRef\"\u003e29\u003c/span\u003e]. All these actions can help nurses play a key role in mitigating the impacts of climate change on patient outcomes and promoting sustainability in healthcare.\u003c/p\u003e \u003cdiv id=\"Sec25\" class=\"Section2\"\u003e \u003ch2\u003eImplications for the international audience\u003c/h2\u003e \u003cp\u003eThe present review has highlighted several methodological weaknesses in the reviewed studies. One of the most significant challenges was related to sampling. Most studies employed convenience sampling in specific regions or only one institution with rather small sample sizes which were not diverse enough, and with limited response rates, which may raise questions about the representativeness of the sample and generalizability of the findings. With current technological possibilities for global research integration, comparative studies may seem a promising direction, with special regard to communities more vulnerable to experiencing impacts of climate change due to their health status or geographical, demographic, and social characteristics. However, it is important to continue to address specific research objectives through qualitative or mixed\u0026ndash;method studies, which provide useful perspectives to explore the lived experience of all actors who participate in the interplay of climate change and nursing. As the review findings suggest, students seem to be ready to implement sustainable practices in clinical settings, but organizational policy and workplace culture often do not support their motivation. It is crucial to explore the settings where the change was successfully implemented and to verify the factors that facilitate it. Lastly, it is essential to look for ways to raise environmental awareness of practicing nurses, especially in developing countries, and explore how to empower them to adopt sustainable practices that will not represent another burden on their already busy work pace but will integrate quality patient care with low environmental impact. There is a growing body of evidence suggesting that various forms of sustainability education and integrating the issue of climate change and health in the curriculum may increase the levels of knowledge, awareness, and motivation to act sustainably in students. The challenges we identified need to be addressed \u0026ndash; competing curricular priorities and lack of expertise and resources on the part of faculty. Once educators have enough support, they can start to perceive these issues as clinically relevant and find a way to integrate them into the curriculum.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec26\" class=\"Section2\"\u003e \u003ch2\u003eLimitations\u003c/h2\u003e \u003cp\u003eOnly studies published in English were included possibly resulting in omitting relevant research published in non-English studies. The authors come from different backgrounds and there was some discrepancy in evaluations of the methodological quality of the studies at the beginning, however, several discussions took place until the agreement in the team was achieved.\u003c/p\u003e \u003c/div\u003e"},{"header":"CONCLUSION","content":"\u003cp\u003eThe purpose of the present systematic review was to critically examine empirical studies on the impact of climate change on patient health outcomes from the nursing perspective and to synthesize the evidence reported in quantitative, qualitative, and mixed-method studies available through all relevant databases searches. If a shift to sustainable healthcare and introducing climate change-related topics into the curriculum is to be made, it is crucial to understand the nursing perspective, the most numerous and most influential and trusted healthcare workforce, who is expected to implement changes in practice. Although the reviewed studies have some methodological limitations, provide promising findings on nursing education and practice. Nurses, who work hard to find the balance between quality patient care and low environmental impact healthcare, are faced with barriers related to organizational policy and workplace culture. Sustainability education seems to improve the environmental awareness of nursing students; however, the curriculum is already too extensive, and the same barriers present in clinical settings prevent students from implementing the changes. In conclusion, competing priorities in both educational and clinical settings, although they seem legitimate, need to be solved to effectively address the challenge of climate change and nursing.\u003c/p\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003cstrong\u003e\u003cem\u003eEthics approval and consent to participate\u0026nbsp;\u003c/em\u003e\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eNot applicable.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e\u003cem\u003eConsent for publication\u0026nbsp;\u003c/em\u003e\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eNot applicable.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e\u003cem\u003eAvailability of data and materials\u0026nbsp;\u003c/em\u003e\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eAll data generated or analyzed in this study are included within this article and its additional files.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e\u003cem\u003eCompeting interests\u0026nbsp;\u003c/em\u003e\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe authors declare they have no competing interests.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e\u003cem\u003eFunding\u0026nbsp;\u003c/em\u003e\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe authors declare this study received no external funding.\u0026nbsp;\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e\u003cem\u003eAuthors' contributions\u0026nbsp;\u003c/em\u003e\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe authors confirm their contribution to the paper as follows: study conception and design: JT, DK, AS, TS; data collection: DK, AS; analysis and interpretation of results: JT, DK; draft manuscript preparation JT, DK, AS, TS. All authors read and approved the final version of the manuscript.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e\u003cem\u003eAcknowledgments\u003c/em\u003e\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eNot applicable.\u0026nbsp;\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\n\u003cli\u003eFeliciano D, Recha J, Ambaw G, MacSween K, Solomon D, Wollenberg E. Assessment of agricultural emissions, climate change mitigation and adaptation practices in Ethiopia. Clim Policy. 2022;22(4):427\u0026ndash;44. http://dx.doi.org/10.1080/14693062.2022.2028597 \u003c/li\u003e\n\u003cli\u003eWorld Meteorological Organization. The Global Climate 2011-2020: A decade of acceleration [Internet]. Geneva: WMO. 2023 [cited 2024 Apr 18]. Available from: https://wmo.int/publication-series/global-climate-2011-2020-decade-of-acceleration\u003c/li\u003e\n\u003cli\u003eWorld Health Organization. Climate change [Internet]. Geneva: WHO. 2023 [cited 2024 Feb 16]. Available from: https://www.who.int/news-room/fact-sheets/detail/climate-change-and-health \u003c/li\u003e\n\u003cli\u003eCrimmins A, Balbus J, Gamble JL, Beard CB, Bell JE, Dodgen D, et al. The Impacts of Climate Change on Human Health in the United States: A Scientific Assessment. [Internet]. Washington, DC: US Global Change Research Program; 2016; 312 pp. [cited 2024 Feb 16]. Available from: http://dx.doi.org/10.7930/J0R49NQX \u003c/li\u003e\n\u003cli\u003eThe Intergovernmental Panel on Climate Change. Special Report on Climate Change and Land [Internet]. Geneva: WMO; 2019 [cited 2024 Feb 16]. Available from: https://www.ipcc.ch/srccl/\u003c/li\u003e\n\u003cli\u003eUnited Nations. Yearbook of Global Climate Action, 2023: Marrakech Partnership for Global Change Action [Internet]. Bonn: UNFCCC; 2023 [cited 2024 Feb 16]. Available from: https://unfccc.int/documents/632342\u003c/li\u003e\n\u003cli\u003eWorld Meteorological Organization (WMO). 2023 State of Climate Services for Health [Internet]. 2023 [cited 2024 Feb 16]. Available from: https://wmo.int/publication-series/2023-state-of-climate-services-health \u003c/li\u003e\n\u003cli\u003eNorman I, Griffiths P. Nurses save the planet. Int J Nurs Stud. 2021;123(104061):104061. http://dx.doi.org/10.1016/j.ijnurstu.2021.104061\u003c/li\u003e\n\u003cli\u003eWatts N, Amann M, Ayeb-Karlsson S, Belesova K, Bouley T, Boykoff M, et al. The Lancet Countdown on health and climate change: from 25 years of inaction to a global transformation for public health. Lancet. 2018;391(10120):581\u0026ndash;630. http://dx.doi.org/10.1016/s0140-6736(17)32464-9\u003c/li\u003e\n\u003cli\u003eLugten E, Hariharan N. Strengthening health systems for climate adaptation and health security: Key considerations for policy and programming. Health Secur. 2022;20(5):435\u0026ndash;9. http://dx.doi.org/10.1089/hs.2022.0050\u003c/li\u003e\n\u003cli\u003eButterfield P, Leffers J, V\u0026aacute;squez MD. Nursing\u0026rsquo;s pivotal role in global climate action. BMJ. 2021;n1049. http://dx.doi.org/10.1136/bmj.n1049\u003c/li\u003e\n\u003cli\u003e\u0026Aacute;lvarez-Nieto C, \u0026Aacute;lvarez-Garc\u0026iacute;a C, Parra-Anguita L, Sanz-Martos S, L\u0026oacute;pez-Medina IM. Effectiveness of scenario-based learning and augmented reality for nursing students\u0026rsquo; attitudes and awareness toward climate change and sustainability. BMC Nurs. 2022;21(1):245. http://dx.doi.org/10.1186/s12912-022-01023-9\u003c/li\u003e\n\u003cli\u003eSayre L, Rhazi N, Carpenter H, Hughes NL. Climate change and human health: the role of nurses in confronting the issue. Nurs Adm Q. 2010;34(4):334\u0026ndash;42. http://dx.doi.org/10.1097/NAQ.0b013e3181f60df9\u003c/li\u003e\n\u003cli\u003eAllen PJ. Climate Change: A Review of Potential Health Consequences. Prim Health Care. 2015;5(1):1000183. 10.4172/2167-1079.1000183\u003c/li\u003e\n\u003cli\u003eVold L, Meszaros M. Rhizomatic assemblages: Connecting climate change to nursing action. Witness: Can J Crit Nurs Discourse. 2021;3(2):18\u0026ndash;35. http://dx.doi.org/10.25071/2291-5796.113\u003c/li\u003e\n\u003cli\u003eLeffers J, Levy RM, Nicholas PK, Sweeney CF. Mandate for the nursing profession to address climate change through nursing education. J Nurs Scholarsh. 2017;49(6):679\u0026ndash;87. http://dx.doi.org/10.1111/jnu.12331\u003c/li\u003e\n\u003cli\u003eHarper SL, Cunsolo A, Babujee A, Coggins S, Aguilar MD, Wright CJ. Climate change and health in North America: literature review protocol. Syst Rev. 2021;10(1):3. http://dx.doi.org/10.1186/s13643-020-01543-y\u003c/li\u003e\n\u003cli\u003eRocque RJ, Beaudoin C, Ndjaboue R, Cameron L, Poirier-Bergeron L, Poulin-Rheault R-A, et al. Health effects of climate change: an overview of systematic reviews. BMJ Open. 2021;11(6):e046333. http://dx.doi.org/10.1136/bmjopen-2020-046333\u003c/li\u003e\n\u003cli\u003eHathaway J, Maibach EW. Health implications of climate change: A review of the literature about the perception of the public and health professionals. Curr Environ Health Rep. 2018;5. http://dx.doi.org/10.1007/s40572-018-0190-3\u003c/li\u003e\n\u003cli\u003eHong QN, Pluye P, Bujold M, Wassef M. Convergent and sequential synthesis designs: implications for conducting and reporting systematic reviews of qualitative and quantitative evidence. Syst Rev. 2017;6(1). http://dx.doi.org/10.1186/s13643-017-0454-2\u003c/li\u003e\n\u003cli\u003ePage MJ, McKenzie JE, Bossuyt PM, Boutron I, Hoffmann TC, Mulrow CD, et al. The PRISMA 2020 statement: an updated guideline for reporting systematic reviews. BMJ. 2021;372:n71. http://dx.doi.org/10.1136/bmj.n71\u003c/li\u003e\n\u003cli\u003eCooke A, Smith D, Booth A. Beyond PICO: the SPIDER tool for qualitative evidence synthesis: The SPIDER tool for qualitative evidence synthesis. Qual Health Res. 2012;22(10):1435\u0026ndash;43. http://dx.doi.org/10.1177/1049732312452938\u003c/li\u003e\n\u003cli\u003eOuzzani M, Hammady H, Fedorowicz Z, Elmagarmid A. Rayyan\u0026mdash;a web and mobile app for systematic reviews. Syst Rev. 2016;5(1). http://dx.doi.org/10.1186/s13643-016-0384-4\u003c/li\u003e\n\u003cli\u003eHong QN, Pluye P, Fabregues S, Bartlett G, Boardman F, Cargo M. Mixed Methods Appraisal Tool (MMAT), version. BMJ Open. 2018; \u003c/li\u003e\n\u003cli\u003eErgin E, Altinel B, Aktas E. A mixed method study on global warming, climate change and the role of public health nurses from the perspective of nursing students. Nurse Educ Today. 2021;107(105144):105144. http://dx.doi.org/10.1016/j.nedt.2021.105144\u003c/li\u003e\n\u003cli\u003eYang L, Liu C, Bi P, Vardoulakis S, Huang C. Local actions to health risks of heatwaves and dengue fever under climate change: Strategies and barriers among primary healthcare professionals in southern China. Environ Res. 2020;187(109688):109688. http://dx.doi.org/10.1016/j.envres.2020.109688\u003c/li\u003e\n\u003cli\u003eLuque-Alcaraz OM, Gomera A, Ru\u0026iacute;z \u0026Aacute;, Aparicio-Martinez P, Vaquero-Abellan M. Validation of the Spanish version of the questionnaire on environmental awareness in nursing (NEAT). Healthcare (Basel). 2022;10(8):1420. http://dx.doi.org/10.3390/healthcare10081420\u003c/li\u003e\n\u003cli\u003eSaleh M, Elsabahy MS. Integrating sustainability development education program in nursing to challenge practice among nursing interns in health care. J Nurs Manag. 2022;30(8):4419\u0026ndash;29. https://doi.org/10.1111/jonm.13869 \u003c/li\u003e\n\u003cli\u003eTerry L, Bowman K. Outrage and the emotional labour associated with environmental activism among nurses. J Adv Nurs. 2020;76(3):867\u0026ndash;77. http://dx.doi.org/10.1111/jan.14282\u003c/li\u003e\n\u003cli\u003eBreakey S, Starodub R, Nicholas PK, Wong J. A cross-sectional study to assess faculty and student knowledge of climate change and health: Readiness for curricular integration. J Adv Nurs. 2023;79(12):4716\u0026ndash;31. http://dx.doi.org/10.1111/jan.15729\u003c/li\u003e\n\u003cli\u003eRyan EC, Dubrow R, Sherman JD. Medical, nursing, and physician assistant student knowledge and attitudes toward climate change, pollution, and resource conservation in health care. BMC Med Educ. 2020;20(1):200. http://dx.doi.org/10.1186/s12909-020-02099-0\u003c/li\u003e\n\u003cli\u003eOck M, Choi EY, Oh I, Yun SH, Kim Y-K, Kim H, et al. Perceptions regarding utilization of meteorological information in healthcare in Korea: a qualitative study. Ann Occup Environ Med. 2018;30(1). http://dx.doi.org/10.1186/s40557-018-0214-3\u003c/li\u003e\n\u003cli\u003eSchenk EC, Cook C, Demorest S, Burduli E. Climate, Health, and Nursing Tool (CHANT): Initial survey results. Public Health Nurs. 2021;38(2):152\u0026ndash;9. http://dx.doi.org/10.1111/phn.12864\u003c/li\u003e\n\u003cli\u003eSchenk E, Johnson S. Nurse-sensitive environmental indicators: A qualitative study. J Nurs Manag. 2022;30(8):4378\u0026ndash;86. http://dx.doi.org/10.1111/jonm.13861\u003c/li\u003e\n\u003cli\u003eL\u0026oacute;pez-Medina IM, \u0026Aacute;lvarez-Garc\u0026iacute;a C, Parra-Anguita L, Sanz-Martos S, \u0026Aacute;lvarez-Nieto C. Perceptions and concerns about sustainable healthcare of nursing students trained in sustainability and health: A cohort study. Nurse Educ Pract. 2022;65(103489):103489. http://dx.doi.org/10.1016/j.nepr.2022.103489\u003c/li\u003e\n\u003cli\u003eZhao L, Lin X, Zang Y. Emergency preparedness for heat illness in China: A cross-sectional observational study. Int Emerg Nurs. 2021;54(100957):100957. http://dx.doi.org/10.1016/j.ienj.2020.100957\u003c/li\u003e\n\u003cli\u003eAronsson J, Clarke D, Grose J, Richardson J. Student nurses exposed to sustainability education can challenge practice: A cohort study. Nurs Health Sci. 2020;22(3):803\u0026ndash;11. http://dx.doi.org/10.1111/nhs.12734\u003c/li\u003e\n\u003cli\u003eRojas-Perez HL, D\u0026iacute;az-V\u0026aacute;squez MA, D\u0026iacute;az-Manchay RJ, Ze\u0026ntilde;a-\u0026Ntilde;a\u0026ntilde;ez S, Failoc-Rojas VE, Smith D. Nurses\u0026rsquo; environmental practices in northern Peruvian hospitals. Workplace Health Saf. 2023;21650799231163130. http://dx.doi.org/10.1177/21650799231163130\u003c/li\u003e\n\u003cli\u003eIncesu O, Yas MA. The relationship between nursing students\u0026apos; environmental literacy and awareness of Global Climate Change. Public Health Nurs. 2024;41(1):67-76. https://doi.org/10.1111/phn.13255 \u003c/li\u003e\n\u003cli\u003eBellack JP, Musham C, Hainer A, Graber DR, Holmes D. Environmental health competencies: a survey of nurse practitioner programs. AAOHN J. 1996;44(7):337\u0026ndash;44.\u003c/li\u003e\n\u003cli\u003eKalogirou MR, Dahlke S, Davidson S, Yamamoto S. How the hospital context influences nurses\u0026rsquo; environmentally responsible practice: A focused ethnography. J Adv Nurs. 2021;77(9):3806\u0026ndash;19. http://dx.doi.org/10.1111/jan.14936\u003c/li\u003e\n\u003cli\u003eConrad K. The era of climate change medicine-challenges to health care systems. Ochsner J. 2023 Spring;23(1):7\u0026ndash;8. http://dx.doi.org/10.31486/toj.23.5033\u003c/li\u003e\n\u003cli\u003eWatts N, Adger WN, Agnolucci P, Blackstock J, Byass P, Cai W, et al. Health and climate change: policy responses to protect public health. Lancet. 2015;386(10006):1861\u0026ndash;914. http://dx.doi.org/10.1016/S0140-6736(15)60854-6\u003c/li\u003e\n\u003cli\u003eKim EJ. U.S. global change research program: The impacts of climate change on human health in the United States: A scientific assessment: (2016). Washington, DC: Author. 312 pages. https://health2016.globalchange.gov/downloads. J Am Plann Assoc. 2016;82(4):418\u0026ndash;9. http://dx.doi.org/10.1080/01944363.2016.1218736\u003c/li\u003e\n\u003cli\u003eRataj E, Kunzweiler K, Garthus-Niegel S. Extreme weather events in developing countries and related injuries and mental health disorders - a systematic review. BMC Public Health. 2016;16(1):1020. http://dx.doi.org/10.1186/s12889-016-3692-7\u003c/li\u003e\n\u003cli\u003eCunsolo A, Ellis NR. Ecological grief as a mental health response to climate change-related loss. Nat Clim Chang. 2018;8(4):275\u0026ndash;81. http://dx.doi.org/10.1038/s41558-018-0092-2\u003c/li\u003e\n\u003cli\u003eLevy K, Woster AP, Goldstein RS, Carlton EJ. Untangling the impacts of climate change on waterborne diseases: A systematic review of relationships between diarrheal diseases and temperature, rainfall, flooding, and drought. Environ Sci Technol. 2016;50(10):4905\u0026ndash;22. http://dx.doi.org/10.1021/acs.est.5b06186\u003c/li\u003e\n\u003cli\u003ePark MS, Park KH, Bahk GJ. Interrelationships between multiple climatic factors and incidence of foodborne diseases. Int J Environ Res Public Health. 2018;15(11):2482. http://dx.doi.org/10.3390/ijerph15112482\u003c/li\u003e\n\u003cli\u003eLake IR, Barker GC. Climate Change, Foodborne Pathogens and Illness in Higher-Income Countries. Curr Environ Health Rep. 2018;5(1):187-196. https://doi.org/10.1007/s40572-018-0189-9 \u003c/li\u003e\n\u003cli\u003eMordecai EA, Caldwell JM, Grossman MK, Lippi CA, Johnson LR, Neira M, et al. Thermal biology of mosquito-borne disease. Ecol Lett. 2019;22(10):1690\u0026ndash;708. http://dx.doi.org/10.1111/ele.13335\u003c/li\u003e\n\u003cli\u003eSpringmann M, Mason-D\u0026rsquo;Croz D, Robinson S, Garnett T, Godfray HCJ, Gollin D, et al. Global and regional health effects of future food production under climate change: a modelling study. Lancet. 2016;387(10031):1937\u0026ndash;46. http://dx.doi.org/10.1016/S0140-6736(15)01156-3\u003c/li\u003e\n\u003cli\u003eGalway LP, Beery T, Jones-Casey K, Tasala K. Mapping the solastalgia literature: A scoping review study. Int J Environ Res Public Health. 2019;16(15):2662. http://dx.doi.org/10.3390/ijerph16152662\u003c/li\u003e\n\u003cli\u003eBerry HL, Bowen K, Kjellstrom T. Climate change and mental health: a causal pathways framework. Int J Public Health. 2010;55(2):123\u0026ndash;32. http://dx.doi.org/10.1007/s00038-009-0112-0\u003c/li\u003e\n\u003cli\u003ePollack AA, Weiss B, Trung LT. Mental health, life functioning and risk factors among people exposed to frequent natural disasters and chronic poverty in Vietnam. BJPsych Open. 2016;2(3):221\u0026ndash;32. http://dx.doi.org/10.1192/bjpo.bp.115.002170\u003c/li\u003e\n\u003cli\u003eMatthews V, Longman J, Berry HL, Passey M, Bennett-Levy J, Morgan GG, et al. Differential mental health impact six months after extensive river flooding in rural Australia: A cross-sectional analysis through an equity lens. Front Public Health. 2019;7:367. http://dx.doi.org/10.3389/fpubh.2019.00367\u003c/li\u003e\n\u003cli\u003eVeenema TG, Thornton CP, Lavin RP, Bender AK, Seal S, Corley A. Climate change-related water disasters\u0026rsquo; impact on population health: Climate change disasters health impact. J Nurs Scholarsh. 2017;49(6):625\u0026ndash;34. http://dx.doi.org/10.1111/jnu.12328\u003c/li\u003e\n\u003cli\u003eWhite BP, Breakey S, Brown MJ, Smith JR, Tarbet A, Nicholas PK, et al. Mental health impacts of climate change among vulnerable populations globally: An integrative review. Ann Glob Health [Internet]. 2023;89(1):66. Available from: http://dx.doi.org/10.5334/aogh.4105\u003c/li\u003e\n\u003cli\u003eCadet MJ. Integrating climate change concepts into advanced practice registered nurses curricula with the application of the National Organization of Nurse Practitioner Faculties competencies. J Prof Nurs. 2022;41:157\u0026ndash;65. http://dx.doi.org/10.1016/j.profnurs.2022.05.006\u003c/li\u003e\n\u003cli\u003ePolivka BJ, Chaudry RV, Mac Crawford J. Public health nurses\u0026rsquo; knowledge and attitudes regarding climate change. Environ Health Perspect. 2012;120(3):321\u0026ndash;5. http://dx.doi.org/10.1289/ehp.1104025\u003c/li\u003e\n\u003cli\u003eChen C, Chen J, Fang R, Ye F, Yang Z, Wang Z, et al. What medical waste management system may cope With COVID-19 pandemic: Lessons from Wuhan. Resour Conserv Recycl. 2021;170(105600):105600. http://dx.doi.org/10.1016/j.resconrec.2021.105600\u003c/li\u003e\n\u003cli\u003eChauhan A, Singh SP. Selection of healthcare waste disposal firms using a multi-method approach. J Environ Manage. 2021;295(113117):113117. http://dx.doi.org/10.1016/j.jenvman.2021.113117\u003c/li\u003e\n\u003cli\u003eWorld Health Organization (WHO). Health-care waste [Internet]. 2018 [cited 2024 Apr 7]. Available from: https://www.who.int/news-room/fact-sheets/detail/health-care-waste\u003c/li\u003e\n\u003cli\u003eG\u0026ouml;r\u0026ccedil;\u0026uuml;n \u0026Ouml;F, Aytekin A, Korucuk S, Tirkolaee EB. Evaluating and selecting sustainable logistics service providers for medical waste disposal treatment in the healthcare industry. J Clean Prod. 2023;408(137194):137194. http://dx.doi.org/10.1016/j.jclepro.2023.137194\u003c/li\u003e\n\u003cli\u003eMcPhail S. Multimorbidity in chronic disease: impact on health care resources and costs. Risk Manag Healthc Policy. 2016;9:143\u0026ndash;56. http://dx.doi.org/10.2147/rmhp.s97248\u003c/li\u003e\n\u003cli\u003eRaghupathi W, Raghupathi V. An empirical study of chronic diseases in the United States: A visual analytics approach to public health. Int J Environ Res Public Health. 2018;15(3):431. http://dx.doi.org/10.3390/ijerph15030431\u003c/li\u003e\n\u003cli\u003ePeng J, Wu X, Wang R, Li C, Zhang Q, Wei D. Medical waste management practice during the 2019-2020 novel coronavirus pandemic: Experience in a general hospital. Am J Infect Control. 2020;48(8):918\u0026ndash;21. http://dx.doi.org/10.1016/j.ajic.2020.05.035\u003c/li\u003e\n\u003cli\u003eSeif F, Noorimotlagh Z, Mirzaee SA, Kalantar M, Barati B, Fard ME, Fard NK. The SARS-CoV-2 (COVID-19) pandemic in hospital: An insight into environmental surfaces contamination, disinfectants\u0026apos; efficiency, and estimation of plastic waste production. Environ Res. 2021;202:111809. https://doi.org/10.1016/j.envres.2021.111809\u003c/li\u003e\n\u003cli\u003eShaw E, Walpole S, McLean M, Alvarez-Nieto C, Barna S, Bazin K, et al. AMEE Consensus Statement: Planetary health and education for sustainable healthcare. Med Teach. 2021;43(3):272\u0026ndash;86. http://dx.doi.org/10.1080/0142159X.2020.1860207\u003c/li\u003e\n\u003cli\u003eRosa WE, Kurth AE, Sullivan-Marx E, Shamian J, Shaw HK, Wilson LL, et al. Nursing and midwifery advocacy to lead the United Nations Sustainable Development Agenda. Nurs Outlook. 2019;67(6):628\u0026ndash;41. http://dx.doi.org/10.1016/j.outlook.2019.06.013\u003c/li\u003e\n\u003cli\u003eKelly T, Lazenby M. Developing and validating learning domains, competencies, and evaluation items for global health clinical immersion practicums for graduate-level nursing programs. J Adv Nurs. 2019;75(1):234\u0026ndash;52. http://dx.doi.org/10.1111/jan.13851\u003c/li\u003e\n\u003cli\u003eGaudreau C, Guillaumie L, Jobin \u0026Eacute;, Diallo TA. Nurses and Climate Change: A Narrative Review of Nursing Associations\u0026apos; Recommendations for Integrating Climate Change Mitigation Strategies. Can J Nurs Res. 2024;19:8445621241229932. https://doi.org/10.1177/08445621241229932 \u003c/li\u003e\n\u003cli\u003eVall\u0026eacute;e A. Green hospitals face to climate change: Between sobriety and resilience. Heliyon. 2024;10(2):e24769. http://dx.doi.org/10.1016/j.heliyon.2024.e24769\u003c/li\u003e\n\u003cli\u003eHarris OO, Bialous SA, Muench U, Chapman S, Dawson-Rose C. Climate change, Public Health, health policy, and nurses training. Am J Public Health. 2022;112(S3):S321\u0026ndash;7. http://dx.doi.org/10.2105/AJPH.2022.306826\u003c/li\u003e\n\u003cli\u003eSalvador Costa S, Melo MJ, Azeiteiro P, Carvalho U, Ryan S. Nursing Interventions to Reduce Health Risks from Climate Change Impact in Urban Areas: A Scoping Review Protocol. Nurs Rep. 2023;13:496\u0026ndash;505. https://doi.org/10.3390/nursrep13010045 \u003c/li\u003e\n\u003cli\u003eCrowder SJ, Tanner AL, Dawson MA, Felsman IC, Hassmiller SB, Miller LC, et al. Better together: Coalitions committed to advancing health equity. Nurs Outlook. 2022;70(6):S48\u0026ndash;58. http://dx.doi.org/10.1016/j.outlook.2022.02.013\u003c/li\u003e\n\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":true,"hideJournal":true,"highlight":"","institution":"","isAcceptedByJournal":false,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true},"keywords":"climate change, environment, nurses, nursing students, patient health outcomes ","lastPublishedDoi":"10.21203/rs.3.rs-4346650/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-4346650/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003cp\u003e\u003cstrong\u003eIntroduction:\u003c/strong\u003e Climate change poses significant threats to the environment, biodiversity, and socioeconomic stability worldwide. Its impact on human health, particularly within healthcare systems, is growing in concern. Nurses, as front-line healthcare workers, play a crucial role in addressing climate-related health risks. However, there is a gap in understanding nursing perspectives on climate change and its implications for patient health outcomes.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAim:\u003c/strong\u003e To synthesize empirical evidence on the association between climate change and patient health outcomes from a nursing perspective.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eMethods:\u003c/strong\u003e A mixed-methods systematic review was conducted following the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA). The search was carried out in January 2023 in six scientific databases including CINAHL, PubMed, Scopus, ProQuest, Web of Science, and OVID Nursing. Studies focusing on climate change and patient health outcomes from a nursing perspective were included. Data extraction, quality appraisal, and synthesis were performed systematically.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eResults:\u003c/strong\u003e The systematic review included 18 studies of a mainly quantitative nature. Three main themes emerged as follows: \u003cem\u003eClimate Healthcare Interplay\u003c/em\u003e; \u003cem\u003eFuture Nurses as Agents of Change\u003c/em\u003e; and \u003cem\u003eNavigating Sustainability Challenges in Nursing\u003c/em\u003e. These themes highlighted nurses' awareness of the interrelation between climate and health, the need for environmental education in nursing, and the challenges that hinder sustainable nursing practices.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConclusion:\u003c/strong\u003e This review underscores the importance of integrating climate change topics into nursing education and fostering organizational support for sustainable nursing practices. Addressing these challenges is essential for nurses to mitigate the health risks posed by climate change effectively.\u003c/p\u003e","manuscriptTitle":"Association Between Climate Change and Patient Health Outcomes: a Mixed-methods Systematic Review","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2024-05-03 20:50:34","doi":"10.21203/rs.3.rs-4346650/v1","editorialEvents":[{"type":"communityComments","content":0}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"1eeb15f0-25a8-4e5b-9684-c45c78117df2","owner":[],"postedDate":"May 3rd, 2024","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"posted","subjectAreas":[{"id":31462056,"name":"Nursing"}],"tags":[],"updatedAt":"2024-05-03T20:50:34+00:00","versionOfRecord":[],"versionCreatedAt":"2024-05-03 20:50:34","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-4346650","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-4346650","identity":"rs-4346650","version":["v1"]},"buildId":"8U1c8b4HqxoKbykW_rLl7","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}