INTRODUCTION

The interaction of living organisms and their environments has always determined the vital processes of the human being. Ecology has studied for decades the effects of this interaction and it is already well known that the current mode of production and energy consumption, together with the changes in the use of the Earth, are generating climatic alterations and important impacts, both in the natural system, as well as in the social and economic. The evidence also shows the effects on human health as a result of climate change ¹⁾⁽², including injuries and illnesses as a result of extreme weather events such as storms and heat waves, the spatial distribution and dissemination of transmissible diseases, especially through the water, food and vectors, and increased prevalence of cardiorespiratory diseases ^3)(4)(5)(6).

On the other hand, the production, collection, manipulation and distribution of food are determined by an economistic dynamic, where the quality of what we eat or the context in which our food is produced matters very little. Foodborne diseases have increased significantly throughout the European continent over the past 10 years.

The implication and the human health impacts of these changes are already unquestionable and constitute the reason why the health sector has been included in its own entity in the search for solutions to the problem ^7). Therefore, the concept of sustainable development is fundamental for health systems, and for health professionals to know the concepts of sustainability and climate change, along with their relationship with people's health and well-being ⁸⁾⁽⁹. In particular, the nursing group is an agent of change that has the capacity to promote health and control the use of health resources. Therefore, in the nursing profession to improve the level of knowledge and skills in sustainability and the effects of climate change will make it possible to change attitudes and modes of action in their daily work, which will improve the health of people ¹⁰.

Universities are leaders in the development of forms of education in order to devise solutions to problems linked to sustainable development ¹¹. However, "nursing students are being poorly trained to understand the connections between climate change, sustainability and health" ^12). Therefore, it is necessary to break the existing educational gap, and pedagogical strategies are required, including the environmental sustainability for the Nursing Degree.

To address these issues, the following objectives were set: 1. To describe the dimensions that nursing education should include in terms of environmental sustainability, climate change and health care. 2. To determine pedagogical strategies that allow the integration of environmental sustainability in the competences of graduates in Nursing.

MATERIALS AND METHODS

A narrative review of the scientific literature was conducted to identify evidence on environmental sustainability and climate change in nursing and health care. Firstly, a bibliographic search strategy was designed in the databases: Cochrane, Cummulative Index to Nursing and Alliance Health Literature (CINAHL), Public Medline (PubMed), Embase, Latin American and Caribbean Literature in Health Sciences (LILACS), Web of Knowledge (WOK), Scopus, Cuiden, Cuiden plus, Cuidatge, Spanish Medical Index (IME), Physiotherapy Podiatry Nursing (ENFISPO), Scielo, Consejo Superior de Investigaciones Científicas (CSIC), ProQuest and Directory of Open Access Journal (DOAJ). The search strategy is displayed in Table 1.

The search was made in January 2015 and was limited to original documents, published in English, Spanish or Portuguese and published from 2004. The letters, journalistic articles and academic works were excluded.

A total of 2174 references were found and an inverse search process was carried out through which six additional references were identified.

The titles of the references retrieved by the search were reviewed to check the eligibility, process after which 130 documents were selected. In the Embase, Cuiden, Cuidatge and Proquest databases, results were obtained, but no publications were finally selected from these databases.

After reading the summary of these documents, 67 documents were selected and after eliminating duplicates, there were 43 documents for analysis.

For the extraction of the data, a data matrix was used in which the answers to the two questions that guided the search were recorded: what should nurses know about sustainable care?, and what pedagogical strategies are used to include issues of environmental sustainability in the curriculum of nursing? During this process, two publications were excluded because they did not respond to the research questions, resulting 41 papers finally analysed and included in this research ^{8)(9)(10)(13)(14)(15)(16)(17)(18)(19)(20)(21)(22)(23)(24)(25)(26)(27)(28)(29)(30)(31)(32)(33)(34)(35)(36)(37)(38)(39)(40)(41)(42)(43)(44)(45)(46)(47)(48} (Figure 1).

Figure 1 Papers selection process 

The information extracted from the analysis of the papers was divided into two parts. The first focused on what nurses need to know about sustainability to provide appropriate care, differentiating the knowledge, skills, attitudes, competences and behaviours they should have. To achieve this knowledge and training, a second dimension was developed, indicating the pedagogical approaches needed to integrate sustainability into nursing curricula, identifying the different educational strategies that can be followed, as well as the theoretical assumptions in which they are based and types of activities that are carried out to get this objective.

RESULTS

Nurses' knowledge about environmental sustainability in health care

Based on scientific evidence found, it has been identified that the nurses' knowledge, skills, attitudes, competences and behaviors about environmental sustainability that they should have.

First, the knowledge to be acquired is related to globalization (global village), environmental impact, health promotion, resource use and proper waste management, food and production process influences, effects of smoking and environmental effects on children's health. It is necessary to explore how the health of people, communities and populations are affected by social, political and environmental factors, and how to describe the interaction of the environment and human health at different levels. In addition, it is necessary to acquire knowledge about the guiding principles of sustainability and conservation of the environment (WHO's Ottawa Charter, 1986, Rio de Janeiro Declaration, 1992), related international and national legislation, and all in the context of inequalities in health and the social determinants of health (Table 2).

In terms of skills, nurses must have communication skills and abilities to provide environmental health education and counselling. This also implies having skills for dialogue and influence in other groups and sectors, as well as for citizen awareness and mobilization. They should reflect on the consequences of climate change and the possible interventions to be designed from a holistic, ethical and critical perspective (Table 3).

Following with the attitudes, it is remarkable the need to have a vision and an orientation towards the future, assuming high levels of responsibility, commitment to the environment, and orientation towards change. Also the predisposition to carry out interventions at different levels, from an ecological view of the social reality (Table 4).

In the same line of skills and attitudes, different competences in environmental health have been identified by the nurses. Based on the knowledge obtained, they should reflect on human action in the environment, and develop the capacity to interrelate and analyse the different parts of the problem as a whole. In addition, the ability to organize and manage projects, communication skills to promote healthy and sustainable environments and to be able to work with other experts in an interdisciplinary way are important (Table 5).

Finally, the nurses' behaviours regarding environmental sustainability have been identified. Consistent with the knowledge, skills, attitudes and competences identified, nurses must proceed in an active, responsible and ethical manner, participating socially and individually. Thus, it is important to develop an ecological framework in nursing, and play the role of community nurse in environmental health. They should educate patients about environmental problems and health effects and advise them on the efficient use of resources and waste management. These behaviours must be applied by nurses both in their personal life and in the health care provided as professionals (Table 6).

Pedagogical strategies to address environmental sustainability in nursing

Two educational approaches have been identified in programs for the inclusion of environmental sustainability in nursing education.

1. Participatory-Action Research (PAR): according to Cotton and Winter ¹³, for nursing education on sustainability, work must be multidisciplinary, guided by a tutor and learning skills must be experience-based.

In this way, PAR can contribute to the learning necessary to transform the understanding of sustainability ^{13)(14)(15)(16)(17)(18)(19}, since it is a method of study and action that seeks to obtain reliable and useful results to improve collective situations, basing research on the participation of the groups to be investigated ⁵¹.

2. Problem-based learning: problem-based learning ^{(13)(14)(18)(21} may be a methodological approach to be used, having to be student-centred, since it has a great responsibility in preserving the environment and is a key point in education for health ^{17)(21)(22)(23}. It consists of an explanation by the teacher of some aspects of a subject they are dealing with and approaching a problem related to it, so that students, autonomously, must solve it through reflection and research, personal or small groups, interrelating all the subjects they study.

DISCUSSION

The results of this narrative review allow identifying the knowledge, skills, attitudes, competences and behaviours that nurses must have about environmental sustainability, as well as the pedagogical strategies most appropriate for their acquisition. As a new contribution, we must point out that in a teaching context such as the current European Higher Education Area, it is of great interest to have a description of the competences needed to develop on environmental sustainability in the curriculum of nursing education.

Since the beginning of the 90's, it has been accepted that university education is decisive for achieving a culture of sustainability in future professionals in any field; this has been recognized and specified in a number of international publications, such as the Charter of Universities for the Sustainable Development in 1993, the Lüneburg Declaration in 1997, the Bonn Declaration in 2009 ¹¹ and more recently the World Conference on Education for The Sustainable Development of Aichi-Nagoya in 2014.

The truth is that all university students should be trained in their disciplines according to environmental and sustainable values ²⁴. But in addition, nursing is a discipline that has much to contribute to the health problems related to climate change. In this sense, nursing students, as future health agents, must acquire different knowledge that leads them to reach a central understanding of sustainability and to develop several special skills and competences in this field; for example, to communicate the problem to the society or to possess a critical and ethical thought, so that in the future this perspective can be considered in their professional activity.

Therefore, it is fundamental that nursing achieve literacy in sustainability ^{8)(10)(13)(18)(25}, including in the curricula different key competences for sustainability, taking into account also that this is a requirement marked by the Spanish legislation (Royal Decree 1393/2007 the 29^th of October, establishing the management of official university education) for the process of harmonization of higher education ¹¹. However, nursing curricula are still far from contemplating the dimension of environmental sustainability in the curriculum. As some authors point out, nurses are still poorly prepared in environmental issues ¹².

On the basis of this evidence, imminent changes in both undergraduate and postgraduate curricula are required. Numerous authors contribute with proposals, such as including theoretical and practical content, research based on experiences, problem-based learning or the use of various educational techniques ^{13)(14)(18)(21)(25)(26}.

However, an issue that remains unclear is where to include sustainability contents. Possible proposals could be to create a subject in the last year of the degree in nursing or specific masters on environmental sustainability and health. Perhaps, since the environment affects many areas of health from different perspectives, initially the most feasible and beneficial would be to include the issue of sustainability transversally in different subjects such as those related to health promotion or community health, sexual and reproductive health, children's health or nutrition.

Although important steps are being taken, it is not enough to incorporate sustainability into the competences to be acquired in nursing; it is essential to have adequate learning environments, for example, creating "green" classrooms. This change must be accompanied by a responsible attitude and behaviour. Nurses must assume a proactive attitude towards environmental sustainability in their daily lives, with simple behaviours such as changes in their diet, reuse and recycling of materials or the use of public transportation.

At present, there are different models of food management and consumption that advocate sustainable land use and responsible and ethical feeding. To know and to spread this type of initiatives like Slow Food or Mensa Civic would be a subject to take into account in the promotion of health realized from nursing. They could even use the media to disseminate these problems that affect public health and alternative consumption patterns. Ultimately, management plans or policy changes could be promoted to achieve these goals.

Another issue is the need for training of teachers in environmental issues, since without them, adequate training would be impossible. The papers of Ull et al., Aznar et al. or Azcárate et al. ²⁷ indicate that Spanish university teachers have deficient knowledge in environmental issues and that most of them have not yet joined the process of sustaining their own teaching practices ²⁸.

Equally important is the continuous training of professionals who already work in health institutions, to update their knowledge to the constant environmental changes that are occurring. In this sense, another series of more global changes are needed.

In order to achieve this, it is essential to consolidate the research in the field of nursing in environmental health, since this will be able to contribute results and to base the nursing leadership in this field. Based on this approach, a team from the University of Jaen, in cooperation with the Universities of Plymouth (UK), Esslingen (Germany) and Maastricht (Netherlands), are developing the NurSusTOOLKIT project ²⁹. The aim of this project is to enhance the availability/relevance of a sound learning offer in Sustainability Literacy and Competency (SLC) in nurse education by developing innovative teaching and learning approaches/materials, disseminating and promoting of good practices through strategic use of information technologies.

CONCLUSIONS

Nursing training in environmental sustainability, climate change and health care should include competences at different levels. First of all, in the individual, understanding the fundamentals and the scope of the problem and acting accordingly in the professional environment and with the personnel. In addition, in the social sphere, nursing profession plays a key role in promoting environmental health.