Contemporary Issues

The use of evidence-informed sustainability scenarios in the nursing curriculum:

Development and evaluation of teaching methods
Janet Richardson , Jane Grose
1
, Maggie Doman
2
, Janet Kelsey
3
School of Nursing and Midwifery, Faculty of Health, Education and Society, Plymouth University, Drake Circus, Plymouth PL4 8AA, UK
s u m m a r y a r t i c l e i n f o
Article history:
Accepted 11 July 2013
Available online xxxx
Keywords:
Sustainability
Nursing
Education
Clinical skills
Climate change
Scenarios
Resource scarcity
Background: Climate change and resource scarcity pose challenges for healthcare inthe future, yet there is little to
raise awareness about these issues in the nursing curriculum and nurses are poorly equipped to practice in a
changing climate. The aims of this paper are to describe how an evidence-informed sustainability and health
scenario based on two sustainability issues (resource depletion and waste management) was introduced into a
nursing clinical skills session, and to report the evaluation of the session.
Methods: Based on evidence from our own research on waste management, sustainable procurement and
resource scarcity, a practical hands-on skill session was delivered to 30 second year student nurses as part of a
scheduled clinical skills day. The session was observed by one of the facilitators and interactions recorded and
this was followed by a brief questionnaire completed by participants.
Findings: Observations of the group sessions and discussion found that students demonstrated limited knowl-
edge about natural resources (such as oil) used in the production of items used in healthcare; they engaged in
discussions following the use of Internet resources, and were able to segregate waste appropriately. Thirty
(100%) students completed the evaluation questionnaire, found the resources used in the skill session helpful,
and thought that the scenarios were realistic. Nineteen reported being more aware of peak oil; 30 were more
aware of risks to patient experience and service delivery if resources become unavailable; 30 reported greater
awareness of the management of waste in healthcare. Comments on the questionnaire indicated a high level
of engagement and interest in the subject.
Conclusion: The problemof climate change and resource scarcity can too easily be seen as a distant or intractable
problem. However one way to make this topic real for students is through the use of clinically relevant scenarios
in skill sessions.
2013 Elsevier Ltd. All rights reserved.
Introduction
It has been suggested that climate change presents the biggest single
threat to health in the 21st Century (HM Government). Healthcare ser-
vices need to plan for the health consequences, and employ mitigation
measures to ensure sustainability, service delivery and business conti-
nuity. The impacts of climate change on health and healthcare are
well documented (Nichols et al., 2009), other challenges relate to the
depletion of scarce or carbon intensive materials. We need to develop
healthcare professionals who will be able to deal with the mitigation
and adaptation challenges that climate change and the possible deple-
tion of fossil fuel and scarce materials present. We take sustainability
to mean more than merely lasting or surviving; it means designing
and delivering health care that uses resources in ways that don't
prejudice future health and wellbeing (Naylor and Appleby, 2012).
There is limited literature on nursing and climate change (or sus-
tainability); nursing students are poorly prepared to understand the
connections between resources, climate change, sustainability and
health (Goodman and East, in press; Barna et al., 2012; Goodman,
2011; GoodmanandRichardson, 2009). Sustainability canbe embedded
in the healthcare curriculumthrough a range of learning opportunities;
for example in the context of public health and health inequalities,
poverty, food security and infectious diseases (Richardson and Wade,
2010). It has been argued that each learning programme should have
sustainability literacy for its nursing students nested within a broader
context of links between health and the natural environment, including
inequalities in health and opportunities for chronic disease prevention
(Barna et al., 2012). Arguably, as climate change and fossil fuel depen-
dency pose serious threats to future healthcare we have an obligation
to prepare our students for the consequences, to ensure that they are
able to deal withthe associatedhealthcare planning andresource issues.
Nurse educators have a responsibility to embed this learning using
practical (vocational) examples; a nurse who cannot make the links
Nurse Education Today xxx (2013) xxxxxx
YNEDT-02565; No of Pages 4
Corresponding author. Tel.: +44 1752 586535.
E-mail addresses: janet.richardson@plymouth.ac.uk (J. Richardson),
jane.grose1@plymouth.ac.uk (J. Grose), M.Doman@plymouth.ac.uk (M. Doman),
J.A.Kelsey@plymouth.ac.UK (J. Kelsey).
1
Tel.: +44 1752 586510.
2
Tel.: +44 1752 587462.
3
Tel.: +44 1752 586525.
Please cite this article as: Richardson, J., et al., The use of evidence-informed sustainability scenarios in the nursing curriculum: Development and
evaluation of teaching methods, Nurse Education Today (2013), http://dx.doi.org/10.1016/j.nedt.2013.07.007
0260-6917/$ see front matter 2013 Elsevier Ltd. All rights reserved.
http://dx.doi.org/10.1016/j.nedt.2013.07.007
Contents lists available at SciVerse ScienceDirect
Nurse Education Today
j our nal homepage: www. el sevi er . com/ nedt
between clinical waste, resource use, carbon reduction and health
inequalities will not be able to devise solutions for future healthcare
challenges.
One way to introduce sustainability to student nurses is through
scenarios that have practical application to clinical practice. The use of
scenarios is integral to Problem Based Learning in clinical education
and promotes communication, team working and problem solving
(Wood, 2003). In healthcare, contemporary education approaches
emphasise the need for active learning (Endacott et al., 2003). Scenario
based learning is founded on situated learning theory, encourages
opportunities for active learning, is based on valuing contextual knowl-
edge, and provides a strategy for bringing students closer to the realities
of their profession (Errington, 2011). Nurses have impact on how
resources in healthcare are used and disposed of; through scenarios in
clinical skills sessions, practical connections can be made between the
sustainable use and potential scarcity of resources, and climate change.
This paper describes the delivery and evaluation of a sustainability
clinical skills session using an evidence-informed scenario. The scenario
was based on healthcare waste management research (Nichols et al.,
2013; Grose et al., 2012), and an evaluation designed to identify items
usedinhealthcare that are important for patient care andare potentially
at risk in terms of future supply (WRAP, 2013; Grose and Richardson,
in press). Grose and Richardson highlighted the vulnerability of
plastic items due to their reliance on crude oil supplies and potential
for recycling.
Aim
The aims of this paper are to describe how an evidence-informed
sustainability and health scenario introducing two sustainability issues
(resource depletion and waste management) was introduced into a
nursing clinical skills day, and to report the evaluation of the session.
Methodology
Apractical hands-onskill sessionwas delivered as part of a scheduled
clinical skills day. The session was observed by one of the facilitators and
interactions recorded and this was followed by a brief questionnaire
completed by participants.
Participants
Thirty nursing students studying the child eld of the undergradu-
ate nursing programme at Plymouth University who were half-way
through their second year of training. Students were participating in
clinical skill days in January 2013. These students had not previously
been involved in skill sessions that focused on sustainability.
Teaching Methods
The sustainability and health skill scenario session formed one of
the four skill stations during a clinical skill day. Learning outcomes
were specied and students engaged in discussion, fact-nding and
practical work. The scenarios and supporting literature were made
available prior to the session. See skills session content in Box 1.
Evaluation
Notes were taken by one of the skill facilitators during the session
and a brief questionnaire designed to capture awareness and feedback
was given to students at the end of the session.
Box 1
Description of skills session.
Learning outcomes
By the end of the session the student will be able to:
Describe where plastic comes from
Assess the impact of the loss of key items on patient experi-
ence and service delivery
Allocate items to the appropriate waste streams.
Materials
Computer
Giving sets, IV sets, syringes
Yellow and black rubbish bags, sharps bin
Tape to make a line on the floor, high/low impact labels
File of background information
Box of waste materials
Methods
1) Scenario: students will be given the following scenario
(20 min):
Aim
The aim of this scenario is to engage you in discussions about
risk and sustainable procurement and for dealing with future
limited availability of resources that are important for patient
care.
Background
The un-interrupted supply of essential items for patient care is
crucial for healthcare organisations. The majority of products
central to healthcare are derived from natural resources such as
oil and cotton, supplies of which are seeing increased global de-
mand with some resources becoming depleted. Initially this will
impact on the costs of acquiring them, adding a further burden
to NHS expenditure. Also of concern is the possibility that
some key resources may become unavailable. The following
scenario has been prepared by identifying an item which might
present a risk to the delivery of healthcare should its supply be
restricted or removed. The scenario describes a situation where
the global availability of raw materials, required for critical prod-
ucts consumed by the NHS has been affected. The scenario is
based on factual information; however the situation described
is fictional.
Participants are asked to consider how and what strategies
could be put in place to mitigate the impact on healthcare
provision of restricted or interrupted supply and associated
price rises. Participants are encouraged to consider how
service provision could be maintained, or even improved,
in response to the challenges set out in the scenario. You
will be asked to follow the questions and prompts following
the scenarios and take notes so you can report back follow-
ing your discussions.
Scenario
It is estimated that globally more than 100 million tonnes
of plastic is manufactured each year. The use of plastics in
healthcare is widespread. On a typical day in one hospital sev-
eral hundred of patients are receiving pill bottles, intravenous
lines (IVs) and undergoing surgical procedures which use plas-
tic, single use products. Given the fact that many of these
items have contact with bodily fluids, none of these compo-
nents are usually recycled.
Please cite this article as: Richardson, J., et al., The use of evidence-informed sustainability scenarios in the nursing curriculum: Development and
evaluation of teaching methods, Nurse Education Today (2013), http://dx.doi.org/10.1016/j.nedt.2013.07.007
2 Contemporary Issues
Findings
Findings from the Observation
Observations of the groupsessions anddiscussionfoundthat students
demonstrated limited knowledge about natural resources (such as oil)
usedinthe productionof products utilisedinhealthcare. Students report-
ed overuse of gloves in clinical practice because they are there, but had
awareness of the alternative to latex gloves. There was some lack of
knowledge regarding the appropriate disposal of clinical waste, though
most allocated the correct item to the correct waste stream.
Internet searching during the session promoted interesting
discussion about possible alternatives to plastics and the increasing
demand for oil (and potential political issues that might arise in oil
producing countries resulting in interruption to supply). Students
discussed the need for the NHS to adapt and nd alternatives, the
need for training to raise awareness, and the potential impacts on
quality of care.
Findings from the Evaluation Questionnaire
All thirty students completed the evaluation questionnaire.
Use of Scenarios
Twenty eight students reported that it was helpful to have the
scenarios prior to the workshop; one said it was ne to have them at
the start of the workshop and one reported that they were not aware
that they were available. All 30 students answered yes to the question
Were the resource materials available in the session useful/helpful?
Examples of comments are included below:
Familiar materials used frequently
Good to see it visually
The computers and journal extracts are helpful at identifying alternatives
and the real impact
Able to relate theory to practice
Makes you think about how your actions have an effect in daily
procedures
Interactive and thought-provoking.
In response to the question Was the scenario realistic?, all students
answered yes. Comments included:
Recognised scenario potential within a clinical setting
This could really happeninafewyears, we need to start to nd alternative
methods of production to meet our needs
Used things that are frequently used on a ward which was good
Makes you think for future practice
Everyday items.
With respect to the learning outcomes for the session 19/30 reported
being more aware of peak oil; 30/30 were more aware of the risk to
patient experience and service delivery if resources become unavailable;
30/30 reported greater awareness of the management of waste in
healthcare. Other awareness reported was:
Cost of incineration question everyday routine and need for recycling
Was thought provoking
Alternative resources awareness of waste
Recycling future lack of resources
Don't just throw away think!
The evaluation questionnaire also asked What other information
would you nd useful/helpful for this workshop? Comments included:
How the NHS sources resources
What is being done in local Trusts to address this issue, i.e. is cardboard/
packaging being recycled? And informationas to what is the anticipated
way ahead and predications for future scenarios
Information sheet to take away
A sheet describing a quick reference guide on where waste should go
including cost of waste
Specic gures on waste locally and nationally and impact some
changes could have
Looking at more products we use, improvements that are made after
research
How we can make a difference as students?
The last item on the evaluation questionnaire stated Please provide
us with any comments about either the scenario or how the workshop
was organised. Thirteen of the 30 students provided a comment:
A good informative session thank you
Really has made me question what to throwaway where, and not to use
equipment that is not needed. Made me think what I can do to help a
problem fast approaching of lack of materials
Good to discuss
Good to discuss and apply to real life situations
Perhaps [might include] audiovisual information e.g. YouTube clips
Time-line was really good, easy to see where each itemts in comparison
to others
Thank you it was helpful
Very good
Good to know prices of waste disposal, really interactive workshop,
interested in our views
Interactive and discussions very good/interesting good learning style
Liked the lowhigh impact workshop, made me think within relation to
practice
Please cite this article as: Richardson, J., et al., The use of evidence-informed sustainability scenarios in the nursing curriculum: Development and
evaluation of teaching methods, Nurse Education Today (2013), http://dx.doi.org/10.1016/j.nedt.2013.07.007
The price of plastic increases and your hospital starts to worry
about how many plastic items it can afford.
Why is the cost of plastic increasing (computer work)?
Why might it not be available (computer work)?
What are the implications for practice?
What do you think can be done?
2) Impact of items on patient care
The line on the floor is marked with no impact on patient
experience or service delivery at one end and significant
impact on patient experience and service delivery on the
other. Students are asked to take an itemfroma healthcare
supplies box and place it on the line where they assess
the degree to which the loss of this item would impact on
patient experience and service delivery. They must explain
to the others the reasons for their decision and some discus-
sion amongst the group takes place about the accuracy of
the decision.
3) Waste disposal
Once all the items have been placed on the line the stu-
dents are given a scenario of what has happened to the
item (i.e., potential for contamination) and asked to put
their item in the waste bag/bin (black, yellow, sharps)
they most feel is appropriate. They will explain the rea-
sons for their choice. The waste bags will have the cost
of their disposal printed on the underside and this will
be revealed at the end of the session.
3 Contemporary Issues
Good and thought-provoking
I really enjoyed this workshop and made me aware of the part I can play
in practice to combat this problem.
As a consequence of running and evaluating this scenario workshop,
the question Why is the appropriate segregation of waste important to
the NHS has been added to the second year clinical skill assessment
(OSCE). Further sessions and assessment have been developed for
years one and three students.
Discussion
As educators we have a responsibility to train healthcare practi-
tioners who are t for purpose, but also t for future practice; climate
change and resource scarcity are very real situations that nurses will
need to deal with in the future. The NHS has a duty to reduce carbon
emissions and embed sustainability into the supply chain (Naylor and
Appleby, 2012) and efforts are moving forward to support this (see for
example details of specic projects on the NHS Sustainable Develop-
ment Unit website: http://www.sdu.nhs.uk/). Whilst there is a growing
body of literature available highlighting the health impacts of climate
change, less attention is given to the potential impacts on healthcare
of resource scarcity. The problem of climate change and resource
scarcity can too easily be seen as a distant or intractable problem,
leaving us feeling that others (i.e. Government) will sort it out, and
any impact we can have is minimal. Kirk (2002) has suggested that
nursing students are poorly prepared to understand the connections
between climate change, sustainability and health. Although efforts to
raise attention about sustainability and nursing are gaining impetus
(Goodman and East, in press; Barna et al., 2012; Goodman, 2011;
Goodman and Richardson, 2009; Richardson and Wade, 2010), sustain-
ability competencies are not currently a requirement within nurse
education. Furthermore, nurse educators need to grasp the urgency
and up-skill themselves in order that they can teach nurses who will
be competent to practice in a changing climate.
Sustainability has traditionally been embedded in the nursing curricu-
lum in the context of public health (Richardson and Wade, 2010). How-
ever one way to make this topic real for students is through the use of
scenarios in skills sessions. The scenario used here was developed
through our own research into sustainable healthcare procurement, and
had previously been used successfully with NHS staff (WRAP, 2013). Col-
leagues were keen to use it with students, and as this was a newmethod
of teaching and incorporated new ideas it was important to evaluate the
session. It is clear from the student feedback that the session was very
well received, stimulated discussion, and provided an innovative learning
approach on a topic not generally covered in nursing curricula. The rele-
vance to clinical practice was crucial in getting the message across, and
this is evident from the comments made by students on the evaluation
form. The scenario used in the sustainability skill session presents a snap-
shot of much wider challenges and needs to be put into the context of
changing global events andgeopolitical issues. Other geographical regions
may choose to focus ondifferent items that are at greater risk of scarcity in
those regions. It may also be appropriate to test the sustainability skill
scenario sessions with students from other health disciplines.
There is no doubt that this approach can introduce issues about sus-
tainability into nursing curricula in a way that is integral to their clinical
skills development and is not an ad-on that could be viewed as tangen-
tial to nursing practice. The scenario session reported here, along
with a theory session in year 1 and other scenarios in year 3 linked to
management and leadership skills, has now been embedded in our
undergraduate curriculum. Sessions are linked to learning outcomes,
with the potential for further sustainability practice assessments in
the future. Opportunities for working with other student groups and
inter-disciplinary team working are also being explored.
In conclusion, the problem of climate change and resource scarcity
can too easily be seen as a distant or intractable problem. One way to
make this topic real for students is through the use of clinically relevant
scenarios in skill sessions.
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Please cite this article as: Richardson, J., et al., The use of evidence-informed sustainability scenarios in the nursing curriculum: Development and
evaluation of teaching methods, Nurse Education Today (2013), http://dx.doi.org/10.1016/j.nedt.2013.07.007
4 Contemporary Issues