Sustainability in Nursing and Midwifery

Action on sustainability and green issues, both political and practical, is required at every level to tackle the climate crisis that is affecting the world. Arguably, the health and care sector has been slower than others in prioritising sustainability and green policies, in part due to infection prevention and control policies among other things. While it is starting to make up ground, there is still much to do and many opportunities for those working in the sector with ideas and innovations to make a real difference. Supporting action to improve sustainability by nurses and midwives is a key aim of Nursing Times and one of the main reasons that we are launching this new category dedicated to green issues. This award seeks to recognise an individual or small group or team of nurses or midwives that has made an exceptional contribution to promoting sustainability and green issues.

Central and North West London NHS Foundation Trust
Improving the escalation process and shared clinical decision-making in an urgent community response pathway

Unnecessary hospital admissions are resource intensive, anxiety-inducing situations, having high financial implications, carbon use, and social impact to the patients, families and carers involved. In my Urgent Community Response (UCR) team, the number of unnecessary admissions instigated by the team’s clinicians increased over a two-month period. Resulting in higher resource use and increased pressure on the system. Long wait times resulted in UCR staff being held up at patients' houses while awaiting an ambulance, limiting the number of new referrals the UCR could see. While some of these admissions were necessary, there was an increase in patients being discharged directly from A&E, sometimes after only a few hours and in the middle of the night. I led a quality improvement (QI) project aimed to decrease the number of unnecessary admissions initiated by UCR staff. We set objectives to decrease variation in decision-making within the team, improve the escalation process and improve clinical communication between team members. By creating an opportunity for staff to communicate with senior nurses while at the patient’s bedside, allowing quicker access to shared clinical decision-making. To add value to the triple-bottom line (environmental, societal and economic impact), the Sustainability in QI framework was implemented, with Plan-Do-Study-Act cycles used to trial iterative tests of change. The Capability, Opportunity, Motivation Behaviour (COM-B) Model was adopted as the theoretical framework to support the behaviour change required by the team to adapt to and use the new interventions. A decrease in the average number of unnecessary admissions instigated by the UCR pathway was seen from 5 patients/week to 2 patients/week. The percentage of patients sent to hospital and admitted to a ward (necessary admission) increased (60% to 82%), indicating that hospital admission was the correct decision. These improvements saved 150kgCo2e/week.

Chester Zoo
Reducing the consumption of paper, ink and plastic

The issue I was trying to resolve was reducing the consumption of paper, ink and plastic within my department. I wanted to have a positive impact on my departments carbon footprint and reduce the impact on the natural world whilst also improving service to my patients. I did this by creating a digitalised system for all patient records and departmental records.. I also switched from paper-based health surveillance to computer based systems and software, thus further reducing the impact of unsustainable practices. Challenges faced included stigma from other departments moving away from previously trusted sources of communication – ie paper reports and records. Patients often continued to hand in their health surveillance questionnaires or post them rather than using secure ways of electronically sending them. Many methods were used to encourage patients to send records electronically, eventually taping shut the OH post box was the final method (which seems to have had a positive impact!)Another challenging aspect was time constraints, trying to create a bespoke system whilst fulling all other aspects of the role and day to day running of the department and converting paper-based records to electronic format. Further challenges was acquiring software that was compatible with electronic use only. It has long been a preferred method to print spirometry results, rather than view electronically. The Outcome has been outstanding. Not only is a paperless office an important environmental practice but it has contributed to a more efficient OH department. We now have a bespoke fully electronic OH system, which can be accessed with hybrid working, further reducing carbon footprint of the requirement to come to the office for both patient and Nurse. Since I started this change, it has been evidence based that digital transformation reduces negative environmental impacts like natural resource consumption, pollution and waste.

Guy's and St Thomas' NHS Foundation Trust
A quality improvement project to improve sustainable prescribing of inhaled therapy for patients with airways disease

Inhaled therapy is central to the management of airways disease. Pressurised meter dosed inhalers (pMDIs), contain hydrofluorocarbon propellants, accounting for 3% of the National Health Service (NHS) carbon footprint (CF). The single biggest source of the NHS CF is reliever therapy in the pMDI format, making up 94% of prescribed inhalers (Jansen at el., 2020). Dry powder inhalers (DPIs), an alternative option, possess a much lower CF due to the absence of propellant. The importance of reducing pMDIs CF contribution has been included in national guidance and NHS England strategy (NHSE). The project aim was to improve sustainable prescribing of inhaled therapy by 15% in patients with airways disease; with a focus on reducing the prevalence of mixed devices and current over usage of reliever therapy in pMDI format. A Quality improvement project design (QIP) was undertaken. The Plan-Do-Study-Act (PDSA) methodology. Three PDSA cycles were undertaken at two monthly intervals. The percentage of patients prescribed the same type of inhaler device (either only DPI or pMDI) after review was measured at baseline and post-intervention. The key stakeholders for the project were patients with airways disease who were reviewed by the Integrated Respiratory Team (IRT), following presentation to secondary care health setting with an exacerbation of their airways disease. Review of inhaled therapy / inhaler technique is a core component of the national care bundle, completed at every review by IRT. We observed a lower than anticipated percentage of patients declining to switch device, only 3.3% to June 23. Baseline / post interventional data demonstrated a 10.5% increase in patients switched to the same style device by the end of June 23, 4.5% below the project aim. Baseline and post interventional data for pMDI reliever usage demonstrated an 27.4% reduction to June 23. This work continues with ongoing bimonthly audit.

HCA Healthcare
Optimising waste segregation to reduce carbon footprint

At our hospital, a significant shift occurred in waste management protocols in response to the COVID-19 pandemic. Initially, all waste was treated as infectious due to the highly contagious nature of the virus. This approach mandated high-level incineration, consuming substantial energy resources. Post-pandemic, with reduced infection rates, a more sustainable waste management system was implemented. The new four-tier waste classification system introduced at the hospital includes infectious, non-infectious, recycle, and domestic waste categories. This transition aimed to optimize waste treatment processes, reduce energy consumption, and align with environmental sustainability goals. However, implementing this system in a small hospital posed unique challenges, particularly in waste segregation. Segregating waste at its source became a crucial aspect of the new system, demanding increased awareness and compliance from staff. The logistics of managing diverse waste streams in a limited space required meticulous planning and efficient infrastructure. Adequate training and education programs were initiated to ensure that hospital staff understood and adhered to the new waste disposal guidelines. Despite the challenges, the transition to a four-tier waste management system reflected the hospital's commitment to environmental responsibility. The incorporation of recycling and domestic waste categories emphasized a holistic approach to waste reduction. We provided training to the clinical staff, porters, and housekeeping staff. We created posters and because are waste holds are very small and we couldn't add another bin we were creative and found a company that provided small reusables bins for infectious patients. This smalls bins are used for the occasional patient consider infectious and it doesn't cause any logistic issues.

Manchester University NHS Foundation Trust
Advocating for change – clinical leadership for sustainability

The issue was a lack of representation from clinical staff within the work of the sustainability team at Manchester Foundation Trust towards achieving NHS net zero targets. The Trust’s Green Plan – Delivering Net Zero Carbon at MFT did not mention nurses or midwives and the contribution they could make towards a more sustainable healthcare system. I reached out to the sustainability team at my Trust in August 2022 to express my interest in working in a clinical sustainability role and was lucky enough to be seconded from my midwifery position for 15 months. Following the results of increased staff engagement directly related to my work, my position was made more permanent in November 2023. I now have a dual role: Delivery Suite Co-ordinator and Senior Sustainability Officer. There are many challenges in engaging NHS staff and the public in the net zero agenda. It has been evidenced that a gap in knowledge exists in relation to health care’s contribution to climate change amongst staff and the public. My initiative was to engage, educate and empower clinical teams, particularly nurses and midwives to understand that the climate emergency is a health emergency and to seek opportunities for discussing this issue with patients. I also wanted to provide authentic support to my colleagues to improve sustainability within their departments. Mitigating against the impact of climate change offers opportunities to improve patient outcomes and we need practical action to rise to this challenge on every level. One of the outcomes was to facilitate the first ever sustainability conference at my Trust to ensure sustainability no longer a niche subject. My plan is to continue in this role, acting as an authentic leader and to pave the way for other nurses and midwives to develop leadership skills towards a more sustainable healthcare system.

Midlands Partnership Foundation University Trust
The Green Wellbeing Project

The Covid-19 pandemic brought unprecedented challenges and vulnerabilities to healthcare systems, particularly in care homes and support facilities. In response, the Green Wellbeing Project — aimed to redesign care service delivery in these settings and prioritise mental health and wellbeing . The project integrated the National Health Service (NHS) ‘delivering a net zero’ plan (NHS England, 2020) into care delivery. Affording residents the opportunity to follow their hobbies and interests, with the added benefit of improving mood and reduced rates of hospital admissions and GP visits through early identification of deterioration. The project leads completed a successful application to the Queen’s Nursing Institute (QNI), Elsie Wagg annual scholarship programme, which supports nurses to deliver gardening projects in conjunction with the National Garden Scheme (NGS). A £5000 funding grant was used to help initiate the project and it was agreed with the project leads and care home managers that the project would be delivered through a six-week pilot. Through these sessions, healthcare professionals delivering the project holistically assessed the residents, observing any barriers to optimising their health and wellbeing. Continuity in care delivery was provided to enable early identification of deterioration in residents and a non-pharmacological approach to therapy-based care interventions was used. This included residents taking part in several activities, exploring the outdoor space and accessing gardens. Time restraints and availability of clinicians posed a challenge but the involvement of students and VCSE organisations supported this. The project outcomes showed enhancements in quality of care for residents and reduced healthcare costs by taking a more preventative approach to care and providing timely interventions and early assessment of needs. This contributes to a more sustainable future. The project identified that continuity of care delivered by the same health professional is a major factor for effective and efficient healthcare.

NHS Blood and Transplant
Training for specialist nurses in deceased organ and tissue donation across the UK

Nurses in the NHS Blood and Transplant Organ and Tissue Donation Directorate work across 4 UK nations and other territories. Our nurses live and work across these nations and work within NHS Hospital Trusts on an honorary contract basis. Our challenge following the pandemic, (when our training was undertaken virtually), was to manage expectations and the appetite to revert to in person training. Whilst a challenge, this also proffered an opportunity to assess how we engage and train our nurses, share practice and continue to reduce our carbon footprint to meet the operational needs of our service. Ongoing sustainable training of our specialist nurses is essential to enable and optimise the facilitation of deceased organ and tissue donation. Our nursing colleagues undertake the donation assessment, approach families and loved ones to explore decisions around organ and tissue donation, complete the consent and authorisation (Scotland) processes. Then characterise (assess) the donor and manage and optimise donors in the hours prior to organ retrieval in the operating theatre. Our aim was to combine the benefits of on-line and in-person training across both organ and tissue donation specialities. The operational specialist nursing teams are required to provide a 24/7 – 365 on call presence across the UK in order to save lives through the gift of organ donation for those who die in the appropriate circumstances. Managing this on call service while providing the opportunity for learning and development has proved a challenge in our unique organisation; historically training required large distance travel and was arranged on a national basis. The transplant waiting list in the UK has over 7000 people actively awaiting a life-saving organ and over 6000 people awaiting a cornea transplant (NHSBT, 2024), our nurses work as dual advocates for both the donor, their family and those awaiting a transplant.

Royal Surrey NHS Foundation Trust
Self-removal of catheters at home following a radical prostatectomy for treatment of prostate cancer

Royal Surrey NHS Foundation trust is a high volume centre for robotic assisted radical prostatectomy for treatment of prostate cancer. Following the surgery every patient is being discharged with a either a urethral or suprapubic catheter. Clinic-based catheter removal requires the patient to make an appointment with a doctor or nurse, visit the hospital, and have scans to assess urinary retention—all time and resource-consuming processes as well as proving to be costly for the patient. With the imitative of self-removal of catheter at home we are reducing our carbon footprint, reduce the costs of running nurse-led clinics and patients do not require travel to the hospital and pay for fuel, a parking or train ticket ticket. We have introduced the self-removal of catheter at home as part of a Clinical Champions improvement project in collaboration with Prostate Cancer UK (initiated by Mr Wissam Abou Chedid) and it remained a nurse-led service since the beginning. One of the challenges was patient engagement and apprehension of removing a catheter at home. We managed to overcome this by providing teaching to the patients prior to discharge as well as written instructions and access to a demonstration video. To date 656 men have successfully removed their urethral catheter at home and 39 successfully removed their suprapubic catheter at home without any immediate complications. We are working closely with multiple London trusts who have successfully introduced our concept of self-removal of catheters in their hospitals and are aiming to provide support and teaching for any other trust who might be interested.

University Hospital Southampton NHS Foundation Trust
Pie and Porridge Project

The Pie and Porridge Project sought to address the food waste associated with catering in a busy, tertiary referral hospital in England. Intensive global food production causes soil, water and air pollution, all of which negatively impact on our health and future ability to produce sufficient nutritious food. Reducing food waste meets the triple bottom line of being better for the environment (due to decreased perceived need for intensive farming and reduced packaging), better for the patient (due to reduced pollution associated with food production) and better for hospital finances (due to reduced food requirements and reduced waste disposal). The aims of the project were to understand the ward level drivers of food waste, quantify ward level food waste, develop strategies to reduce food waste and develop a recycling stream for food packaging. This was accomplished by implementation of ‘Weighing week’ in which both patient food waste and trolley food waste were quantified across 10 adult wards across a variety of specialisms. Qualitative data on the reasons for food waste at ward level was collected using informal interviews with Ward Hosts and patient feedback. Ward level food packaging waste and patient food choices were quantified using data on patient menu choices. The challenges were to bring together hospital and catering contractor staff, from ward level to senior management; getting food sustainability onto the agenda of a busy hospital; and long-term commitment for change to current practice. The changes that have been implemented include milk bottle recycling, better fruit supply, changing the menu to increase the number and visibility of vegetarian and plant-based options, reduction of beef options, and (our favourite!) the introduction of mini meals. Future plans include discussions about foil recycling with the major supplier, targeting pudding waste, and looking at food waste disposal.

University Hospitals Sussex NHS Foundation Trust
Patient First, Planet First – Green Plan 2021

Within the public sector, the NHS is the largest emitter of CO2, making up 4% of the UK's carbon footprint. And with 9.5 billion miles of all road travel in England associated with the NHS business, plus huge amount of waste produced, our environmental impacts go far and wide. Sussex Orthopaedic Treatment Centre (SOTC) joined the green study that cut carbon footprint, reduced costs and saving time for more than 1000 patients. SOTC is now set to increase its use of more sustainable, digital resources by introducing a new electronic notes system, to further reduce the use of paper and better manage clinical information. We are reducing and eliminating the use of plastic packaging through the use of reusable gowns, drapes and water soluble laundry bags. Traditionally, using single-use surgical instruments are known to have a high carbon footprint. In SOTC, we use reusable surgical instruments which can be sterilised on-site, and are better quality instruments, with lesser carbon footprint. Furthermore, the Trust has invested £5 million for a full upgrade of our in-house sterilisation and laundry services to maximise this opportunity.

University of the West of England
Sustainable global public health module in Bsc (hons) nursing programme

The climate crisis is a massive public health challenge with healthcare being both a vital part of the solution and a driver of emissions. There is a lack of evidence and also awareness of the impact of climate change upon health among the nursing profession and this module aims to educate nurses to meet the needs of the future population. This is particularly important given that 2023 saw average temperature exceed 1.5 degrees above pre-industrial levels. At UWE, we have designed a core module that addresses the impact climate change is and will increasingly have upon health and consider the actions that are required to adapt practices to meet these needs. This puts the patient and service user front and centre of the teaching, considering what is needed for those left vulnerable to the changing climate and ultimately invests the student in mitigating practices which are required by the Greener NHS. Uniquely, we consider things across the local, regional, national and international domains, ensuring that students are prepared for the social and climate justice goals of the future.