Nursing students' and educators' perspectives on sustainability and climate change: An integrative review

Aim: To identify and synthesize research on the awareness, attitudes and action re - lated to sustainability and climate change from the perspective of nursing students and educators globally. Design: Integrative review. Methods: The review was guided by Whittemore and Knafl. Included studies were ap - praised using the Mixed Methods Appraisal Tool. A deductive content analysis based on Elo and Kyngäs' methodology was employed. Data Sources: CINAHL, MEDLINE, EMBASE, Web of Science, British Education Index, GreenFILE and Scopus were searched up to the 8th November 2022. Results: Thirty-two studies were included in the review. Two studies included nursing educators in their samples, the rest focused solely on students. Findings suggest that whilst some students were aware of sustainability issues and felt that nurses have a responsibility to mitigate climate change, others showed limited awareness and be - lieved that nurses have more important priorities. A global interest was seen among students for increased curricular content related to sustainability and climate change. Waste management and education of others were suggested actions students can take; however, barriers included lack of confidence and limited power. Conclusion: There is a need for sustainability education within nursing


| INTRODUC TI ON
Recent years have seen increasingly frequent and severe impacts of climate change on the ecosystem and human health globally, representing a climate crisis threatening current and future generations (Romanello et al., 2022).Risks to health include air pollution, forced migration and changing patterns of infectious disease, compromising physical health and mental wellbeing; effects that are more likely to impact on vulnerable populations (Watts et al., 2018), thus exacerbating health inequalities.Such health inequalities are compounded by the fact that those more affected by adverse health and wellbeing outcomes-such as lower socioeconomic groups-are the same people who are least likely to contribute to climate change, thus reinforcing the injustice (Agyeman et al., 2002).In their work to promote health and wellbeing for populations, nurses are at the forefront of the climate justice agenda (Evans-Agnew et al., 2023).This is particularly relevant to public health nurses, who have an established understanding of the importance of the environment in health outcomes, as well as nurses working in interdisciplinary collaborations wherein complex interventions need to happen at systems levels (Polivka & Chaudry, 2018).Yet nursing is part of a healthcare system that contributes to the climate crisis by releasing greenhouse gases, using toxic material and producing significant amounts of waste (Griggs et al., 2017;Richardson et al., 2016).Therefore, nurses have a moral responsibility to take steps to mitigate such negative impacts (Shaw et al., 2021).
Sustainable development has been defined as "development that meets the needs of the present without compromising the ability of future generations to meet their own needs" (Brundtland, 1987, p. 41).The first global environmental conference, held in Stockholm in 1972, pioneered the idea that environmental issues caused by human activity are a major global concern that needs to be acted upon urgently (Handl, 2012).Twenty years later, in 1992, the second global environmental conference was held in Rio de Janeiro and resulted in the Rio Declaration which built on the work in Stockholm but with a stronger focus on sustainable development.Subsequently, the United Nations member states adopted the eight Millennium Development Goals in 2000, targeted to reduce extreme poverty by 2015.However, in 2015 the goals were not met; therefore, 17 new, more ambitious goals were agreed upon by the United Nations' member states: the Sustainable Development Goals (United Nations, 2015).These are 17 interconnected goals which aim to end poverty, reduce inequalities, build peaceful societies, protect human rights, promote gender equality and protect the planet and its natural resources (United Nations, 2023).Whilst Goal 3 (Good health and wellbeing for all) is clearly linked to nursing, all 17 goals are relevant to the nursing profession since acting on any of them (for example, ending poverty or mitigating climate change) contributes towards health and wellbeing (Lilienfeld et al., 2018).Anåker and Elf (2014) define sustainability in nursing as being based on ecological, global and holistic knowledge, and considering the environment at all levels to maintain a healthy environment for present and future generations.However, concepts such as sustainability and climate change are still relatively new to the nursing profession.Literature reviews exploring nursing research related to climate change, the United Nations Sustainable Development Goals, environmental health and environmental justice provide a useful starting point for understanding these concepts in nursing (LeClair et al., 2021;Lilienfeld et al., 2018;Polivka & Chaudry, 2018).However, no literature review has been found that explores the perception of such concepts from the perspective of nursing students and educators.Commitment (Health Care Without Harm, 2022).Yet this does not translate into mandatory requirements of what to include in nursing education, which is set out nationally by nursing professional bodies.A systematic review on environmental competencies required for nursing students, and pedagogical approaches that are useful when embedding sustainability in nursing education, highlights the urgency for nurses to have the knowledge, skills and competencies to respond to a rapidly changing environment where resources are finite (Lopez-Medina et al., 2019).A starting point for developing adequate education is the experiences of educators and students (Shaw et al., 2021;Tun et al., 2020); thus there is a need to explore the perspectives of nursing students and educators on sustainability and climate change.Ample research has been undertaken in this area, but to date, there is a lack of a systematic review of these studies.

| THE RE VIE W
This systematic integrative review explores sustainability and climate change from the perspective of nursing students and educators.To structure the review, Lozano's (2008) theoretical framework was used (Figure 1).Lozano (2008) argues that there needs to be congruence between three components for an individual to internalize sustainability: informational attitudes (the awareness, beliefs and information that the person has about something), emotional attitudes (how they feel about something) and behavioural attitudes (the actions that they take).In this integrative review, these components are identified as awareness, attitudes and action (Figure 1), and applied to nursing practice as well as private life.

| AIM
This review aims to identify and synthesize research on the awareness, attitudes and action related to sustainability and climate change from the perspective of nursing students and educators.

| Design
A systematic integrative review, which included studies using various research designs such as qualitative, quantitative and mixed methods studies, was employed (Whittemore & Knafl, 2005).
The review followed the five stages outlined by Whittemore and Knafl (2005): problem identification, literature search, data evaluation, data analysis and presentation, and is reported according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) statement (Page et al., 2021, see Table S1).

| Search methods
The SPIDER (Sample, Phenomenon of Interest, Design, Evaluation and Research type) framework (Cooke et al., 2012) guided the selection of search terms for an effective literature search.Search terms were agreed upon by all authors and included subject headings and free-text keywords (Table 1).No year or language limitations were applied to avoid excluding relevant studies.
Seven databases (CINAHL, MEDLINE, EMBASE, Web of Science, British Education Index, GreenFILE and Scopus) were selected with the help of an Information Specialist to include a broad range of literature on healthcare, social sciences, higher education and climate change.The initial search was conducted between 12th and 17th April 2021, and an updated search was undertaken on the 8th November 2022.In addition, relevant studies were identified by screening reference lists of included studies and professional networks.

| Inclusion and exclusion criteria
The SPIDER framework was used to support the inclusion and exclusion of studies (Cooke et al., 2012) (Table 2).

| Search outcome
The PRISMA flowchart (Figure 2) outlines the database search, which initially yielded 1104 papers.After removing duplicates   Page et al., 2021).uncertainties were discussed with the research team.This process was used to ensure interrater reliability, thus establishing an unbiased and consistent data collection strategy (Polit & Beck, 2018).

Records
As a result of this screening process, 63 papers were chosen for inclusion.
Out of the 63 papers selected for inclusion, three could not be found despite extensive efforts, leaving a total of 60 articles screened at the full-text phase.Ten percent of the retrieved papers were screened independently by three authors to ensure interrater reliability.Following 100% agreement, the rest of the articles were split among the same authors, resulting in 32 articles being included in the final systematic integrative review.

| Quality appraisal
Included studies were appraised using the Mixed Methods Appraisal Tool (MMAT) (Hong et al., 2018), which allows for appraisal of studies of different research types.Initially, four articles were independently appraised by three members of the team, who subsequently met to discuss and compare views on the quality of studies.
Following this initial stage, the remainder of the studies were appraised by two team members, again with regular meetings to discuss and resolve uncertainties.The result of the critical appraisal is presented in Table S2.All studies met the screening criteria in the MMAT and were included.

| Data abstraction
Based on Cochrane's framework, a data extraction sheet was developed collaboratively within the research team (Cochrane Collaboration, 2013).
Data about the awareness, attitudes and/or action related to sustainability and climate change were extracted from each included study, together with relevant study characteristics.This work was shared by three members of the team.A summary of this is provided in Table S3.

| Synthesis
A deductive content analysis based on Elo and Kyngäs' (2008) methodology was used for a narrative synthesis of the results.This starts with a preparation phase, wherein units of analysis are selected from the data and subsequently organized into a categorization matrix (Elo & Kyngäs, 2008).To develop this matrix, the adapted framework by Lozano (2008) was used, and data were coded according to the main categories Awareness, Attitudes or Action.The units of analysis were grouped under sub-categories within these main categories.Elo and Kyngäs (2008) explain that the sub-categories describe the content of the main categories, and that the credibility of research findings is established through the link between the results and the data, which is transparent through the units of analysis within each sub-category.

| RE SULTS
In this study, data related to the main category of Awareness often included definitions of concepts (e.g.sustainability) or beliefs about climate change and its impact on human health.Data related to Attitudes included feelings about sustainability and climate change in the context of nursing education; for example, whether these concepts are seen as important or should be included in nursing education.Data related to the main category of Action considered what actions students can take to be more sustainable, as well as the barriers and requirements needed to enable sustainable practices.
The narrative synthesis presented here discusses study characteristics and results related to the sub-categories and the three main categories: Awareness, Attitudes and Action (Table 3).

| Study characteristics
A total of 32 articles were included in this review: 20 were quantita- The geographic distribution and characteristics of participants are outlined in Table 4. Conversely, some studies found good knowledge of climate change's health impacts among nursing students in Ethiopia and China (Nigatu et al., 2014;Yang et al., 2018).Turkish studies found good awareness and concern about the effects of climate change on health, but nursing students felt inadequately equipped through their education to prevent or manage it (Ergin et al., 2021;Sayan & Kaya, 2016;Tuna et al., 2022).

| Awareness
Findings from focus groups in the study by Ergin et al. (2021) suggest that nursing students were concerned about the future effect of global warming on health; for example, they expressed a worry about hunger, drought and respiratory system disorders.One student said: "I think we will not be able to breathe in air without a mask as a result of the climate change brought about TA B L E 3 Summary of main categories, sub-categories and meaning units according to Lozano's framework.by global warming ….I think there will be wars for water."(Ergin et al., 2021, p. 4) Swedish and US students were aware of negative consequences of climate change, whilst the healthcare sector's contribution was not widely recognized (Anåker et al., 2021;Ryan et al., 2020).Some students recognized human activity as the main cause of climate change (Yang et al., 2018), whilst others did not (Felicilda-Reynaldo et al., 2018;Lee et al., 2019).

| Sustainability is an ethical imperative
Studies suggest that the definition of sustainability varies.Turkish students defined sustainability as encompassing environmental, economic and social aspects (Gürgen Şimşek & Erkin, 2022), whereas Swedish students viewed sustainability as a human right for a good life on equal terms, as well as a shared societal responsibility to look after the planet so that future generations will not be affected negatively (Anåker et al., 2021).The latter perspective is reflected by Brazilian nursing educators who opined that society is responsible for preserving the ecosystem and rebuilding moral values, such as appreciation of others, solidarity, sharing and interdependence, to overcome the environmental crisis (Peres et al., 2015).Similarly, Örs (2022) found that Turkish students had a pro-ecological worldview whereby humanity must live in harmony with nature to survive.
A different viewpoint, based on anthropocentrism-the belief that nature exists for human use-was seen in students in the Middle East.Cruz, Alshammari, et al. (2018) found that the vast majority (98.9%) of Saudi nursing students thought that humans have the right to modify the natural environment to suit their needs, and more than half of the participating students from four Arab countries shared this view (Felicilda-Reynaldo et al., 2018).

| Consideration of sustainability and climate change being within the scope of nursing
Twelve studies suggested that students thought that sustainability and climate change are important issues for nursing (Álvarez-García, Álvarez-Nieto, Kelsey, et al., 2019;Álvarez-Nieto et al., 2021;Chen & Price, 2020;Cruz, Alshammari, et al., 2018;Cruz, Felicilda-Reynaldo, et al., 2018;Linton et al., 2020;Richardson et al., 2015Richardson et al., , 2016Richardson et al., , 2017Richardson et al., , 2021;;Sayan & Kaya, 2016).Álvarez-Nieto et al. (2022) found this view to be stronger in later years of studies.Congruently, US students expressed an interest in the carbon footprint of resources used in practice, with a view that nurses have a responsibility to prevent pollution and conserve resources (Ryan et al., 2020).
The positive attitudes seen in these quantitative studies were reflected in qualitative research, wherein students suggested that nurses' work can contribute to a sustainable healthcare system through research, leadership and education (Anåker et al., 2021;Ergin et al., 2021).Congruently, Hanley and Jakubec (2019) found that Canadian students and educators advocated for planetary health promotion.Conversely, some studies found that students felt that sustainability and climate change were not a nurse's responsibility (Felicilda-Reynaldo et al., 2018;Nigatu et al., 2014;Ryan et al., 2020).Students voiced that the main priority for them in placement is learning, and the main objective for nurses is to work with health and ultimately save lives (Anåker et al., 2021;Aronsson et al., 2020).

| Sustainability and climate change should be included in nursing education
All nursing students and educators who were asked whether content about sustainability and climate change should be included in nursing  et al., 2018;Cruz, Felicilda-Reynaldo, et al., 2018;Linton et al., 2020;Richardson et al., 2015Richardson et al., , 2016Richardson et al., , 2017Richardson et al., , 2019Richardson et al., , 2021)).Ideas of content included pollution, climate change and the effects of climate change on health (Ergin et al., 2021;Ryan et al., 2020;Tuna et al., 2022).
Students and educators expressed a need for more frequent and in-depth sustainability education, embedded throughout the nursing curriculum so that the relevance to nursing would be explicit (Anåker et al., 2021;Chen & Price, 2020;Hanley & Jakubec, 2019).Peres et al. (2015) found that Brazilian nursing educators viewed environmental education as an opportunity to rethink nursing education, but felt that there was not enough time or opportunity to reflect and discuss this approach with other educators.

| Students can act sustainably to mitigate climate change
Few studies focused on sustainable behaviour from the perspective of nursing students.Swedish students were conscious about waste management in clinical practice, such as choosing the right bin for each item; however, this might depend on a supportive environment (Anåker et al., 2021;Aronsson, Anaker, et al., 2022).Other ways of incorporating sustainability into clinical practice included recycling and reusing products, and educating colleagues by raising awareness of environmental issues and sustainability principles (Aronsson, Anaker, et al., 2022;Hanley & Jakubec, 2019).Some studies explored what nursing students did to mitigate climate change in their personal lives, and found a range of activities such as forestation, limiting the use of cars, reducing unnecessary water and energy use, recycling, using natural resources in a preventive manner and the use of environmentally-friendly products and public transportation (Ergin et al., 2021;Lee et al., 2019;Örs, 2022).
Research suggested that sustainability education sessions are effective in making nursing students practice more sustainably (Linton et al., 2020;Richardson et al., 2015Richardson et al., , 2017)).Richardson et al. (2016) found that students from different countries had varying levels of application of sustainability principles in practice, with Spanish students scoring the highest.Furthermore, Richardson et al. (2019) found that students in year 3 were more able to practice sustainable than students in year 2, and felt more confident to challenge unsustainable practice during clinical placement.

| There are barriers to sustainable praxis
Students in the UK, Sweden and US expressed that they felt unable to challenge unsustainable practice when in clinical placement (Aronsson et al., 2020;Aronsson, Anaker, et al., 2022;Linton et al., 2020).Reasons for this included a lack of confidence, whereby students felt that they were at the bottom of an informal hierarchy and should not question or challenge those higher up, as well as a general resistance to change in practice, or lacking time or facilities to practice sustainably (Aronsson et al., 2020;Aronsson, Anaker, et al., 2022;Ryan et al., 2020).

| DISCUSS ION
This integrative review explored nursing students' and educators' awareness of and attitudes towards sustainability and climate change, as well as any action they engage in to be more sustainable.Given that there was no time limit set on the database search, it is worth noting that the first paper found reporting on this topic is from 2014 (Nigatu et al., 2014), and the vast majority (25 out of This highlights the opportunity for international collaborations within the field. Most papers focused on students, with only two papers including nursing educators in their samples (Hanley & Jakubec, 2019;Peres et al., 2015).Educators' perspectives are of interest as the integration of sustainability into nursing starts with an educator who sees the importance and has some knowledge of the topic (Parry & Metzger, 2023).The limited findings from this integrative review indicate that nursing educators did recognize the importance of these concepts in nursing, but faced barriers such as lack of time and opportunity to discuss and reflect together with other educators.
However, there is a clear gap in the literature pertaining to nursing educators' perspectives.Actions that nursing students can take to be more sustainable and mitigate climate change were highlighted in a few studies, with examples including waste management and education of others in clinical practice, as well as being mindful of environmentally friendly behaviour in private life.However, students identified barriers to this, such as lack of confidence.This relates to Bandura's theory of self-efficacy (1997), which stipulates that a person's belief in their ability to succeed affects whether they do.Kollmuss and Agyeman (2002) note that a common barrier to pro-environmental behaviour is having an external locus of control, wherein individuals feel that only powerful others can make change happen -their actions are insignificant.Power (2016) argues that an important aspect of nursing education is facilitating the development of change agency within students.This has the potential to enable students in becoming change leaders and practice innovators in environmentally conscious and sustainable healthcare (Nichols et al., 2022).However, it is important to acknowledge that another barrier to implementing practice changes was related to organizational structure, wherein students perceived themselves at the bottom of an informal hierarchy.Therefore, training focused solely on the individual's self-efficacy without addressing structural and organizational factors is not only insufficient but might perpetuate a blame culture wherein the inability to cope is seen as a personal failure (Taylor, 2019).
This highlights the importance of top-down leadership to address factors in the clinical environment that undermine nurse resilience (Virkstis et al., 2018).

| Limitations
Despite careful consideration of multiple search terms, discussed and agreed by all authors to attempt to capture the breadth of research available, it is likely that some relevant search terms were missed.For example, we did not include search terms related to climate justice, climate adaptation or mitigation, environmental health, or environmental degradation or crisis.However, we feel reasonably confident that our search was comprehensive due to the breadth of search terms used and the initial high number of retrieved articles (n = 1104).
Whilst including research from different designs is a strength of integrative reviews (Whittemore & Knafl, 2005), in this review it resulted in a high degree of heterogeneity in data, making it complex to analyse.Therefore, a deductive content analysis was employed, as it was helpful in structuring the analysis and ensuring that findings from all studies were synthesized within the categorization matrix.
However, using a deductive approach poses a risk of missing information that does not fit within the framework (Elo & Kyngäs, 2008).
Nevertheless, the framework used (Lozano, 2008)   • Most read nursing journal in the world: over 3 million articles downloaded online per year and accessible in over 10,000 libraries worldwide (including over 6,000 in developing countries with free or low cost access).
• Positive publishing experience: rapid double-blind peer review with constructive feedback.
• Rapid online publication in five weeks: average time from final manuscript arriving in production to online publication.
• Online Open: the option to pay to make your article freely and openly accessible to non-subscribers upon publication on Wiley Online Library, as well as the option to deposit the article in your own or your funding agency's preferred archive (e.g.PubMed).
The present paper thus contributes to existing knowledge by specifically focusing on nursing education globally.Education has an essential role in achieving the Sustainable Development Goals and mitigating climate change(Shaw et al., 2021).Since nurses comprise the largest segment of the global healthcare workforce (The World Health Organization, 2022), nursing education must prepare students with the knowledge and skills needed to practice sustainably and address the health and wellbeing consequences of climate change (International Council of Nurses, 2018).This requires a shift from the traditional aim of nursing education to develop clinical skills and competencies towards a curriculum that includes sustainable development issues (Goodman & East, 2014).In some countries, for example in Sweden and the United Kingdom (UK), governmental requirements mandate higher education institutions to promote sustainable development (The Quality Assurance Agency for Higher Education & Advance HE, 2021; The Swedish Higher Education Act, 1992), thus aligning with an overarching commitment to integrate sustainability education in all curricula within higher education (UNESCO, 2017).Examples of where content about climate change and sustainability is embedded in nursing programs include the NurSus project (nursus.eu)and the Nursing School

13652648, 0 ,
Downloaded from https://onlinelibrary.wiley.com/doi/10.1111/jan.15950by Plymouth University, Wiley Online Library on [28/11/2023].See the Terms and Conditions (https://onlinelibrary.wiley.com/terms-and-conditions)on Wiley Online Library for rules of use; OA articles are governed by the applicable Creative Commons License tive descriptive based on surveys, four were quantitative comparative based on either pretest/posttest design or case control design, three were mixed methods and five were qualitative.Most of the papers reported research on nursing students (n = 30), with only two studies including nursing educators in their sample.The articles were published between 2014 and 2022 in English from various countries: Australia, Brazil, Canada, China, Egypt, Ethiopia, Germany, Iraq, Palestinian Territory, Saudi Arabia, Spain, Sweden, Switzerland, Taiwan, Turkey, the United Kingdom (UK) and the United States of America (US).The participants in the included studies were nursing students from a variety of years of study, and sometimes a variety of fields of study (e.g.adult health, child health and mental health).
5.2.1 | The state of the planet is affecting human health and wellbeingStudies showed mixed results regarding nursing students' awareness of the consequences of climate change to human health.Felicilda-Reynaldo et al. (2018) found that only half of their participants in four Arab countries thought climate change was something negative, whilst Moselhy et al. (2022) found a lack of awareness about the concept of carbon footprint in two thirds of their Egypt student participants.Similar findings by Örs (2022) suggest that the vast majority of students at a Turkish university (92.8%) did not 13652648, 0, Downloaded from https://onlinelibrary.wiley.com/doi/10.1111/jan.15950by Plymouth University, Wiley Online Library on [28/11/2023].See the Terms and Conditions (https://onlinelibrary.wiley.com/terms-and-conditions)on Wiley Online Library for rules of use; OA articles are governed by the applicable Creative Commons License have adequate environmental knowledge when assessed based on how many right answers they gave to questions on environmental matters.Some studies focused on environmental risk factors (e.g.ultraviolet radiation and air pollutants) to children's health and found insufficient knowledge among nursing students (Álvarez-García et al., 2018García et al., , 2020;; Álvarez-García, Álvarez-Nieto, Sanz-  Martos, et al., 2019).
the planet is affecting human health and wellbeing Climate change has negative consequences to human health There are environmental risk factors to children's health Climate change can exacerbate socioeconomic inequalities Human activity contribute towards climate change Sustainability education can improve awareness Sustainability is an ethical imperative Sustainability encompasses environmental, economic and social aspects Sustainability is a human right Sustainability is a shared societal responsibility Anthropocentrism overshadows sustainability as an ethical imperative Attitudes Consideration of sustainability and climate change being within the scope of nursing Sustainability and climate change are important issues for nursing Nurses have a responsibility to prevent pollution and conserve resources Nurses' work can contribute to a sustainable healthcare system Nurses can inspire others to work towards sustainability Nurses are researchers, leaders and educators in preventing climate change Climate change and sustainability are not part of nurses' responsibility Sustainability and climate change should be included in nursing education Content about sustainability and climate change should be included in nursing education Student nurses need to learn about pollution, climate change and the effects of climate change on health Sustainability education should be embedded throughout modules in the nursing curriculum Environmental education provides an opportunity to rethink nursing education Action Students can act sustainably to mitigate climate change Healthcare services need to learn to sort waste A supportive work environment is needed to prioritize sustainability in practice It is challenging for students to incorporate sustainability in practice Students can model sustainable behaviour to raise awareness Students can educate others about sustainability principles Individuals have a personal accountability in using natural resources in a preventative manner and reduce their carbon footprint Sustainability education session are effective in making students practice more sustainable There are barriers to sustainable praxis Lack of confidence Students are at the bottom of an informal hierarchy There is a resistance to change in practice There is a lack of time or facilities to enable sustainable practice 13652648, 0, Downloaded from https://onlinelibrary.wiley.com/doi/10.1111/jan.15950by Plymouth University, Wiley Online Library on [28/11/2023].See the Terms and Conditions (https://onlinelibrary.wiley.com/terms-and-conditions)on Wiley Online Library for rules of use; OA articles are governed by the applicable Creative Commons License TA B L E 4 Geographic distribution and characteristics of participants.in one university in their first year (n = 113), third year (n = 102) and fourth year (n = 83) Álvarez-García, Álvarez-Nieto, Kelsey, et al. (2019) Spain and the UK 267 nursing students in one Spanish university (n = 110) and one UK university (n = 157) Spain: Second year (n = 106), third year (n = 4) UK: First year (n = 43), Second year (n = 63), third year (n = 51) Álvarez-García, Álvarez-Nieto, Sanz-Martos, et al. (2019) Spain 2462 nursing students from eight different universities in their first year (n = 745), second year (n = 645), third year (n = 611) and fourth year (n = 429) Álvarez-García et al. (2020) UK 232 child health nursing students in one university in their first year (n = 75), second year (n = 92) and third year (n = 65) Álvarez-Nieto et al. (2021) UK, Spain, Germany and Australia 846 nursing students in their first year, in two different UK universities (n = 421), two different Spanish universities (n = 232), one German university (n = 48), one Swedish university (n = 38) and one Australian university (n = 107) Álvarez-Nieto et al. (2022) Spain 96 students in one university.Data was collected at three points: -in their first year, before any sustainability education -in their second year, after sustainability session -in their third year, after two sustainability sessions Anåker et al. (2021) Sweden 12 nursing students at one university Aronsson et al. (2020) UK 310 students in their second year (n = 200) and third year (n = 110) Aronsson, Anaker, et al. (2022) UK and Sweden 147 nursing students in their third year, in one UK university (n = 121) and one Swedish university (n = 26) Chen and Price (2020) China and UK 101 nursing students in their first year, in one Chinese university (n = 69) and one UK university (n = 32) Cruz, Alshammari, et al. (2018) Saudi Arabia 280 nursing students in their second year (33.2%), third year (32.9%) and fourth year in their second year (n = 235), third year (n = 415) and fourth year (n = 409), from Egypt (n = 302), Iraq (n = 200), the Palestinian Territories (n = 277) and Saudi Arabia (n = 280) Ergin et al. (2021) Turkey 154 public health nursing students in their senior year at one university Felicilda-Reynaldo et al. (2018) Egypt, Iraq, Palestinian Territories and Saudi Arabia 1059 nursing students in their second year (n = 235), third year (n = 415) and fourth year (n = 409), from Egypt (n = 302), Iraq (n = 200), the Palestinian Territories (n = 277) and Saudi Arabia (n = 280) Grose and Richardson (2016) UK 292 nursing students in one university Child health nursing students: second year (n = 12) Adult health nursing students: second year (n = 167) and third year (n = 113) Gürgen Şimşek and Erkin (2022) Turkey 199 nursing students in first year (n = 81), second year (n = 64) and third year (n = 54) in one university Hanley and Jakubec (2019) Canada 40 participants: 32 nurses in education and practice from the Canadian provinces of Quebec, Alberta and British Columbia 8 Quebec-based nursing students Lee et al. (2019) Taiwan 1147 nursing students in their third year, across 13 different nursing colleges Linton et al. (2020) US 89 final year students in one university Moselhy et al. (2022) Egypt 279 nursing students in their first year (n = 80), second year (n = 75), third year (n = 63) and fourth year (n = 61) in one university Nigatu et al. (2014) Ethiopia 68 nursing students in general nursing (n = 55) and psychiatric nursing (n = 13) Peres et al. (2015) Brazil 17 nursing educators with more than 1 year's experience in undergraduate nursing education across 5 different nursing institutions Richardson et al. (2015) UK 57 nursing students in one university Child health nursing (n = 29) who participated in a sustainability education session Adult health nursing (n = 28) who did not participate in the session (Continues) 13652648, 0, Downloaded from https://onlinelibrary.wiley.com/doi/10.1111/jan.15950by Plymouth University, Wiley Online Library on [28/11/2023].See the Terms and Conditions (https://onlinelibrary.wiley.com/terms-and-conditions)on Wiley Online Library for rules of use; OA articles are governed by the applicable Creative Commons License in their first year, from UK (n = 450), Spain (n = 124), Switzerland (n = 146) and Germany (n = 196) Richardson et al. (2017) UK 676 adult and child health nursing students in their second year in one university Richardson et al. (2019) UK 145 nursing students in year 1, 2 and 3 in one university Richardson et al. (2021) UK 301 nursing students in one university studying adult heath (n = 172), child health (n = 51), mental health (n = 46) and combined programme of more than one field (n in their first year (n = 38), second year (n = 57), third year (n = 41) and fourth year (n = 12) in one university Yang et al. (2018) China 313 nursing students in their third and final year from five different universities Örs (2022) Turkey 278 nursing students from their first year, second year, third year and fourth year, evenly distributed, in one university TA B L E 4 (Continued) 13652648, 0, Downloaded from https://onlinelibrary.wiley.com/doi/10.1111/jan.15950by Plymouth University, Wiley Online Library on [28/11/2023].See the Terms and Conditions (https://onlinelibrary.wiley.com/terms-and-conditions)on Wiley Online Library for rules of use; OA articles are governed by the applicable Creative Commons License curricula answered positively (Chen & Price, 2020; Cruz, Alshammari, 32 articles) were published after 2017.The year with most publications (six papers) was 2022, even though the database search was completed on the 8th November 2022, thus any studies published after that would not have been included.The increasing number of publications on this topic since 2014 suggests a growing global interest in this area, especially considering the representation of 17 countries across six continents.The country which was most represented in the body of literature was the UK, with other countries making strong contributions, particularly Turkey and Spain.

Findings
about awareness are contradictory, with some studies indicating that nursing students have a good understanding of the health impacts of climate change, whilst others report a need for more awareness, including the healthcare sector's contribution to climate change.The study conducted by Felicilda-Raynaldo et al. (2018) discovered that 16% of students expressed a positive view towards climate change, while 33% were neutral.The researchers suggested that these controversial responses could be attributed to the absence of climate change and sustainability education in the nursing curriculum of the region.This observation is consistent with the findings of this review, which indicate that sustainability education can enhance student awareness and knowledge.However, with the media coverage having grown and become more accurate over time (IPCC, 2022), it is surprising to find opinions to suggest 13652648, 0, Downloaded from https://onlinelibrary.wiley.com/doi/10.1111/jan.15950by Plymouth University, Wiley Online Library on [28/11/2023].See the Terms and Conditions (https://onlinelibrary.wiley.com/terms-and-conditions)on Wiley Online Library for rules of use; OA articles are governed by the applicable Creative Commons License that climate change could be beneficial.Nevertheless, what reaches an individual through news websites and social media is not always scientific evidence but could include ambiguous and unclear information about climate change, or even expressions of climate change denial (Al-Rawi et al., 2021).This reinforces the need for a curriculum that is underpinned by research-based knowledge(Elken & Wollscheid, 2016).
is specific to internalization of sustainability at an individual level, and was chosen based on a familiarity within the research team of the different aspects of nursing students' (in particular) perspectives of sustainability and climate change.No data was found that could not be coded under one of the main categories.The majority of studies in this review were quantitative, and employed a data collection process based on a tool or questionnaire to measure awareness of and/or attitudes towards sustainability and climate change concepts.A range of different tools were utilized within the studies, making it difficult to compare and contrast findings.Again, the deductive content analysis was helpful in overcoming this problem, since data from different studies could be mapped to the different main categories regardless of the tool used.

13652648, 0 ,
Downloaded from https://onlinelibrary.wiley.com/doi/10.1111/jan.15950by Plymouth University, Wiley Online Library on [28/11/2023].See the Terms and Conditions (https://onlinelibrary.wiley.com/terms-and-conditions)on Wiley Online Library for rules of use; OA articles are governed by the applicable Creative Commons LicenseThe Journal of Advanced Nursing (JAN) is an international, peer-reviewed, scientific journal.JAN contributes to the advancement of evidence-based nursing, midwifery and health care by disseminating high quality research and scholarship of contemporary relevance and with potential to advance knowledge for practice, education, management or policy.JAN publishes research reviews, original research reports and methodological and theoretical papers.For further information, please visit JAN on the Wiley Online Library website: www.wileyonlinelibrary.com/journal/jan Reasons to publish your work in JAN: • High-impact forum: the world's most cited nursing journal, with an Impact Factor of 2.561 -ranked 6/123 in the 2019 ISI Journal Citation Reports © (Nursing; Social Science).

TA B L E 1 Search terms. Sample AND phenomenon of interest AND evaluation
Downloaded from https://onlinelibrary.wiley.com/doi/10.1111/jan.15950by Plymouth University, Wiley Online Library on [28/11/2023].See the Terms and Conditions (https://onlinelibrary.wiley.com/terms-and-conditions)on Wiley Online Library for rules of use; OA articles are governed by the applicable Creative Commons License