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Nurse Education Today 31 (2011) 733737

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Nurse Education Today

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The need for a sustainability curriculum in nurse education

Benny Goodman
Faculty of Health, University of Plymouth, Knowledge Spa, Truro TR1 3HD, United Kingdom

a r t i c l e

i n f o

Article history:
Accepted 14 December 2010
Transformative education
Climate change

s u m m a r y
This paper addresses the imperative to address sustainability and climate change in nurse education. This will
be done by outlining the socio-political and policy context and a discussion of a triad of sustainability
climate changehealth. However this is not about introducing new content. The form of education itself has to
change and to address goals other than the transmission of skills and knowledge to prepare graduate nurses
for a role in the NHS. Key concepts and propositions for a sustainability education within nursing will be
outlined. This is offered in the spirit of stimulating argument and debate.
2010 Elsevier Ltd. All rights reserved.

There is a link between sustainability, climate change and health
(Grifths et al., 2009; Goodman and Richardson, 2010 Fig. 1) which
makes it an imperative that we examine notions of sustainability and
climate change in nurse education. This paper will begin by briey
outlining the socio-political and policy context. This will be followed
by a discussion on sustainability education, focusing on the what is
education for question. An answer is to base education on some key
principles such as that of Education for Sustainability (EfS) (Sterling,
2001; CSF, 2010) which focuses on transformative rather than
transmissive education, then we will be considering Selby's (2007)
Propositions followed by 7 key concepts for sustainability education
(SDEP, 2000). To further assist thinking there will be a list of
recommendations for consideration by curriculum planners.

The need: the sustainabilityclimate changehealth link

Climate change is resulting from increasing carbon dioxide (and
CO2 equivalent) emissions as a result of fossil fuel energy use and
consumption (IPCC, 2007) and other human (anthropogenic)
inuences (Pielke, 2010). Despite ideas of progress and technological
advance which undoubtedly have brought health benets (Ben-Ami,
2010), current economics (with its emphasis on GDP growth) and
lifestyles are unsustainable (Schumacher, 1974, Meadows et al., 2005,
Kagawa and Selby, 2010; Assadourian, 2010) and may in the future
challenge health gains enjoyed in the developed nations of the west
(Grifths et al., 2009). Unsustainable economics (and lifestyles based
on current economic structures) also contribute to climate change
(Abdallah et al., 2009; Naess, 2006; Newman, 2006; Sinclair, 2009;
Jackson, 2009; Hamilton, 2010) and to ecological degradation (Orr,
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1994). Thus addressing carbon emissions and climate change cannot

be achieved without addressing sustainable living.
Sustainable living entails ensuring that current patterns of
consumption and lifestyles do not endanger the physical base for
coming generations (WCED, 1987; Goodman, 2008; Sinclair, 2009;
Hamilton, 2010). Climate change threatens health (Grifths et al.,
2009) as it threatens the physical environment, individuals' psychosocial environment and the political environment (Selby, 2007;
Taylor, 2009; Jackson, 2009; Hamilton, 2010), the latter, for example,
if water becomes a scarce commodity and replaces oil as a source for
conict (Nilekani, 2007). Environmental pollutants, radioactivity and
toxins also affect the health of current generations (for example see
Dhara and Dhara, 2002) and future generations by increasing the
likelihood of passing on genetic defects.
Climate change (mitigation and adaptation) and sustainability have
become important for, and accepted by the corporate sector (Bali
Communiqu, 2007; The Economist, 2010; WBCSD, 2010), the UK
Government, e.g. the Climate Change Act 2008 (Department for
Environment Food and Rural Affairs, 2008), the education sector
(UNESCO, 2004; Centre for Sustainable Futures, 2007, the Higher
Education Academy, 2009; HEFCE, 2009; ESDGC, 2010) and UK
Healthcare (Department of Health, 2008a; National Health Service
Sustainable Development Unit, 2008). Costello et al. (2009) argue that
climate change has been identied as the biggest threat to global health
of the 21st century. In this context, health workers have been urged by
the BMA (2008) to take action on climate change. International nursing
organisations have also highlighted this as an imperative (American
Nurses Association, ANA, 2008; International Council of Nurses, 2008;
Canadian Nurses Association, 2009, 2010).
Some of the most pressing health issues facing are international
(World Health Organisation, 2007) and contribute to what has been
called the world problematique (Peccie, 1982), i.e. a set of closely
interconnected problems (political, economic, social, cultural, health,
technical etc.) which cannot be dealt with separately. The policy
context that illustrates the global nature of health, sustainability and


B. Goodman / Nurse Education Today 31 (2011) 733737

Fig. 1. The SustainabilityClimate changehealth triad.

climate change includes the WHO Millennium Development Goals

(WHO, 2000), the Brundtland Report (WCED, 1987), the United
Nations Conference in Environment and Development Rio de Janeiro
(UNCED, 1992), the IPCC report (2007) and the Bonn Declaration
(UNESCO, 2009).
Health (at both individual and population levels) is based upon
both sustainable living and mitigating and adapting to climate change
(McMicheal and Powells, 1999; Department of Health (DH), 2008a;
Department of Health, 2008b; British Medical Association (BMA),
2008; Costello et al., 2009; WHO, 2009). In addition to healthy genes,
human health is based on the fundamentals of physical environment
(clean air, clean water, sufcient food and safe waste disposal) and
also upon good psycho-social-political environments (e.g. low
unemployment and absence of military conict). A sense of aesthetics
and the need to ask what constitutes the good life for human
happiness cannot be ignored when assessing human health and wellbeing (Hamilton, 2004; NEF, 2010). Health is also founded upon on
social and environmental factors (WHO, 2010) that transcend
national boundaries. Therefore, as the determinants for health are
social and often global, one way of addressing the issue is through
developing a sense of global citizenship (Falk, 1994; Lagos, 2002;
Byers, 2005). In addition, because sustainability, climate change and
global health are inextricably linked, health has to have sustainability
at its core (Goodman and Richardson, 2010). Thus there is a
sustainabilityclimate changehealth triad (Fig. 1) which needs to
be addressed more explicitly by nursing education.
What is education for?
Corcoran (2010 p xiii) argues that the prospect of unsustainability,
requires a fundamental change ofeducation which neatly sums up
the argument. Public issues need action to address them but action
will be partly directed and based upon the education preparation and
capabilities of individuals, organisations and societies. However there
is a problem with education as it currently is. We may educate, but for
what purpose? Orr (1992) asks the what then? question and (1994)
contends that education is not the solution, it is the problem. We have
not asked what education is for.
From this perspective, educating nurses to be t for NHS purpose
misses the point if in doing so they stay eco-illiterate (Orr, 1992),
unable to make the links between human health and the environment
or to be able to challenge base assumptions. A curriculum that does
not explicitly address global health and sustainability and instead
focuses too much on biomedical skills acquisition will not equip
graduates for the wider challenges as outlined by, for example,
Costello et al. (2009).
The goal of education ought to be a contested space. However, the
answer to the question what is education for may be taken for
granted and uncontested during curriculum development. For
example, one view is that nursing is an ethical practice orientated
towards health and well-being (NMC, 2008, 2010). However this says

nothing about the political and social context of nursing. Nothing

about what is ethical. However, without notions of sustainability, or
eco-literacy, this may not mean (for example) an international
orientation challenging power structures or challenging current
assumptions about the need for growth, development (Selby, 2007),
or consumerism (Hamilton, 2004) that adversely affects health and
well-being (James, 2007; Hamilton and Denniss, 2005). Without a
sustainability perspective, the goal of nursing may be reduced to
producing technically competent quasi biomedical practitioners but,
given the global health challenges which will of course impact the UK,
this should not be the main driver and should not be taken for
Therefore nursing education must examine its role. Sterling (2001)
sets out what the role of education could/should be:
To replicate society, culture and citizenship a socialisation
To train for employment a vocational function
To develop the individual a liberal humanist function
To encourage a fairer society and a better world a transformative
This framework mirrors earlier work by Scrimshaw (1983) who
argued that curricula are based on competing ideologies:
Instrumentalism stresses utility and relevance to existing social
and economic order, which may itself be static or changing;
education for a purpose, possibly dominant ideology in professional
education based on the need to provide trained professionals for
Liberal Humanism education is a good in and of itself, it does not
have to lead to qualications for skills and careers; inheritance of
cultural knowledge is highly valued.
Reconstructivism education has a role in equipping learners for
social roles, changing power structures, challenging orthodoxy;
education for social change.
Progressivism challenge, shaping and changing personal identity,
concerned with personal growth and development of self as well as
those of communities.
The nursing curriculum should be asked to identify what roles it
seeks to play and then to explain where it facilitates these roles and
what ideology underpins it. Nursing education ought to move further
beyond an instrumentalist ideology and a vocational role. Given the
global crises facing humanity, academia cannot be neutral and
objective researching and charting current trends and processes. For
health, the challenge is to encourage a global outlook within the
context of training an NHS workforce. Despite the policy statements
on climate change and sustainability, the NHS itself will not look
beyond its own borders and the training needs of its own staff and
may not be fully alive to the challenges that require personal and
social transformation.
Whatever sustainable health care may mean in terms of actual
action, the idea takes one out of narrow contexts bounded by local,
regional or national UK boundaries and forces one to think about the
interconnectedness of health and well being of people living outside
of the UK as well. In this task, we would need to move beyond
individualistic bio-medical models of health and illness and draw
upon more ecocentric paradigms (Kleffel, 1996, 2004; Goodman and
Richardson, 2010). We would have to examine current curricula to
identify where we are focused on disease and illness in the individual
and to where we adopt more a social determinants of health model in
addition to our public health approach.
This task has begun in the University of Plymouth Faculty of Health
modules where the embedding of sustainability has begun (Goodman
and Richardson, 2010). Sterling et al. (2008) produced guidance
(sowing seeds) for curriculum planners and developers which may
prove as useful starting points. In addition, the principles

B. Goodman / Nurse Education Today 31 (2011) 733737

underpinning sustainability education (Sterling, 2001; CSF, 2010),

ecological literacy (Orr, 1994) and sustainable literacy (Stibbe, 2009)
would enhance discussion.
For example, Danvers (2009) emphasises ideas such as the
interconnectedness between people and planet and being in the
world whereby people have the ability to think about the self in
interconnection and interdependence with the surrounding world
(p185). Strachan (2009) argues for a systems thinking ability to
recognise and analyse interconnectedness between and within
systems (p84).
This is not just about content, or the product (a graduate nurse t
for NHS purpose). This is also about process the how we go about
delivering the curriculum. We need to think about the experience for
students on a three year programme and the hidden messages the
campus itself and the curriculum sends out. Therefore a curriculum
not only considers content but the world view and processes engaged
in by faculty and students. A consideration of sustainability education
would assist in this process and will be discussed next.
Sustainability education
In order to meet the global challenges set by climate change and
ecological degradation, Sterling (2001) argues that we need a
paradigm shift away from transmissive forms of education towards
transformative forms of education. To achieve sustainable health and
well-being, nurses will have to engage in transformative and deep
(second and third order) learning, otherwise nurses will engage in a
more of the same approach to health that will not address the
enormous international challenges facing us.
Transmitting an education that ensures graduates are better
equipped (rst order learning) to perform clinical skills but fails to
link human health with ecological health is therefore not the point.
Education ought to be a process of transforming individuals, and
organisations, so that base values and assumptions regarding our
relationship with each other and the planet are taken into account and
challenged (second and third order learning). To challenge the taken
for granted, it is helpful to consider the need for learning to move
beyond rst order to second and preferably third order learning
(Sterling, 2001).
First order learning takes place within current educational
boundaries and philosophies. It is adaptive learning, the acquisition
of skills and knowledge to assist in adapting to new roles. It does not
challenge basic values and assumptions. In nursing, for example, rst
order learning would be knowledge around pharmacology and skills
for drug administration in order to ensure students become safe
practitioners. It would not critique the need for certain drugs (or the
activities of drug companies) in the rst place. Sterling's example is
that of learning to manage a household budget, this learning does not
need to examine our own values. It is the acquisition of a technical
rational skill.
Second order learning involves critically reective learning. This is
about examining assumptions that underpin rst order learning. In
the above example, not only would we learn pharmacology and
administration principles but we would also question the need for
drug therapy in the rst place in any given condition. We would
examine assumptions about a biomedical approach to health and
illness that uncritically applies some drug treatments that are
unsustainable in terms of economic cost, resource use and human
health. In addition, second order learning is learning about how we
think and how we come to conclusionsit is learning about learning.
Third order learning is transformative learning and allows us to
change perspectives and paradigms. It is creative, is a shift in
consciousness, and involves a deep awareness of alternative world
views (Sterling, 2001 p15).
It is second order and third order learning that we need to foster in
our students as sustainable living requires a transformative education


to critically understand our base values and assumptions that

underpin action, decisions and behaviours.
The challenges posed by the world problematique and global
warming has led to some (radical?) proposals for education by David
Selby (2007) who argues Everyone has to understand and come to
terms with the fact that we are threatening our own existence. To
confront this requires a Copernican revolution in aims, structures,
processes of education and perhaps in the loci of learning. As the
heating happens, education and educational institutionswill be
deeply disrupted and if unresponsive to the need for transformation,
will disintegrate as people nd other more relevant loci for learning
what they have to learn. He then outlines propositions for education
which should give curriculum developers a pause for reection. Space
precludes a deeper discussion of these concepts but they include
confronting denial, addressing loss and despair, shifting to a holistic
understanding of the relationship between humans and the planet,
cultivating a poetic understanding of existence, examining what the
good life means and rethinking notions of citizenship.
In addition to this are 7 key concepts for sustainability education
(Sustainable Development Education Panel, 2000) which could
underpin nursing curriculum development. These are: Interdependence, Citizenship, Future Generation's needs, Diversity, Equity and
Justice, Sustainable Change and Uncertainty and Precaution. To that,
we could add a focus on well-being. The evidence base for which
suggests that the elements are: Connecting, Giving, Activity, Taking
Notice and Learning (Aked et al., 2008). The challenge for nursing is
understanding these concepts and thinking about their application in
an already crowded curriculum.

Points to consider
As this is a normative account on what nurse education is for, the
recommendations below encourage a change of view from an
instrumentalist, transmissive, teacher led, technico-rational skill
acquisition model to produce graduates solely for the NHS to one
that also accesses transformative, participative, student centred and
liberal humanistic, progressivist and reconstructivist education.
1. Clarify both the role of nurse education and the educational
ideology driving curriculum development.
2. Identify where we are engaging in rst (adaptive), second
(critically reective) and third order (transformative) education.
3. Discuss and critique Selby's propositions and the 7 key concepts
(SDEP 2000).
4. Emphasis notions of well-being (e,g. Aked et al., 2008).
5. Consider either an infusion model (sustainability issues are
woven throughout the curriculum) or a generic module available
to all disciplines but tailored to each.
6. If the theme is infused throughout the curriculum, developers
could reect on learning outcomes using a sustainability lens. For
example, for infection control we could reect on changes in
practice to address the sustainability of single use items.
7. Design space in the curriculum to allow an experience in or with
the natural environment.
8. Encourage students to visit green spaces in their locality and think
about the impact of this for the population to link in with some
learning outcomes such as promoting wellbeing.
9. Encourage student engagement with both urban and rural natural
environments. Towards this we need to build our wider
placement experience for students (possibly under lifelong or
life wide learning) and develop collaborative working relationships with multi discipline groups, local authorities and third
10. Encourage a poetic understanding through positively sanctioning the use of art in the curriculum. Discuss academic credits with







B. Goodman / Nurse Education Today 31 (2011) 733737

our Arts colleagues. Design curricular space to include artistic

expression and experience.
Use e learning technologies as much as possible to model
sustainable practice: for example podcasts, webcasts, e portfolios.
Design assessment of practice documents that can be accessed
and submitted online.
Foster a trans-disciplinary approach to health that accesses for
example Economics, Politics, Design, Philosophy, Environmental
Science literature and theory. Encourage students to go beyond
purely Nursing and Medical texts.
Ensure we have a thoroughgoing critique of the biomedical
individualistic model of health. Build on current strengths of
holistic and public health frameworks.
Encourage the development of personal action plans around
sustainability in portfolios. Students could decide which aspect of
their health and well-being could be improved by changing to one
aspect of a lower carbon lifestyle. They could measure that change
over three years. For example one goal could be to reduce car use
(use SMART). Students could identify how they put the 5
principles of well being into their personal lives.
Consider joining or the setting up of a student community of
practice on sustainability-climate change and health based on
the current Cornwall Facebook group approach. http://www.

The challenges facing humanity in the 21st century require a
radical rethink of business as usual education. Education is
important, but is not the only game in town. There are other agencies
and ideologies shaping the future. However, education is the HEI's
sphere of immediate inuence and although it may be morally
questionable to ask the next generation to clear up after our own mess
we may have little choice. The principles for educational programmes
are enunciated above but they may be seen to be mediated through a
notion of health and nursing that has to have a moral and political
dimension if we are to move civilization towards moral, economic and
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