doi: 10.1111/nup.

12143
Original article

Developing the concept of sustainability in nursing

Benny Goodman MSc PGDE BSc (Hons) RN RNT

Lecturer, Plymouth University, Truro, UK

& Abstract Sustainability, and the related concept of climate change, is an emerging
domain within nursing and nurse education. Climate change has been
posited as a serious global health threat requiring action by health pro-
fessionals and action at international level. An
aker & Elf undertook a
concept analysis of sustainability in nursing based on Walker and
Avant’s framework. Their main conclusions seem to be that while defin-
ing attributes and cases can be established, there is not enough research
into sustainability in the nursing literature. This paper seeks to develop
their argument to argue that sustainability in nursing can be better
understood by accessing non-nursing and grey literature and, for exam-
ple, the literature in the developing web-based ‘paraversity’. Without
this understanding, and application in nursing scholarship, nurses will
have a rather narrow understanding of sustainability and its suggested
links with social and health inequalities and the dynamics underpinning
unsustainable neoliberalist political economy. This understanding is
based on the social and political determinants of health approach and
the emerging domain of planetary health. However, this is a major chal-
lenge as it requires a critical reflection on what counts as nursing knowl-
edge, a reflection which might reject sustainability and political
economy as irrelevant to much of nursing practice.

Keywords: sustainability, climate change, concept analysis, political

economy, determinants of health, nursing.

2012; Aronsson, 2013; Adlong & Dietsch, 2015;

Introduction
Allen, 2015) and nursing education (Johnston et al.,
Sustainability, and the related concept climate 2005; Goodman, 2008, 2011; Goodman & Richard-
change, is an emerging domain within nursing (Hunt, son, 2009; Goodman & East, 2013; Richardson et al.,
2006; Goodman, 2011; Sattler, 2011; Polivka et al., 2013). Climate change has been posited as a serious
health threat (Costello et al., 2008; McMichael et al.,
Correspondence: Benny Goodman, Lecturer, Plymouth 2012; IPCC, 2014) requiring action by health profes-
University, Knowledge Spa, RCH Treliske, Truro TR1 3HD, sionals (Gulland, 2008; Patton, 2008; Reale, 2009;
UK. Tel.: 01872 256468; fax: 01872 256451; e-mail: b.goodman- Costello et al., 2011; Harding, 2014; Thomas, 2014)
1@plymouth.ac.uk and action at international level (Durban Declaration

298 © 2016 John Wiley & Sons Ltd

Nursing Philosophy (2016), 17, pp. 298–306

on Climate and Health, 2011; WHO, 2016). The status
of climate change as health threat has however been
contested (Goklany, 2009a, 2009b, 2012; Goodman,
2014), but it remains an important determinant of
health (Barton & Grant, 2006; Griffiths, 2009). In this
context, An
aker & Elf (2014) undertook a concept
analysis (Walker & Avant, 1982) of sustainability in
nursing. This article seeks to develop their argument
to argue that sustainability in nursing can be better
understood by accessing non-nursing literature, to
address the socio-political context in more depth.
This should include going beyond accepted peer-
reviewed nursing journals and include literature such
as that written by Wendell Berry (Berry, 1995) who
writes eloquently on human health and our relation-
ship to the natural environment. There is also a grow-
ing body of work online and of an academic standard
to qualify for what might be called the ‘Paraversity’
(Rolfe, 2013; Goodman, 2015a). Without this under-
standing, and application in nursing scholarship,
nurses will have a rather narrow understanding of
sustainability. There is a need to link social and
health inequalities (Dorling, 2013; Marmot, 2015)
and the dynamics underpinning unsustainable neolib-
eralist political economy (Harvey, 2005, 2014; Sayer,
2015) with the concept of sustainability. Climate
change is just one aspect, albeit a very important
aspect, of that linkage. This understanding is based
on the social (Raphael, 2004; WHO, 2013; Davidson,
2015), political (Ottersen et al., 2011), and ecological
(Lang & Rayner, 2012, 2015; Rayner & Lang, 2012;
Goodman, 2014, 2015b) determinants of health (Bar-
ton & Grant, 2006). However, this is a major chal-
lenge as it requires a critical reflection on what counts
as nursing knowledge, a reflection which might con-
sider sustainability and political economy as irrele-
vant to much of nursing practice. Before addressing
the definition of sustainability in nursing, the socio-
political ‘pattern of knowing’ will be outlined to form
the justification for the ensuing discussion.
The fifth ‘pattern of knowing’ in
nursing
Jill White (White, 1995) added a fifth pattern of
knowing in nursing to Barbara Carper’s four
© 2016 John Wiley & Sons Ltd
Nursing Philosophy (2016), 17, pp. 298–306
Developing Concept of Sustainability 299
(Carper, 1978): the ‘Socio-Political’. White argued
the other four patterns provided answers to the ‘who,
how, and the what’ of nursing practice but not the
‘wherein’, the context. This, White argued, is the pat-
tern of knowing essential to an understanding of all
the other four. Socio-political knowing that is gained
from a fuller understanding of the ‘sustainability lit-
erature’, might lift the ‘gaze’ from introspective
nurse patient relationships at the bedside and
requires the situating of that relationship within the
wider socio-political context. This may result in chal-
lenging the taken for granted assumptions about
practice, health, the profession, and wider health pol-
icy. To that could be added the raising of questions
about political economy and engaging in philosophi-
cal enquiry about such concepts such as ‘non-duality’
(Loy, 1988), a concept Wendell Berry implies in his
essay ‘health is membership’ (Berry, 1995).
White quoted Chopoorian who suggested: ‘nursing
ideas lack an archaeology of the social, political and
economic worlds that influence both client states and
nursing roles’ (White, 1995 p84). This ‘archaeology
of ideas’ still seems relatively poorly discussed within
nursing education and practice. Davies argued that
‘some of our concepts are missing’ in a critique of
the Sociology of Health and Illness (Davies, 2003).
By that is meant that there had been a lack of a ‘soci-
ology’ of organizations in the sociology of health and
illness, a sociology which is able to reveal concepts
such as discourses of managerialism (Traynor, 1996,
1999; Gilbert, 2005; Traynor et al., 2010) or to reveal
patterns of power and accountability for policy and
its consequences (Scambler, 2012; Freudenberg,
2014; Schrecker & Bambra, 2015). Davies argued
that
sociology needed to take seriously the politics of NHS
modernisation. (p. 183)
It is suggested here that many nurses might not
have such a set of critical concepts, such as ‘govern-
mentality’ or ‘frontiers of control’, to give them a
more critical discourse upon which to base critical
action or ‘praxis’ (Cox & Nilsen, 2014). There are a
few papers addressing political activism in nursing,
providing critical theories and concepts (Hewison,
1994; Antrobus et al., 2004; Racine, 2009; Phillips,
300 Benny Goodman
2012; Shariff, 2014), and other papers which discuss
politics and nursing (Masterson & Maslin-Prothero,
1999; Davies, 2004; Salmon, 2012; Traynor, 2013).
These works suggest an interest in the interplay of
the socio-political context and nursing practice and
provide some evidence of relevance of this ‘pattern
of knowing’. White argued that nurses must ‘explore
and expose alternative constructions of health and
health care, find means of enabling all concerned to
have a voice in care provision and develop processes
of shared governance for the future’ (p85). Exploring
sustainability, climate change and health assists in
that work. Indeed, a focus on global governance for
health in the context of climate change and environ-
mental challenges is a key theme of recent reports
(Ottersen et al., 2011, 2014) in non-nursing literature.
This leads us onto consider how nurses are to under-
stand what sustainability means.
Defining sustainability in nursing
An
aker & Elf (2014) argue that the ‘term is not
clearly defined and is poorly researched in nursing’
(p382). This applies not only in nursing. Sustainabil-
ity has diverse and contested meanings in many disci-
plines (Williams & Millington, 2004; Thompson,
2011). The quest to tie down the concept is possibly
futile, as An
aker and Elf themselves suggest that: ‘a
concept analysis is never a finished product’ (p388).
They provide a definition which is a helpful contribu-
tion to the discussion, and their model and contrary
case illustrate for clinical nurses the value of trying
to understand sustainability in practice. Throughout
the paper, they provide attributes and definitions
from various sources and refer to, but do not fore-
ground, social and health inequalities arising from
wider determinants of health including political
economy, which also underpins understandings of
sustainability and climate change (Goodman &
Richardson, 2009; Sayer, 2015).
The defining attributes identified in Anaker and
Elf’s concept analysis were as follows: ecology, envi-
ronment, the future, globalism, holism, and mainte-
nance. The attribute ‘globalism’ indicates that they
are getting close to discussing and emphasizing polit-
ical economy underpinning such issues as climate
change, ocean acidification, and soil erosion which
are three of the nine planetary boundaries which, it
is argued, delineate a ‘safe operating space for
humanity’ (Rockstrom et al., 2009; Steffen et al.,
2015). Nonetheless, the analysis misses something
important, that is the neoliberal (Harvey, 2005;
Freudenberg, 2014) and environmental, socio-politi-
cal context of health (Barton & Grant, 2006; Otter-
sen et al., 2011; Scambler, 2012; Sayer, 2015; WHO,
2015) characterized by social and health inequalities
(Dorling, 2013). This is the link between capitalism,
climate change, and sustainability (Griffiths, 2009;
Goodman, 2014; Klein, 2014; Sayer, 2015). Various
writers (Jackson, 2009; Hamilton, 2010; Urry, 2011;
Marshall, 2014; Sayer, 2015) suggest or imply that it
is our political orientations (Douglas & Wildavsky,
1992), moral intuitions (Haidt, 2012), and our social
and economic relationship with carbon which are
foundations upon which we as communities and indi-
viduals assess environmental issues and our reactions
to them.
Urry particularly on this point (2011) coins the
term ‘high carbon economy–society’ to describe capi-
talism. He argues that the starting point for an analy-
sis of why society engages in particular practices and
habits is the observation that energy is the base com-
modity upon which all other commodities exist.
Thus, community behaviours are implicitly locked
into high carbon systems that are taken for granted
aspects of our lifeworld. Urry suggests that much of
social science has been carbon blind and has anal-
ysed social practices without regard to the resource
base and energy production that we now know are
crucial in forming particular social practices. It is
these social practices that provide the structure
within which our agency operates.
most of the time people do not behave as individually
rational separate economic consumers maximising their
individual utility from the basket of goods and services they
purchase and use given fixed unchanging preferences. . .(we
are) creatures of social routine and habit. . .fashion and
fad. . .(we are) locked into and reproduce different social
practices and institutions, including families, households,
social classes, genders, work groups, schools, ethnicities,
generations, nations. . .. (Urry, 2011 p4)
© 2016 John Wiley & Sons Ltd
Nursing Philosophy (2016), 17, pp. 298–306

These social practices arise out of our ‘lifeworld’
(Husserl, 1936, 1970; Habermas, 1981), that is our
internal subjective viewpoints as well as the external
viewpoints of the social and political ‘system’. A high
carbon economy–society thus provides the backdrop
for values, assumptions, and social practices that are
taken for granted in everyday life. Defining sustain-
ability therefore requires acknowledgement of such
lifeworlds and the socio-political systems in which
they ‘operate’.
Nursing, sustainability, and
acontextual concept analysis?
The wider body of the literature, including that in
the social and political sciences and philosophy, may
give nurses tools and concepts to further develop
their understanding of sustainability and its relation-
ship to human health and the political economy of
capitalism (Hamilton, 2003; Jackson, 2009; Johnson
et al., 2010; Sayer, 2015). Without this understanding,
and application in nursing scholarship, nurses may
miss the arguments linking the growth dynamics
underpinning the neoliberalist capitalist political
economy (Chomsky, 1997; Harvey, 2005; Sayer,
2015), climate change (Klein, 2014; Sayer, 2015), and
unsustainable lifestyles (Hamilton, 2010). This sits
within the social and political determinants of health
approach (Barton & Grant, 2006; Ottersen et al.,
2011; Scambler, 2012; Davidson, 2015) and the
emerging domain of planetary health (Lang & Ray-
ner, 2012, 2015). This paper argues that to fully
develop the concept in nursing, an analysis or at the
least an understanding of the political economy of
neoliberal capitalism could be a component of
nurses’ understanding of sustainability and health.
This is because political economy relates to both
health and social inequalities (Wilkinson, 2005;
Wilkinson & Pickett, 2009; Stiglitz, 2012; Dorling,
2013, 2014; Marmot, 2015; Schrecker & Bambra,
2015) and to issues around sustainability and climate
change. However, this is a major challenge as it
requires a critical reflection on what counts as nurs-
ing knowledge (White, 1995), a reflection which
might reject sustainability and political economy as
irrelevant to much of nursing practice.
© 2016 John Wiley & Sons Ltd
Nursing Philosophy (2016), 17, pp. 298–306
Developing Concept of Sustainability 301
An
aker & Elf’s (2014) inference that nursing
misses foregrounding political economy and society
might be a result of the method employed to search
the literature, as well as their acknowledged lack of
discussion in the nursing literature of political econ-
omy. Of course there might be very little reason cur-
rently for nursing literature to discuss political
economy, based as it is on knowledge (biosciences,
biomedicine) that may well be largely antithetical to
critical social and political science. Adult nurses in
particular might face a real challenge in accepting
this idea in practice as Ion and Lauder argue:
For very good reason, adult nursing remains committed to
a biomedical vision of illness which, while cognisant of the
importance of a holism, is tied to a physical approach to
care. (Ion & Lauder, 2015)
In addition, Walker and Avant’s method was origi-
nally published (1982) before the development of
academic blogs and websites such as academia.edu
and therefore may not be explicit in its direction to
search beyond accepted channels. This emerging lit-
erature, which may contribute to the construction of
the ‘paraversity’ (Rolfe, 2013; Goodman, 2014), will
therefore be missed as source of information and dis-
cussion on topics such as linking sustainability,
health, climate change, and capitalism.
There are several key papers discussing the link
between human health, political economy, and the
environment. Goodman & Richardson (2009) explic-
itly link sustainability, climate change, and health
conceptualizing them as three sides of a triad. To
fully understand one requires an understanding of
the other two. The three, in this conception, are indi-
visible. Further, the link involves political economy
and socio-economic behaviour as crucial underpin-
nings for climate change and sustainability issues.
Barton & Grant’s (2006) health map discusses key
determinants for health including biodiversity, global
ecosystems, and climate change. Each one of those
of course involves human activity and disruption to
create what some are calling a new geological era,
the ‘Anthropocene’ (Zalasiewicz et al., 2010). Lang
& Rayner (2012) discuss the concept of ‘Ecological
Public Health’, while the Canadian Public Health
Association (2015) has just published its own report
302 Benny Goodman
on ‘Global Change and Public Health: Addressing
the ecological determinants of health’ which on page
1 argues:
. . .changes in the earth’s ecological systems are driven
principally by our social and economic systems, and by the
collective values and institutions that support them.
This echoes the World Health Organization’s defi-
nition of the social determinants of health which
explicitly mentions distributions of resources, money,
and power (WHO, 2015). The report does not name,
or analyse, in any more depth what that economic
system is, as it seems to take for granted that it is
capitalism. Ottersen et al. (2014) emphasize the
political determinants of health which, alongside the
WHO’s (2008) social determinants of health
approach, acknowledges the role of powerful global
actors and the lack of global governance for health.
Health equity and social determinants are now a cru-
cial component of the post 2015 sustainable develop-
ment goals (WHO, 2015).
For example, powerful global actors, that is the
Fossil Fuel Industry, may be acting in a way to
either downplay the risks to human health from ris-
ing atmospheric carbon dioxide, or engaged in pro-
tecting their assets’ (coal oil and gas) value for the
short term over and above longer term risks to cli-
mate. Exxon Mobil have argued that world climate
policies are highly unlikely to stop the production
and selling of fossil fuels (Exxon Mobil shrugs off
climate change risk to profit – BBC News, 2014)
while Shell have been accused (Macalister, 2015) of
accepting a four degree rise in global mean temper-
atures. This is in the context of a reported $5 tril-
lion annual subsidy in fossil fuel subsidies (Coady
et al., 2015) while the Bank of England considers a
‘carbon bubble’ (Carrington, 2014), that is the drop
in value of assets if fossil fuels are kept in the
ground through the imposition of any global gover-
nance regimes to curb carbon emissions. This is an
aspect of the political economy of capitalism that
must be understood as a driver underpinning
human health. At the time of writing, world leaders
and delegates are meeting in Paris for COP 21. At
this meeting, there will be another meeting of the
The Sustainable Innovation Forum (SIF15) which is
a business focused event held during the annual
Conference of Parties (COP). The 2-day forum will
convene participants from business, government,
finance, the United Nations, non-governmental
organizations, and civil society to ‘create an unpar-
alleled opportunity to bolster business innovation
and bring scale to the emerging green economy’
(COP21 Paris, 2015). This forum operates within
the paradigm of capitalism rather than seeking radi-
cal reform. However, it illustrates the complexity of
players dealing with sustainability issues, some of
whom, for example the US-based Heartland Insti-
tute and Cato institute, argue capitalism is the solu-
tion rather than the problem (Goklany, 2009a; Ben-
Ami, 2010).
Scambler (2012) outlines ‘the greedy bastards
hypothesis’ to describe how the capitalist class execu-
tive can ‘command’ the political power elite to enact
policies in their favour, with the unintended conse-
quences of exacerbating health inequalities. Evi-
dence that corporate activities impact on political
decision-making is provided by the delays to air pol-
lution standards, Euro 6 (Archer, 2015; Neslen,
2015). Volkswagen’s use of software to cheat emis-
sions testing in the United States (Topham, 2015)
indicates the lengths corporates will go (Oreskes &
Conway, 2011; Freudenberg, 2014) to avoid external-
ity costs resulting in the externality of, for example,
increased air pollution. Therefore, any concept of
sustainability in nursing that does not understand
political economy misses something important in
understanding both the concept of sustainability and
of health.
Anaker and Elf’s definition of
sustainability
. . .a core of knowledge in which ecology, global and holis-
tic comprise the foundation. The use of the concept of sus-
tainability includes environmental considerations at all
levels. The implementation of sustainability will contribute
to a development that maintains an environment that does
not harm current and future generation’s opportunities for
good health’. In this, it echoes the Brundtland commis-
sion’s definition of sustainable development (WCED,
© 2016 John Wiley & Sons Ltd
Nursing Philosophy (2016), 17, pp. 298–306

1987) which has been critiqued for being uncritical of busi-
ness and growth-based capitalism (Sinclair, 2009)
This definition is a good start but requires develop-
ment. Nurses, particular nursing scholars interested
in health and public health, need to consider the
argument already suggested around the dynamics of
capitalism as a major driver for both carbon emis-
sions and unsustainable practices. It is perfectly pos-
sible to begin the study of sustainability and
environmental health within taken for granted para-
digms, but what is required is a cultural critique of
the values and systems that support environmental
damage (Martusewicz et al., 2014) and a better
understanding how the economy and sustainability
issues such as climate change, interact (Better
Growth, Better Climate, 2015). Nurses, if they stick to
nursing journals and literature, will not find a large
amount of material that discusses this. For example,
the Royal Society of Arts has a wealth of papers,
presentations, and works streams addressing climate
change (Hahnel, 2015; Rowson, 2015a, 2015b) which
address causes, behaviour changes, political econ-
omy, and culture change.
Conclusion
An
aker & Elf (2014) argue that there is a need for
theoretical and empirical studies of sustainability in
nursing. This could include accessing literature
unknown to most nurses. Writers such as Aldo Leo-
pold, Wendell Berry, Paul Hawken, Mike Hulme,
John Urry all provide insights into human well-being,
health, and the social context. Related concepts
include ecojustice education, education for sustain-
ability, dualism, anthropocentrism, anthropocene,
neoliberalism, modernity, and capitalism. A problem
for nursing scholars is that these related concepts are
not readily seen as relevant to nursing, and thus,
there may be a reticence of nursing journals to pub-
lish them, and a reticence in nurse education to dis-
cuss them. There may be a need to resort to both
non-nursing peer-reviewed journals but also to web-
based materials open to all. Anaker and Elf acknowl-
edge in their limitations (p387) ‘the lack of research
literature available for review in which sustainability
© 2016 John Wiley & Sons Ltd
Nursing Philosophy (2016), 17, pp. 298–306
Developing Concept of Sustainability 303
was the major topic and in which sustainability was
not linked to other concepts’. This paper goes further
in trying to make those wider links for nurses. A
problem however for nurses is the sheer scale of the
literature and concepts that are involved. The task
for nursing scholars is to consider just what is feasi-
ble, useful, and relevant as part of their scholarly
development and curriculum work.
Acknowledgements
Thanks to Anna Anaker and Marie Elf for stimulat-
ing further thought on this idea.
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