Sustainability is a concept that promotes the ability to meet the needs of the present generation while protecting the ability of future generations to meet their own needs (Quinn and Baltes, 2007). Sustainable development and carbon management are corporate responsibilities and there is an escalating expectation in the developed world that all organisations, and healthcare providers in particular, will develop strategies to reduce carbon and manage waste (Naylor and Appleby, 2012). The United Kingdom (UK) National Health Service (NHS) will be a major contributor to meeting these targets; the carbon footprint of the NHS in England during 2012 was approximately 25 million tonnes of carbon dioxide (MtCO2e) (HM Government, 2013; Sustainable Development Unit (SDU), 2013b). Thus the UK NHS will need a concerted effort to implement strategies to reduce this, especially as patient activity and healthcare demand is increasing. While it was expected that combined emissions would meet the 10% reduction by 2015, the Climate Change Act 2008 (c.27) target requires a further 4.5% reduction over the next 3 years from the current calculation (SDU, 2013a).
There is a growing body of international evidence to suggest that climate change is causing a rise in global temperatures, leading to a negative effect on health, through a range of direct and indirect exposures. These include heat-related illnesses, exacerbations of pulmonary and cardiovascular disease, traumatic injuries and illnesses from extreme weather events. Additionally, an increase in the incidence of vector-borne and zoonotic diseases, the increased risk of mortality and morbidity through co-existing mental health, alcohol and drug disorders will impact on health care. This in turn will lead to greater activity in ambulance calls and may compromise the ability to maintain response time targets and admissions to emergency departments (Hess et al, 2009; Bassil et al, 2011; Cusack et al, 2011; Murray et al, 2011; Tong et al, 2012; Williams et al, 2012; Turner et al, 2013; Thornes et al, 2014).
There is limited empirical research on the management of sustainability in emergency medical services (EMS) (Hess et al, 2009). A number of studies have attempted to quantify the carbon footprint of ambulance operations, demonstrating that EMS systems worldwide are energy intensive (Blanchard and Brown, 2011; Brown et al, 2012; 2013). Total emissions for the Australian EMS are estimated at between 216 369 and 546 688 tonnes CO2e annually, with the North American emissions estimated between 660 000–1.6 million tonnes CO2e (Blanchard and Brown, 2011; Brown, et al, 2012). In the UK, the total annual figure for ambulance services has been estimated as 214 972 tonnes CO2e (Green Environmental Ambulance Network, 2012).
In the UK, fuel consumption and rising costs of fuel is one of the areas recognised as being a threat to sustainability (Williamson, 2011). A North American study also supports this, as it demonstrated that approximately 75% of energy consumption in EMS comes from vehicle fuel use (Blanchard and Brown, 2011).
However, not all fuel use is attributable to patient activity. It has been estimated that energy use between emergency calls (when the ambulance engine is left running to power electrical equipment) can account for 65% of an EMS shift, with 0.9 litres of fuel used per hour (Hess et al, 2009; Williamson, 2011). Efforts to mitigate this have been initiated by some ambulance providers by fitting methanol fuel cells. Yorkshire (UK) Ambulance Service NHS Trust have predicted a saving of £1.75–£2.4 million through the implementation of these and at the same time significantly reduced the carbon footprint of the ambulance fleet (Williamson, 2011). Others have experimented with solar panels, saving around $7 000 per vehicle per year (Lawrence, 2012).
There is also a need to reduce the amount of waste generated by healthcare activities (SDU, 2013a). The management of waste contributes significantly to the carbon footprint of healthcare organisations and current healthcare waste management practice is often expensive, polluting and wasteful. Contemporary publications on the effective management of waste within the NHS have highlighted a need for change in behavioural practice with disposal/recycling; research in this area is gathering momentum (Elgitait et al, 2009; Manzi et al, 2013).
The UK South Central Ambulance Service NHS Foundation Trust's (2013) Sustainable Development Management Plan (SDMP) highlights the increasing cost pressure associated with the disposal of waste. This is a widespread problem in health care and there is contemporary literature highlighting problems associated with segregation of waste (Pereira et al, 2013). This is also mirrored in a study of three major NHS hospitals in the North West region in the UK (Elgitait et al, 2009). The authors advocated that audits should be conducted, involving a review of staff waste management practices and, in particular, the effectiveness of segregation procedures.
The question of sustainability in EMS practice should also be addressed in the context of education. Training in EMS and paramedicine varies across countries. Within the UK, all paramedical educational programmes leading to registration with a regulatory body (the Health and Care Professions Council (HCPC)) should meet the specific standards of education, training and proficiency (HCPC, 2009; 2014). Although a syllabus may vary among education providers, all curricula should follow the UK professional body curriculum guidelines (College of Paramedics (CoP), 2014). However, the subject of sustainability and carbon reduction is not explicitly mentioned in the CoP guidelines, and there is currently a scarcity of available evidence to suggest that sustainability is included as a topic in EMS/paramedicine training worldwide.
In contrast, a number of nursing and medical academics have been writing about embedding sustainability in the curriculum. For example, efforts to develop training in health and sustainability using approaches that are relevant to practice have been reported in the literature (Richardson et al, 2014).
EMS practitioners use significant resources and EMS practice will inevitably be affected by climate change; potential limits of scarce natural resources will require practitioners to understand the implications of a changing climate. Williams et al (2015) suggest that paramedic students have the potential to be the next agents of change in the professionalisation of the paramedic discipline and are therefore a prime target for winning ‘hearts and minds’ regarding sustainable EMS care. By adopting the right practices, advocated by strategic objectives, paramedic students can be the vanguard for influencing best practice in the workplace and could become the future advocates for sustainability behaviour. This is congruent with UK ambulance service Trusts' Sustainability Development Management Plans (SDMPs). Planning reductions in the CO2e for ambulance Trusts involves both investment into improving energy performance and renewable technology, as well as the education of staff (South Central Ambulance Service NHS Foundation Trust, 2013).
The aim of this study was to assess the effectiveness of an educational intervention designed to raise awareness and generate discussion among healthcare practitioners (UK paramedic students) about sustainability and climate change.
Methods
A pre- and post-intervention study was designed to evaluate paramedic students' attitudes towards climate change and sustainability, and to assess changes in attitudes and knowledge following an educational intervention.
Sample
The target population for this study was undergraduate paramedic students in the UK. For the purpose of this study we sampled all undergraduate paramedic students in one University in England at the start of their second year of training. This sample was chosen as the sustainability session (the educational intervention) had previously been evaluated with student nurses in the same university (Richardson et al, 2015) and the intention was to integrate this session into the paramedicine programme. A previous study using the Sustainability Attitudes Survey found no significant difference on attitudes between nursing students who received the sustainability education intervention and those who did not, based on a sample of 29 and 28 participants respectively. No data exists to support a power calculation for a pre- and post-intervention using the Sustainability Attitudes Survey; in order to account for a possible Type II error a post-hoc power analysis was planned in the event of non-significant findings. All 45 second-year paramedic students participated in the educational intervention and 44 completed a pre- and post-intervention questionnaire. One student was late to the session and was only able to complete a post-intervention questionnaire so was excluded from the analysis. Students were asked to provide their names on the questionnaire in order that the pre- and post-intervention questionnaires could be matched for data analysis purposes. However, on data entry all participants were given a participant number; anonymity and confidentiality was assured and names were not used in the analysis.
Intervention
The intervention is a health and sustainability scenario session that has been delivered to over 500 student nurses and other healthcare professionals such as dentists and general practitioners. The session is evidence-based and designed to represent a hypothetical but clinically relevant scenario that engages students in discussion about the impact of health care on the environment, and issues regarding sustainability and climate change (Richardson et al, 2014). Students are facilitated in small groups for about 50 minutes to consider a scenario where the price of plastic is increasing; using the internet they are encouraged to discuss where plastic comes from and factors that might lead to a price rise. Items used in everyday clinical practice that are made from natural resources such as plastic and cotton are handed to students and they are asked to consider the impact on patient care if the natural resource were no longer available to make the item. An ‘impact line’ is provided and students place the item on the line that ranges from ‘no impact on patient care’ to ‘high impact on patient care’. The purpose of this is to encourage students to discuss how these items are used (and over-used) and to think about what alternative items or materials might be substituted. The students are then provided with a brief scenario indicating whether the item is potentially contaminated, and asked to allocate the item to ‘clinical waste’, ‘domestic waste’, or ‘other’ (and explain the ‘other’, e.g. re-use or recycle). Finally they are asked to guess the cost of disposing of a 5 kg bag of domestic waste and a 5 kg bag of clinical waste; costs (based on the average calculation for England) are revealed at the end of the session. For details of how the session works see: http://youtu.be/zIFT2Dbg08o.
Measures
The questionnaire ‘Sustainability Attitudes Survey’ employed in this study was developed and piloted at Plymouth University (UK) with 2nd year student nurses. Questions were designed to elicit agreement or disagreement with statements regarding climate change and sustainability, and the inclusion of these topics in the nursing and healthcare curriculum. Questions regarding demographic details and previous exposure to sustainability sessions were also included. Development of the questionnaire was based on discussions with experts from nursing education and sustainability and took the form of group discussions. Formulation of the items was straightforward with special emphasis to ensure that only one unit of meaning was included. The questionnaire has been translated into French, Dutch, Spanish and German and has been used to evaluate the attitudes of student nurses in six Schools of Nursing in Europe (Richardson et al, 2016). Items on the survey were adapted for use with paramedicine students. The attitude items can be found in Box 1.
A 7-point Likert scale with the end-points 1 = ‘strongly disagree’ and 7 = ‘strongly agree’ was used. Likert scales of this format are widely used in social and health research. Many studies show that this form of assessment may yield reliable and valid information on target constructs (Bertram, 1999).
Students were also asked to state the average cost of disposal, in the NHS, of a 5 kg bag of domestic waste and a 5 kg bag of clinical waste. On the questionnaire they were provided with six options and asked to circle their response. This data was treated as categorical using correct and incorrect answers as data for analysis. A further question: ‘what natural resource is plastic made from?’ was included. The aim of these three items was to capture specific learning from the focus of the sustainability and health scenario session; data from these questions were analysed using crosstabs and McNemar test.
Data were entered into SPPS using a participant number in order that anonymity was assured and that individual responses could not be identified. Ethical approval was provided by the University Faculty of Health and Human Sciences Research Ethics Committee.
Results
Forty four (98%) students who participated in the education session completed the pre- and post-questionnaires.
Data were analysed using SPSS statistical package version 21. Examination of histograms and Kolmogorov-Smirnov tests of normality suggests that the data deviated from normality, p<.05 in 7/18 of cases indicating that using a non-parametric test would be a cautious approach. Therefore Wilcoxon Matched-Pairs Signed-Rank tests were used to examine the differences between the scores of the pre- and post-intervention survey, a higher mean rank indicated that attitudes were more towards ‘strongly agree’.
Wilcoxon tests found significant differences (p=0.00) between the pre- and post-intervention questionnaires for the following statements: climate change is an important issue for health care; climate change is an important issue for paramedical services; issues about climate change should be included in the healthcare curriculum; sustainability should be included in the healthcare curriculum. Mean ranks indicate that participants were more likely to agree with the statements following the sustainability scenario session. Significant differences were also found for the following statements: sustainability is an important issue for health care (p=0.019); sustainability is an important issue for paramedical services (p=0.05); I apply sustainability principles in my healthcare practice (p=0.001); I apply sustainability principles at home (p=0.042). Negative z scores for the mean ranks reflected greater agreement with the statements following the sustainability scenario session. There was no significant difference between the pre- and post-intervention questionnaire for the statement: the segregation of healthcare waste is important (p=0.065). This might be explained by the number of ties for this statement (23/44), and 7/44 scored this item lower on the post-scenario questionnaire than on the pre-scenario questionnaire (see Table 1).
| Q1B Climate change important for health care - Q1A Climate change important for health care | Q2B Climate change in paramedical services - Q2A Climate change in paramedical services | Q3B Issues about climate change should be included in healthcare curriculum - Q3A Issues about climate change should be included in healthcare curriculum | Q4B Sustainability is an important issue for health care - Q4A Sustainability is an important issue for health care | Q5B Sustainability is an important issue for paramedicine - Q5A Sustainability is an important issue for paramedicine | Q6B Sustainability should be included in the healthcare curriculum - Q6A Sustainability should be included in the healthcare curriculum | Q7B I apply sustainability principles in my healthcare practice - Q7A I apply sustainability principles in my healthcare practice | Q8B I apply sustainability principles at home - Q8A I apply sustainability principles at home | Q9B The segregation of healthcare waste is important - Q9A The segregation of healthcare waste is important | |
|---|---|---|---|---|---|---|---|---|---|
| Z Asymp. Sig. (2-tailed) | −4.080b .000 | −4.754b .000 | −4.679b .000 | −2.345b .019 | −2.839b .005 | −4.330b .000 | −3.469b .001 | −2.037b .042 | −1.848b .065 |
Wilcoxon Signed Ranks Test
Based on negative ranks
The McNemar tests performed on the knowledge questions: what natural resource is plastic made from (Table 2); cost of clinical waste (Table 3); cost of domestic waste (Table 4), suggested participants were more likely to answer this correctly following the health and sustainability scenarios (p=0.000).
| What natural resource is plastic made from? 2 | Total | |||
| Yes | No | |||
| What natural resource is plastic made from? 1 | Yes | 21 | 2 | 23 |
| No | 18 | 3 | 21 | |
| Total | 39 | 5 | 44 | |
| What is the average cost of disposal of clinical wate in the NHS? 2 | Total | |||
| Yes | No | |||
| What is the average cost of disposal of clinical wate in the NHS? 1 | Yes | 3 | 1 | 4 |
| No | 34 | 6 | 40 | |
| Total | 37 | 7 | 44 | |
| What is the average cost of disposal of domestic waste in the NHS? 2 | Total | |||
| Yes | No | |||
| What is the average cost of disposal of domestic waste in the NHS? 1 | Yes | 8 | 2 | 10 |
| No | 30 | 4 | 34 | |
| Total | 38 | 6 | 44 | |
Discussion
Climate change and sustainability are important issues in health care and EMS (Blanchard and Brown, 2011; Brown et al, 2012; 2013). Practitioners should have the necessary training to equip them to work within a changing climate, and understand how items they use in everyday practice can be compromised due to reliance on scarce natural resources (Richardson et al, 2014).
In the absence of other examples of embedding sustainability into the emergency medicine curricula in the UK, this intervention has value. In order for paramedics to be fit for the future and have the awareness to function in an environment of increasingly fewer resources, current knowledge and attitudes need to be explored and challenged. The benefit of working in small groups is that existing knowledge can be shared among group members and new knowledge made relevant to practice. Education for sustainable development theory recommends active, participative and experiential learning methods that involve participants in challenging their thinking and ability to act (Sterling, 2012). The sustainability scenario session used with the paramedic students provided a safe environment for them to think about how they could change behaviour and reduce waste.
Our data suggests that, for this sample, participating in a health and sustainability scenario session that relates directly to clinical practice can improve knowledge about the use of natural resources in clinical practice, and increases understanding about the cost of waste management. Furthermore, attitudes towards sustainability and climate change, and including these topics in the curricula changed significantly following the scenario session. One interesting finding was that there was no significant difference in attitudes for statement about waste and the importance of healthcare waste segregation. However, the more accurate assessment of the relative cost of disposing of landfill and clinical waste does suggest increased knowledge following the session.
Conclusions
This paper has described a small step in the process of embedding sustainability teaching in health practitioner education. This educational approach needs to be further tested with a range of healthcare staff from across the UK and in other developed countries. Negative attitudes to climate change or lack of familiarity with group work may create a need for the training session to be adapted. Training diverse disciplines in healthcare provision may require different everyday clinical items to be used in sustainability sessions. However, this intervention has been shown to positively affect attitudes and knowledge, and will benefit from being embedded into EMS curricula.
Follow-up research is required to measure behaviour change in the short, medium and long term in order to fully evaluate the effectiveness of this sustainability session.