Nursing Interventions to Reduce Health Risks from Climate Change Impact in Urban Areas: A Scoping Review

Abstract

In recent studies, public health has been considered a key stakeholder in climate mitigation and adaptation in cities since they are more exposed to the impact of climate change. Nurses represent a vast majority of public health professionals, playing a key role in health promotion that allows them to influence individuals, families, and communities in adopting healthier behaviours and decarbonized lifestyles. Therefore, the purpose of this study is to map the existing evidence on nursing interventions, which are being led or implemented to reduce the health risks related to climate change in urban areas. The present review follows the JBI methodological framework, including a search on PubMed, MEDLINE complete, CINAHL Complete, Scopus, Web of Science, SciELO (Scientific Electronic Library Online), BASE (Bielefeld Academic Search Engine), and RCAAP. Hand searched references were also considered, including quantitative, qualitative, and mixed-methods studies between January 2014 and October 2024, for a more contemporary perspective. A three-step search strategy and data extraction tool were used by two independent reviewers. Twenty-seven studies in English and Portuguese were eligible for inclusion, all targeting a population of professionals with nursing-related roles: two case studies, one Delphi panel, one descriptive study, one historical research paper, two using a methodological design format, four narrative reviews, one observational study, nine review articles, three scoping reviews, and three systematic reviews. Eight categories of nursing interventions that contribute to decarbonized lifestyles, reducing health risks in relation to climate change, were acknowledged. Nurses play a key role in empowering individuals, families, and communities, promoting climate awareness and literacy, supporting health policy change, advocating for the most vulnerable and engaging in environmental activism, using evidence-based research, and taking advantage of marketing strategies and social media.

1. Introduction

Addressing climate change is no longer considered the realm of ecologists and environmental scientists, as “health providers…educators, and leaders, nurses” too are required to ensure communities are well prepared to face the impact of the variability of the climate on human health [1].

Therefore, governments and civil society need to be prepared to face present and future challenges. The Lancet and the University College London Institute (UCL) stated in their earlier report that climate change would not only constitute the most significant global threat of the 21st century but claimed that interventions from all sectors of society would be required to tackle its impact on human health [2].

International discussion regarding climate change began in 1972 in Sweden when the United Nations (UN) First Earth Summit was held and the issue of climate change raised for the very first time [3]. Several Conferences of the Parties (COPs) have been held since, focusing on limiting global warming by 1.5 degrees and pursuing the Paris Agreement goals [4]. More recently, in 2023 in Dubai, participating countries agreed to ensure climate justice by providing new fundings for loss and damage to support the most climate-vulnerable countries. In 2024, Azerbaijan hosted the last COP (29th)—UN Climate Change Conference Baku—where it was agreed to triple finance for developing countries by 2035 [5]. This new agreement will lead to cheaper and cleaner energy, protecting billions of lives from the impacts of climate change, if all nations in the agreement pay their part [5].

What does this mean for society? Addressing climate change entails new ways of living and working. It challenges all governmental institutions as well as private sectors to commit themselves to adaptation and mitigation strategies towards carbon reduction by 2030 and net zero by 2050 [4].

Considering the UN leads policymaking, health providers and the nursing profession should adopt the UN Sustainable Development Goals (SDGs) as a framework to ensure resilient health systems are in place and communities are well prepared to face the challenges brought by climate change. SDGs 6 and 7 (clean water and sanitation; affordable and clean energy) as well as SDGs 11–15 (sustainable cities and communities, responsible consumption and production, climate action, life below water, life on land) are all planetary health-centred and a focus for nursing to act upon [6].

Nurses are amongst the most trusted professions in the world and thus are in a very advantageous position to climate-educate and promote environmental change [7]. The question is: What is nurses’ role in practice, policymaking, advocacy, and education to reduce the health risks from the impacts of climate change?

Since Florence Nightingale introduced the Environmental Theory, nurses have increasingly played a key role in communicating environmental risks [7] as well as presenting climate action to patients, families, and their communities. Since nurses act as key players in educating the public in general, they can also be a resource to their peers on climate literacy and strategies to help the health sector reduce its emissions and control climate health [8].

Nurses are both individuals—managing the consequences of climate change themselves—and professionals, often contributing to climate change in a negative way through healthcare and their actions at the bedside or towards their community, whether intentionally or unintentionally [7].

Reducing healthcare greenhouse gas emissions, implementing strategies for climate efficiency in healthcare facilities, ensuring climate preparedness but also adopting better lifestyles are actions that can be introduced by nurses as individuals but also as a professional group by empowering their peers and communities. As frontline workers fighting climate change, directly or indirectly, nurses can be seen working in catastrophic disasters, pandemics, floods, hurricanes, amongst others. Their role is essential in weather disasters, emergency departments, health centres, and the community by preventing the impacts of climate-related incidents [8].

As an example, since the 2020 pandemic, the healthcare sector has increased plastic waste (by overusing Personal Protective Equipment—PPE), which was one of the COVID-19 pandemic’s environmental side effects [9]. The sector needs to better manage its current carbon footprint by involving all workers—healthcare professionals, managers and leaders, especially those in nursing—to deal with increased energy use [8].

Nurses across the world are not only qualified professionals to lead climate action, but also influencers and educators that can empower colleagues, student nurses, and communities by actively engaging individuals in sustainable climate mitigating actions. This is possible in their four domains: education, practice, research, and policy [10]. As a result, they can intervene to improve community resilience, offering opportunities for citizens’ participation and empowerment to address climate change [11].

Currently, good practices require nurses to identify and diagnose environmental hazards resulting from climate change impacts in urban areas and determine adequate interventions that can lead to behavioural changes [7]. These interventions should follow the United Nations’ guidelines [7] for climate action within cities, such as helping individuals and families to mitigate their negative environmental impact, implementing decarbonizing lifestyles, or adapting to climate impacts. Some of these actions include increasing resilience, reclaiming green spaces, and areas that can provide a positive mental health boost in cities, while also reducing health risks associated with climate change [12]. Additionally, nurses are well positioned to be involved as key stakeholders with the “medical, public health, and emergency management community in all aspects of disaster planning, mitigation, response, and recovery” [13].

As to the responsible consumption and production targeted by UN SDG 12, nurses can play a pivotal role by simply asking the questions, “Can we use less? Can we reuse? Can we recycle?” [7], and can influence others to ask themselves the same questions. Human diet is the result of consumption habits that have been influenced through the years by historical, cultural, and social influences. The different agrifood systems developed worldwide have adapted to the particularities of each territory, resulting in a diversity of diets around the world. Nevertheless, fossil fuels and pesticides have globally transformed traditional agriculture [14], also resulting in changes in methods of production, distribution, and commercialization around the world. Consequently, this caused diet patterns based on unsustainable practices that impact our planet, leading to higher levels of greenhouse gases (GHGs). Based on data from the Intergovernmental Panel on Climate Change (IPCC) [15], twenty five percent of GHGs originated from agriculture, forestry, and soil use. Hence it is urgent to promote local and regional alternatives and educate populations into decarbonized and sustainable diets [16].

The Final Report of the High-Level Panel of the European Decarbonisation Pathways Initiative, a package of measures to decarbonize lifestyles, developed by the European Commission (EC) in 2018, supports alternative diets and a transition from a beef-based diet to a plant-based, which will eventually translate into reducing dairy consumption and animal proteins and consequently cut GHS by around 10% [17].

Nurses can use their voice to promote decarbonized lifestyles, encouraging people to eat locally sourced fruit and vegetables and decrease the impact on the environment, while improving people’s health [7]. Although nurses may find in this an opportunity for climate health-related promotion, they must consider each population’s context. Some families on low income may not be able to make healthier choices over processed food. And some populations living on islands or in regions with little arable land, for instance, may be dependent on imported products due to the lack of agricultural production [7].

The EC Reports’ package of measures, aligned with the Paris Agreement mentioned above, point to the need for reducing Europe’s carbon footprint to neutral levels in 2050, working towards the concept of “livable cities,” where behaviour change strategies and social innovations are required from policymakers, politicians, and private businesses for replication and implementation [18]. Healthcare workers such as nurses can work alongside urban planners to design cities with cycling pathways, more opportunities for walking, and decreasing carbon emissions caused by vehicles [12]. Nurses can develop “green teams” to promote green infrastructures and sustainable designs for climate resilient cities and institutions [7]. Greenways, for instance, originally defined in the Lille Declaration, in 2000, offer communities healthier lives as they promote non-motorized routes, inspiring closer relationships between citizens and simultaneously decreasing pollution levels in cities [19]. Greenway planning resulting in linear vegetated green spaces are growing around the world and include natural, recreational, and cultural resources [20,21]. Developing such infrastructures will encourage their use as health resources and reduce the impact of climate change, increasing communities’ “health status”.

The UN’s framework, in the context of SDG 7—Affordable and clean energy—sustainability principles should be followed by architects, landscape planners, engineers, and builders, working alongside nurses when planning, designing, constructing, or reshaping healthcare facilities to reduce energy, waste, and GHG emissions. By contributing to reduce the urban island heating effect near hospitals or health centre areas, nurses can highlight within these teams the need for planting more trees or using sunshades, creating pedestrian and bicycle access between buildings, and avoiding car use inside or near the facilities [8].

Nurses as global citizens may inspire others and lead by example; using bottom-up approaches that prepare the public and communities to best mitigate and adapt to climate change may prevent our planet from warming up to 4.3 °C by the end of the twenty first century. Nursing interventions are therefore vital in preparing resilient communities. Central to this approach is assessing and diagnosing vulnerable and at-risk communities. According to Melo, nurses can anticipate communities’ health needs by addressing each one as a nursing care unit, as framed by his Model of Assessment, Intervention and Community Empowerment (MAIEC) [22]. According to this theoretical model, communities can be considered nursing care units, and nurses key professionals in enhancing communities’ health status, by assessing, identifying, and diagnosing health risks due to compromised processes, participation, or leadership, respectively, in relation to any phenomenon [22]—such as climate change. As frontline workers within the Public Health sector, nurses are well placed to implement the necessary interventions and help reduce unwanted health risks from climate change impacts in urban areas. However, working with transdisciplinary teams and establishing partnerships with other key stakeholders for climate action, nurses can enhance their influence, monitoring the most vulnerable by assessing health threats (i.e., infectious diseases), health behaviours, mortality, or morbidity rates within communities. These actions can include contact interventions with such communities—i.e., email or phone alerts on how to best deal with extreme heat and specific air pollution events, as well as helping them develop their emergency preparedness plans.

Fortunately, nursing activism has been launched globally, and environmentally concerned nurses are getting together across the world to face health and climate challenges. Health Care without Harm (HCWH), the American Nurses Association (ANA), and the International Council of Nurses (ICN) are examples of institutions that are highlighting the relevance of the role of nurses in supporting mitigation and adaptation strategies by contributing to climate-related national policies and action plans [23].

Hence, it is vital to review evidence on the current interventions developed by nurses to reduce the health risks from climate change impacts in urban areas and determine if the public health sector is following contemporary scientific and international recommendations for addressing the challenge posed by climate change on the health of urban communities.

For this purpose, a preliminary search on PubMed and MEDLINE Complete was conducted in which no current or in-progress systematic reviews or scoping reviews were found that mapped existing evidence on nursing interventions to reduce health risks from climate change impacts, specifically, in urban settings.

Although Sayre, Rhazi, Carpenter, and Hughes [8] partially addressed the topic, they did not provide any mapping of evidence on such interventions in urban areas. Thus, the authors decided to fill this gap by conducing the current scoping review with the objective of mapping published and unpublished research on this emergent field of intervention.

2. Review Question

The present scoping review focused on the following question:

- Which interventions are identified in the literature as being led or implemented by nurses to reduce health risks from climate change in urban areas?

3. Inclusion Criteria

3.1. Participants

The present review has included articles and studies involving nurses who promote community-based interventions using climate mitigation or adaptation strategies towards a reduction in health risks from climate change impacts in urban settings.

3.2. Concepts

The combination of the three core concepts “Community Health Nursing”, “Environmental Health”, and “Climate Change” were at the core of this review:

3.2.1. Community Health Nursing

According to the Portuguese Nursing Professional Association “Community Health Nursing” includes both public health and family health nursing [24], focusing on the empowerment of the individual, population, or community’s needs, engaging in activities such as health promotion, active care, or enabling each one in their own rehabilitation process, supporting all until their end of life.

3.2.2. Environment

The WHO concept of “Environment” [25] is closely linked to health promotion and encloses the current package of measures of the European Commission, aligned with the Paris Agreement from 2015 [4]. To achieve what some authors designate as “livable cities” [26,27] a reduction in the carbon footprint to neutral levels in 2050 is needed, with behaviour change strategies and social innovations developed by policymakers, politicians, and private businesses for replication and dissemination.

3.2.3. Climate Change

Nevertheless, to reduce the world’s carbon footprint as planned, stakeholders and the population, in general, require climate health literacy to acknowledge the contemporary concept of “Climate Change”. Within the present review, this concept was based on the definition used by the United Nations [28] which relates climate change directly or indirectly with human activity, trigging a significant impact on the global atmosphere and creating over time the climate variability that is currently being experienced around the world.

3.3. Context

This review will focus solely on interventions in urban environments, including hospital settings as communities or nursing care units [22].

Factors such as the “urban heat island” effect and a higher vulnerability amongst urban populations, in relation to the extreme effects of climate change—with the increase of CO₂ emissions in these settings—led to the choice of this particular research context.

3.4. Type of Studies

Within the present review, the authors have considered quantitative, qualitative, and mixed-methods studies for inclusion. Published or unpublished texts, opinion papers, and other grey literature such as thesis/dissertations have also been considered alongside relevant sources obtained from references lists and the authors’ professional network.

4. Materials and Methods

This review has followed the JBI (Joanna Briggs Institute) methodology for scoping reviews and was carried out in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses extension for Scoping Reviews (PRISMA-ScR) checklist [29] (please refer to Table S1).

An a priori protocol was conducted and published earlier in 2023 where objectives, inclusion criteria, and methods of analysis were clarified with detail in advance. This protocol has already been registered on the OSF registry platform.

4.1. Search Strategy

For the purpose of this review, the authors chose a three-step approach for the search strategy as follows:

I—A preliminary search initially conducted once the authors started to work on their a priori protocol [30] was already registered and published in 2023; PubMed, MEDLINE complete, CINAHL Complete, Scopus, Web of Science, SciELO (Scientific Electronic Library Online), BASE (Bielefeld Academic Search Engine), and RCAAP (Repositório Científico de Acesso Aberto de Portugal) were the databases used to identify the most relevant articles on the subject.

II—A thorough and more updated search was recently conducted on the same databases by using applicable keywords, Mesh descriptors, and other search terms in order to retrieve eligible titles and abstracts (please refer to Table S2).

III—As part of the third step of the search strategy, the authors chose to use a purposive method of data collection in qualitative research by screening references lists of the articles retrieved to add further significant studies which would have been missed otherwise (Snowballing Sampling). Of these, only two full-text articles were considered.

Information Sources

For reliability purposes, Google Scholar was not used as it only allows a limited number of documents without retrieving all evidence-based documents required.

All databases mentioned in the previous subsection—PubMed, MEDLINE complete, CINAHL Complete, Scopus, Web of Science, SciELO (Scientific Electronic Library Online), BASE (Bielefeld Academic Search Engine), and RCAAP (Repositório Científico de Acesso Aberto de Portugal)—contributed to retrieve both published and unpublished material, as well as grey literature. Finally, references searched by hand were also considered for inclusion.

4.2. Study Selection

The authors’ a priori protocol from 2023 included relevant articles published since 2005—the year in which the Kyoto Protocol was approved. However, as so many new policies and approaches have been contemplated since, a more contemporary perspective is now required. Thus, it was decided for the purpose of the present review that only articles and studies from within the last ten years were to be considered for inclusion, reflecting more current and up to date practices. Ultimately, full-text articles between 1 January 2014 and 31 October 2024, written in English or Portuguese, were selected using the inclusion criteria.

Following a double-blind process performed by two independent reviewers, the search retrieved a total of 650 records. A total of 340 of these records were duplicated studies and consequently deleted, resulting in a total of 310 records to be screened alongside 2 others found using snowballing. From these, an initial review of titles and abstracts was conducted, and 31 full-text articles were initially selected as the most relevant ones. Following thorough and comprehensive review, 4 were excluded (1 due to ineligible population, 1 due to ineligible context, and 2 due to full-text unavailability). In total, 27 were included within the narrative synthesis (please refer to Figure 1—Flow diagram of the review).

Figure 1. Flow diagram for scoping review process adapted from PRISMA statement by Tricco, Moher, and colleagues [29].

Following the database search, all relevant studies identified in the above-mentioned period were uploaded into Rayyan [31]. This platform organizes all data retrieved, identifying duplicated records, resolving each one in a thorough double-blind review process performed by two independent reviewers, against the inclusion criteria.

All disagreements were resolved through discussion, not requiring any third-party involvement.

4.3. Data Extraction

A data extraction tool was used by the authors, independently, including detailed information about all interventions identified in the literature as led or implemented by nurses to reduce health risks from climate change in urban areas.

Additionally, the tool developed included information about the authorship of each item included, country of origin, publication type, aim of the study, study design, population, and context.

All disagreements throughout the data extraction stage were resolved through dialogue and academic discussion within the authors.

The data extraction tool is aligned with the aim and objectives of the present review question, with the detailed information for each study item included to support the paper. (please refer to Table A1).

4.4. Data Analysis and Presentation

The present review was supported by a data extraction tool as well as a narrative summary of the results encountered, as per recommendations of the JBI scoping review guidelines [32].

By doing so, the authors will describe how each result relates with the aim and question of the review, analysing all data generated through frequency and text analysis, enabling the mapping of the main categories of interventions led or implemented by nurses in urban areas to reduce health risks from climate change.

5. Results

5.1. Study Inclusion

The database search retrieved a total of 647 studies as well as 3 records identified through additional searches. A total of 340 duplicates were deleted, and 310 records were screened for eligibility alongside 2 additional papers considered using snowballing.

Two independent reviewers using a blind process screened all titles and abstracts, and 31 full-text records were selected for comprehensive reading. Of these, 4 were excluded due to ineligible population (N = 1), ineligible context (N = 1), or full-text unavailability (N = 2) (please refer to File S1).

T 27 records selected for inclusion were exported from Rayyan to a free online version of Zotero, used in the present study as a references management tool, which acted as a facilitator through the selection process.

Both search and selection processes are fully reported in the present study and presented in a Preferred Reporting Items for Systematic Reviews and Meta-Analysis (PRISMA) checklist, clarifying the entire process [29] (please refer to Table S1).

5.2. Characteristics of Included Studies

Please refer to Table A1 to locate all studies included and numbered (from 1–27). Most of the studies (eighteen) were developed in the Unites States of America (USA), two of which were conducted in partnership (one with the Philippines). These numbers demonstrate not only the American robust research infrastructure, and large economy, but also its historic emissions and concern regarding climate change impacts on public health. The American Nurses Association (ANA) is an example of an American organization representing millions of registered nurses that has made a valuable and proactive contribution on the dissemination of relevant climate change knowledge, issuing position statements and guidance for professionals [33]. Three studies have been conducted in Australia; one study was conducted in Canada and another one in South Africa. The remaining ones were carried out in Europe—one in Portugal, two in the United Kingdom (UK), one from a partnership between the UK, Spain, Germany, and The Netherlands (please refer to Figure 2).

Figure 2. Absolute frequency of geographical location of studies included.

As to the year of publication, the authors chose to consider more contemporary studies, between 2014 and 2024, finding twenty-seven relevant studies, two from 2013, one from 2015, four from 2017, one from 2018, three from 2019, three from 2020, one from 2021, four from 2022, two from 2023, and more recently, in 2024, six studies were identified as significant, showing a growing awareness of climate change as a public health issue—please refer to Figure 3.

Figure 3. Absolute frequency for publication year of included studies.

Amongst the twenty seven papers, the authors identified two case studies (2,21), one Delphi panel used as a study design method (23), one descriptive study (4), one historical research paper (11), two papers using a methodological design format (5,7), four narrative reviews (13,15,16,19), one observational cross-sectional study (10), one recommendations review (9), eight review articles (1,3,6,8,12,17,24,27), three scoping reviews (14,18,20), and three systematic reviews (22,25,26).

The main aim of sixteen papers was to share or increase the level of knowledge on climate change-related topics (1–7,13,14,16–18,20,24,25,27), followed by four papers whose objective was to identify nurses’ contributions, actions, and solutions to address environmental challenges and to mitigate or adapt to CC (11,12,19,22). Three papers aimed to provide for and evaluate sustainability exemplars in nursing settings (9,10,21), two focused on advocating for healthy learning environments and disaster nursing education, with a focus on nursing curricular preparedness (15,23), one aimed to add nurses‘ voices to the public and political discourse on CC (8), and one (26) aimed to investigate the effectiveness of CC mitigation strategies—please refer to Figure 4.

Figure 4. Absolute frequency for aims observed in studies included.

5.3. Review Findings

5.3.1. Population

As confirmed by Figure 5 presented below, the authors identified seventeen papers (1,7,11–13,15–25,27) that refer to nurses in general, with five studies (1,4,9,10,27) directed towards nurse lecturers and nurse educators and three to nurse leaders or coordinators (1,14,23), whilst all other papers targeted a population of ambulatory care nurses (2), health educators and promotors (26), pediatric nurses (8), public health nurses (5), or other advanced practice registered nurses (6). It can be inferred that although 100% of the studies targeted nurses, a vast majority (63%) focused on general nurses as a professional group who may have a voice and a role in reducing health risks from climate change, regardless of their area of expertise.

Figure 5. Absolute frequency of population targeted by studies included.

However, the authors wish to highlight that five (18.5%) out of the twenty-seven papers intended to target their content directly to nurse lecturers, educators, and academics. These are key stakeholders with the potential to use their role in society to disseminate CC-related knowledge and literacy amongst students and the new generations of nurses as professionals.

5.3.2. Context

Papers eligible—as per the inclusion criteria requirements presented in a previously published scoping protocol—involved urban contexts and urban communities (such as hospital settings seen as community nursing care units), as these represent a major risk in the health of the urban population due to phenomena such as the “urban heat island” factor. Papers targeting exclusively rural contexts were excluded from this study.

As analyzed by the authors, nineteen out of the twenty-seven papers focused on all settings, irrespective of their context, but the remainder of them, eight studies, were exclusively directed to urban studies (4–6,9,10,18,21,27).

5.3.3. Review Question

Within the literature review, the authors defined eight “categories a posteriori” as conceptualized by Bardin [34], enabling a synthesis of the interventions being currently led or implemented by nurses to reduce health risks from climate change in urban areas (please refer to Table 1).

• Education and Training interventions are discussed as actions being implemented by nurses in 24 of the papers (1,2,4,7–27), meaning that 89% of the studies listed the importance of disseminating knowledge on CC amongst nurses, but also on the health consequences associated with it. Educating self, peers, and communities on CC-related diseases as well as building environmental health literacy and empowerment is key for these authors. In this category, a variety of interventions are highlighted as essential for educating and training:
  • Increasing awareness of heat-related illnesses; increasing awareness of evidence-based-practice; increasing awareness of environmental sustainability in nursing practice; increasing awareness of weather related morbidity and mortality (drowning, electrocution, cardiovascular events, and mental health effects); increasing awareness of waterborne diseases (humidity levels, severity of rain, water contamination with pathogens and chemicals); increasing awareness of vector-borne (mosquito and ticks) and zoonotic diseases and symptoms; increasing awareness of recreational water-related illnesses.
  • Increasing knowledge of the mental health impacts (MH) of flooding, displacement, and others.
  • Including/enhancing CC in the educational curriculum in nursing schools at undergraduate and postgraduate levels; increasing student/staff and faculty awareness of CC.
  • Developing case studies or problem-solving teaching; exposing students to disaster training through simulation and exercises; developing electronic tools for nurse educators (simulations, examples, curricular guidelines); promoting active learning about CC amongst students, replacing textbooks with current peer-reviewed publications; promoting “doing something” instead of just passive listening; introducing discussion forum topics and scenario-based learning/mobile learning; providing student feedback to optimize student learning on CC.
  • Offering interprofessional education (social services, etc.).

2.

Clinical interventions (assessment/screening/prevention/promotion/treatment) are discussed in 16 of the papers included (2,3,5–8,10–12,14–18,20,25), meaning 59% of the studies included autonomous actions from these professionals—eco-nursing knowledge and skills (practicing independently, demonstrating leadership and community engagement) that can be sub-divided in primary, secondary, and tertiary measures as follows:

• Primary measures—preventing CC-related diseases; promoting public and environmental health; preventing children/students in the communities from being exposed to harmful air; educating on prevention measures to reduce indoor air pollution, educating all school-levels teachers on the importance of identifying sources of moisture and mould, opening windows daily, using fans, maintaining ventilation, repairing leaking windows, preventing condensation on cold surfaces; modifying school activities to prevent exposure, practice times or locations; consulting level of outdoor air pollution/smoke/small particles; educating the community about health risks associated with CC; counselling families and their children on the hazards of health pollution; encouraging reduction in activity and remaining indoors during adverse pollution conditions; school nurses to monitor air quality index and students, preventing asthma exacerbation/increasing treatment frequency, etc.; educating families with chronic conditions in preparing for natural disasters or disruption of healthcare with a 1–2 week supply for children; helping to educate families on practices to reduce risk of dermatological diseases; advise parents to keep children off the water in the presence of warning signs of animal droppings, snails, or others; teaching on washing hands/body with clean water and soap afterwards for precautionary measures; teaching on main symptoms (cramps and diarrhea) from contaminated lakes, ponds, swimming pools, etc.; preventing the use of ice made from untreated water; alerting for the presence of Legionella contamination in warm environments; supporting safe water practices; supporting healthier lifestyle choices; promoting new work practices to prevent sedentarism; promoting exercise; educating the population on extreme weather events; raising awareness for CC; disseminating knowledge on emergency preparedness and response, including pediatric population and individuals with special care needs; understanding disaster risk preparedness for effective responses; optimizing health and abilities, preventing weather-related injuries; promoting behaviour change to influence healthier diet choices, by reducing red and processed meat consumption, increasing plant or meat-free alternatives as they can reduce up to 30% of GHG emissions whilst they also reduce the risk of chronic diseases.
• Secondary measures—monitoring vulnerable populations; screening for illnesses; screening for heat intolerance; identifying/diagnosing students at high risk of developing allergy or asthma-related symptoms; identifying diagnosed student–athletes and ensuring appropriate playing time and exertion levels are established; reporting and supporting surveillance of water-related illnesses; assessing heat vulnerability in homebound populations; ensuring mosquito surveillance; ensuring surveillance of endemic and emerging diseases and checking the need for individualized physical and MH care in vulnerable populations.
• Tertiary measures—managing CC-related diseases; assisting students in managing their allergies and asthma, preventing flare-ups, minimizing the requirement of maintenance medication or hospital admissions; developing action plans for each one of those students; ensuring interprofessional collaboration to ensure increase in impact for school nurse roles; early identifying families and children at risk, providing anticipatory care to them; applying suitable communication skills methodologies to promote self-protective behaviour during natural hazards.

3.

Community actions to improve urban resilience are mentioned in 16 of the papers included (1,6–8,11,12,14–20,22,24,25), meaning that 59% of the studies included refer to local and also organizational actions not only to mitigate carbon emissions but also adapting to the impact already caused by CC:

• Local actions—liaising with local emergency responders so they have a list of people with complex health conditions in the case of extreme weather disasters; offering cooling stations in case of heat waves; engaging with other key stakeholders and having warning and observation systems in place, encouraging children to play outdoors when safe; establishing local recovery groups and enlisting the aid of community networks to mitigate physical/psychological damage.
• Organizational actions—sharing public health announcements on signs and symptoms of heat stress/need for increasing fluid consumption and reduction in activity; engaging with peers in analyzing sub-district vulnerabilities; planning emergency preparedness; increasing the outreach on the concept of sustainability regarding energy efficiency, reducing waste, recycling techniques, awareness of locations for bins for recyclable products (coffee pods, Styrofoam, plastic straws, disposable cutlery, plastic bottles), turning off lights, using hand sanitizer, limiting water usage as well as single use devices (SUDs), using instead alternative disposable products as biodegradable plastics or compostable items (i.e., bamboo cutlery); and ensuring waste is reduced and appropriately diverted as per policy recommendations (recycling effort on paper, metals, sharps, containers, fluorescent lamps, batteries, electronics, organic food waste, pallets, unused medical supplies, and even SUDs); improving health systems resilience and implementing disaster plans for hospitals, assessing flood disaster strategies and social inequalities.

4.

Health policy formulation is mentioned in 14 (5,6,8,9,11–14,17–20,22,24) of the 27 papers included, meaning that 52% of these studies refer to the following interventions: implementing regulatory programs to reduce GHEs; implementing landfill diversion programs; ensuring proper signage and education are in place; engaging with policymakers; implementing healthcare leadership and role modelling; motivate nurses to follow guidelines for biological/hazardous material disposal; ensuring the reduction of over-prescriptions, ordering smaller dose vials, and educating on pharmaceutical waste; tracking and reporting back on key performance indicators (KPIs), identifying facility champions; sharpening documentation of risk exposures on traffic, crowding, air or water; supporting the creation of an interprofessional collaborative taskforce to prepare care plans for individuals and communities affected by climate-related health problems; ensuring social justice and contributing to the development of health policies.

5.

Environmental Advocacy and Activism interventions are referred in 13 of the 27 papers included (1,2,4,6,8,9,11,12,15,19,20,22,25), meaning 48% of these studies refer to a variety of actions based on the following: advocating for environmental changes to reduce heat exposure or improve community resilience; leveraging national sustainability initiatives; limiting further environmental degradation and remediating the impacts of CC; advocating to improve urban planning and the development of urban spaces—such as addressing the impact of rising temperatures, applying legal limits on emissions near playgrounds and schools, preventing exposure to air pollutants, etc.; advocating for improved public health policies in place in order to control GHSs and addressing CC consequences on children’s health outcomes; collaborating with other organizations whenever necessary; advocating and linking for composting landscape waste and recycling in municipal and organizational facilities; advocating for regulatory protection and enforcement of international directives and guidelines; promoting dialogue and collaboration between all stakeholders; strengthening the voice of vulnerable populations; supporting automobile fuel economy standards; advocating for policies towards the reduction of carbon-based energy, promoting renewable, clean sources of energy generation in universities and healthcare systems; in regard to outdoor pollution, supporting regulations for 350 ppm or less carbon in the local atmosphere; building a culture of awareness and responsibility around reducing personal contribution to increased atmospheric carbon; advocating the care of all individuals, families, groups, communities, and populations.

6.

Participation in social media/use of digital technology is quoted in 7 of the papers included (4,8,12,13,17,18,23), meaning that 26% highlight the relevance of nurses in engaging with the public, sharing presentations within their communities, marketing the benefits of behaviour change such as the increase in physical activity and others. Social media is used for public engagement, as are other digital technologies such as distance learning platforms, online courses, virtual simulation, team-based learning, gaming, short message service (sms) messages, news stories, posters, among others.

7.

Green Business interventions are implied in 8 (1,4,6,9,17,19,21,22) of the 27 papers included, meaning that over 30% of the studies revealed that nurses’ organizational involvement in environmental sustainability is a current trend in clinical and academic settings. Green practices reviewed include the following: promoting energy efficiency, conservation, and sustainability within healthcare settings (i.e., lighting, heating and cooling systems); implementing clear signage and sustainable orientation in laboratories; implementing reuse and recycling programs, resource conservation and the adoption of renewable energy, using waste reduction and net-zero strategies (i.e., electronic medical records, avoiding incorrect disposal of medicines/drugs down the drain, single use plastic segregation and recycling; using interactive resources such as digital education material in academic settings); starting green teams for energy conservation, promoting cycling and walking or organizing bike rides; promoting environmentally friendly actions such as recycling, donating used furniture and using reusable gowns, turn sheets, containers and liners, among others. These greening business operations, climate-friendly practices aim at minimizing waste (i.e., clothing swaps, changing purchasing behaviour, reduction in single-use products, investment in reusable products); reinforcing knowledge on the relation between nursing waste reduction and GHGs reduction); and promoting sustainable purchasing; developing skills and infrastructure within institutions.

8.

Research interventions are also referred to in 5 (5,12,17,20,22) of the 27 papers included, meaning that 19% of the studies noted nurses’ contributions to preparing articles for peer-reviewed journals or conducting other-related research with climate change and nursing practice and education. In these, some highlight the importance of studies related to the specific needs of children with asthma, to the need for more evidence-based practices, implementing mitigating strategies and working in ways that can lead to proficiency in the climate change domain. Furthermore, one of the studies [26] stressed the importance of supporting nursing research on electronic health records as a best practice for meeting waste reduction requirements for a net-zero healthcare sector.

Table 1. Absolute frequency and relative frequency for nursing interventions.

Nursing Interventions	Absolute Frequency (FI)	Relative Frequency (f/n)
Education/Training interventions	24	0.888888889
Clinical interventions	16	0.592592593
Community interventions to improve urban resilience	16	0.592592593
Health policy formulation	14	0.518518519
Environmental advocacy and activism	13	0.481481481
Participation in social media/use of technology	7	0.259259259
Green business interventions	8	0.296296296
Research interventions	5	0.185185185
Total	27	1

Table 1. Absolute frequency and relative frequency for nursing interventions.

Nursing Interventions	Absolute Frequency (FI)	Relative Frequency (f/n)
Education/Training interventions	24	0.888888889
Clinical interventions	16	0.592592593
Community interventions to improve urban resilience	16	0.592592593
Health policy formulation	14	0.518518519
Environmental advocacy and activism	13	0.481481481
Participation in social media/use of technology	7	0.259259259
Green business interventions	8	0.296296296
Research interventions	5	0.185185185
Total	27	1

6. Discussion

The present review comprehensively searched literature between January 2014 and October 2024, retrieving a total of 650 papers, identifying from these 27 relevant studies for inclusion. Within these studies, the authors were able to define eight categories of nursing interventions to reduce health risks from CC in urban areas. The number of studies, although high, reflects a trend towards more discussion of some of the concepts. However, when explored together, the concepts of community health nursing, environmental health, and climate change only revealed a small amount of research, which supports the rationale for the present review. However, through the years, the authors have noticed an increase in interest for researching this particular field to address the health impacts of climate change in our communities and across the globe.

The interventions synthesised above are listed as an evidence-based practice that is currently being implemented to mitigate the health consequences of CC.

Although community health nurses tend to work in the community, they may also work in other settings, along with school nurses, paediatric nurses, mental health nurses, etc. Thus, all nursing professionals working in the community or even in hospitals’ “nursing care units,” a type of small community, have a variety of reasons to engage in CC mitigation and adaptation to reduce health risks on individuals, families, or urban communities.

To revisit the review findings, please refer to Figure 6 below.

Figure 6. Summary evidence: overview of identified populations with corresponding contexts and type of interventions identified in urban areas.

The present study reinforces the role of nurses in reducing health risks from climate change by leading or implementing interventions such as the ones described above and enhanced through developing partnerships with other fields.

Authors like Adlong and Dietsch [35] discuss the importance of disseminating education and knowledge about the consequences of climate change. Through this strategy, other peers can be updated with new knowledge and evidence for best practices that will enable them to empower their communities to cope with CC impact.

Sibindi, Chipps, and Crowley [36] highlight the need for diagnosing, managing, and preventing climate-related illnesses. Monitoring vulnerable populations is key to nursing in urban communities that are often subject to stronger impacts from adverse weather events, such as floods. Having the necessary eco-nursing skills is crucial to identify distinct disease burdens, depending on the geographical location of the population. Although professional nurses may be ill-prepared to participate more actively in CC-related initiatives, knowledge deficiencies can be overcome by integrating CC and sustainability topics into nursing curricula and using evidence-based research to improve practice.

However, Bernhardt, Quinn, and Cox [37] stress that there are already innovative strategies being implemented in the field, where CC-related knowledge and evidence-based practices are being applied. This includes the use of screening tools for climate-related illnesses, such as the ones caused by heat waves, which particularly impact older adults. By applying best practices, ambulatory care nurses are now able to identify heat intolerance in particular populations, enabling a reduction in emergency department visits as well as hospital admissions. These practices need to be shared across the professional community.

The present review also shows that nursing responsibilities and interventions continue far beyond clinical care. Veenema, Rush, DePriest, and McCauley [13] discuss the long-standing role that nurses play in ensuring social justice by promoting policy change through new health policies, at different levels, from their places of work, and in close collaboration with other key stakeholders. Disaster planning policies are just one example of these types of proactive policy outcomes.

Authors like McCauley and Hayes reinforce this notion that nurses have always advocated for environmental health since the beginning of the profession, regardless of their specialty or practice setting. They highlight the importance of being involved in environmental activism, protesting against harmful community exposure to environmental impacts, whether they relate to chemicals, environmental hazards, playing behaviours, or time spent in institutional settings that may not adhere to safety standards [38].

According to Radu [39], Wadi, Cheikh, Keung, and Green though, prevention is not a sufficient strategy to address climate change. Societies around the world need to promote new behaviours. Nurses can play a vital role in stressing the importance of engaging in more sustainable dietary behaviours, such as shifting to plant-based diets, which may lead to a 30% reduction on GHG emissions [40]. Social media, marketing, online technology, and platforms are particularly helpful for nurses in clinical settings or nurse lecturers in academic settings to promote the benefits of new dietary behaviours and patterns in societies where the consumption of fruit and vegetables is far below recommendations [40].

In addition to promoting healthier diets, nurses’ public health strategies include advocating for healthier and more sustainable lifestyles such as walking and cycling and promoting exercise and active living for vulnerable groups, according to Salvador Costa, Leitão, Silva, Monteiro, & Melo [12]. Also, other greening strategies may include promoting clothes swapping, waste reduction, water and energy conservation, or developing green teams [39].

To boost green operations in the health sector, data needs to be shared to encourage best practices. Authors such as Sibindi, Chipps, and Crowley [36] and Valentine-Maher, Butterfield, and Laustsen [41] note that proficiency in CC-related nursing research continues to act as a key driver to change practices and implement mitigating strategies by nurses.

7. Limitations of Study

Although the present study could have been enhanced with the inclusion of articles describing other interventions related to different extreme weather events, such as fine airborne particulate matter or with articles written in languages other than English and Portuguese, the authors believe that they achieved the main objective for the present review by mapping the literature and the state of the art in the field.

Furthermore, adding studies from continents other than Europe, Africa, or North America could have added value to this manuscript. Nevertheless, however limited, the present review has contributed to the conclusions shared below.

8. Conclusions

The authors of the present review were able to identify 27 relevant papers that responded to the key question initially presented for the study. Although research in the field has been increasing, the data analysed and extracted show the need for continuous studies to further identify nursing interventions in the field, worldwide. Moreover, further research is required to study the impact and effectiveness of nursing interventions in the field and how these contribute to reduce health risks from climate change impacts.

Nurses working in urban settings represent the population targeted by the present study. Eight categories of nursing interventions were clearly identified and distinguished within the literature as being currently led or implemented by these healthcare professionals across the globe. These include education and training interventions, clinical interventions, community interventions to improve urban resilience, health policy formulation, environmental advocacy and activism, participation in social media, and use of technology, green business and research.

Nurses play a vital role as key stakeholders in addressing climate change; however, transdisciplinary collaboration is required to reduce existing CC-related health risks. Likewise, more needs to be done in the future, namely in continuing professional and academic development, and ensuring that CC-related knowledge and environmental health are included within nursing curricula, guaranteeing best practices for current and future professionals. Only by better preparing nurses in the field will these professionals be fully equipped to fulfil their role in effectively reducing the health risks of climate change impacts in urban populations across the globe.