Best Practices for Environmental Sustainability in Healthcare Simulation Education: A Scoping Review

Abstract

Educators must understand current practices and gaps in knowledge regarding environmental sustainability in simulation education to reduce the environmental impact of plastic waste while still maintaining fidelity in simulation education. Therefore, a scoping review was conducted to answer the PICO question, “In healthcare institutions and hospitals, what are the environmentally sustainable practices that can be translated into simulation labs as best practice?” Fourteen studies were identified through a search of seven databases, critically appraised, and analyzed. Three key themes emerged: (1) the 5 R’s, (2) getting people motivated, and (3) larger external collaboration. These themes highlight practical strategies and motivational factors for sustainable practices. An expanded 5 R’s framework (reduce, reuse, recycle, research, and rethink) was introduced to guide a holistic approach. The literature highlights the importance of education, stakeholder engagement, and clearly defined standards as key drivers for motivating individuals and teams to engage in sustainable behaviors. These efforts are most effective when supported by interdisciplinary collaboration, regulatory frameworks, national policies, and technological innovation. Sustainability initiatives should extend beyond individual institutions to foster broader systemic change.

1. Introduction

The healthcare industry significantly contributes to environmental sustainability challenges by creating more than five billion tons of healthcare waste per year [1]. Similarly, healthcare simulation education centers, which train students for practice, contribute to the problem of plastic waste. Simulation is an educational modality that aims to closely imitate the clinical environment using similar products, packaging, and surroundings. Simulation, therefore, produces waste similar to that generated in clinical settings without the risk of contamination or infection that is present in the actual clinical environment. In alignment with Kolb’s Experiential Learning Theory, the use of clinical supplies in practice settings is a necessary investment in learning, as hands-on engagement with realistic materials is essential for students to transform experience into meaningful knowledge [2]. This hands-on practice is critical for developing the psychomotor skills necessary to maintain sterility, prevent cross-contamination, and effectively perform clinical tasks. Therefore, consideration of the supply waste generated from hands-on practice is important to overall sustainability efforts. One study reported that each academic semester at their School of Nursing generated approximately 300 pounds of plastic waste from intravenous tubing alone, excluding other disposable and plastic products [3]. As healthcare student cohorts continue to grow, the cost and accumulation of plastic waste are expected to increase, especially as nursing and medical school programs expand to address ongoing workforce shortages, as noted by a 58.8% increase in baccalaureate nursing graduates over the period of 2012 to 2023 and almost 2% increase in medical school enrollment [4,5]. Given the severity of plastic waste, promoting environmental sustainability must be a priority in clinical education to address its negative impact. Educators must assess current practices and identify knowledge gaps in environmental sustainability within simulation education to minimize plastic waste while preserving simulation fidelity.

Environmental sustainability accounts for a product’s entire lifecycle from creation and use to reuse and disposal [6]. However, putting these concepts into practice can be challenging. For example, there is a continued reliance on single-use plastics, particularly in healthcare settings, due to their effectiveness in preventing cross-contamination and maintaining sterility, especially after the COVID-19 pandemic [7]. The pandemic also created supply chain challenges, making procuring environmentally friendly supplies more difficult. Additionally, recycling is complicated by mixed materials, combined plastics, and substances like polyethylene terephthalate (also known as PET) or high-density polyethylene plastics, which often render otherwise recyclable products non-recyclable [8].

Staff and educators in healthcare simulation centers may be unaware of sustainability practices, including identifying recyclable materials and/or how to recycle them [9,10]. Effective recycling in healthcare facilities depends on how recyclables are segregated, requiring necessary infrastructure upgrades [11]. Kheirabadi and Sheikhi [12] highlight logistical challenges, particularly the limited availability of specialized recycling facilities for biomedical materials. Insufficient recycling infrastructure and a lack of standardization further hinder the implementation of sustainable practices. All of these factors collectively create significant barriers to achieving environmental sustainability in clinical and simulation education.

Despite the clear need, a scarcity of research exists regarding best practices for environmental sustainability in healthcare simulation education. Some articles describe audits of plastic waste in healthcare spaces [13,14,15] but do not present solutions. Similarly, a number of editorial articles emphasize the need for research in this area but do not provide specific guidance [16,17]. Educational spaces could draw insights from current practices in healthcare settings, and vice versa. While simulation education does not face the same infection or biohazard concerns as hospitals or clinical settings, it uses many of the same materials, making it an ideal environment to test sustainability interventions.

In response to this need, members of the International Nursing Association for Clinical Simulation and Learning (INACSL) co-founded the Environmental Sustainability Special Interest Group (SIG), which consists of simulation educators from across the country and internationally. The purpose of this group is to provide a forum for discussion, share ideas, and identify areas where the choices made in healthcare simulation can make a positive impact on local, regional, national, and global environmental sustainability. To initiate this effort, a working group within the INACSL Environmental Sustainability SIG conducted a scoping review of the existing literature on environmental sustainability practices in healthcare simulation education.

Environmental sustainability in healthcare simulation education is a new area of study with an expected lack of published literature. Therefore, the appropriate method selected was a scoping review to explore existing literature on the topic of environmental sustainability in healthcare simulation education, identifying key concepts [18]. The Preferred Reporting Items for Systematic Reviews and Meta-Analyses Extension for Scoping Reviews (PRISMA-ScR) guided findings and reporting [19]. The review also employed the Population, Intervention, Comparison, Outcome (PICO) method to formulate the following research question: In healthcare institutions and hospitals, what are the environmentally sustainable practices that can be translated into simulation labs as best practice?

2. Materials and Methods

2.1. Search Strategy and Selection Criteria

The search included peer-reviewed articles written in English that focused on healthcare in general, the use and/or reuse of plastic supplies, purchasing and production of better products, student acceptability of sustainability efforts, and environmental topics published between 2013 and 2023. Articles were included in the domains of dentistry, veterinary, medical, nursing, pharmacy, respiratory therapy, physical therapy, pharmaceuticals, biotechnology, education, simulation, labs, clinics, offices, hospitals, and universities.

Articles were excluded if the focus was on microplastics or biological studies, municipal or waste management, electrical or electronic waste, sterilization of supplies, hazardous waste supplies, production of better products by large-scale companies, or clean air, water, or soil as the outcome rather than healthcare-related. Articles were also excluded if they were published prior to 2013, were non-English, or included grey literature, editorial, or conference proceedings.

Terms related to sustainability, healthcare, and student acceptability of sustainability efforts were searched, including relevant MeSH terms and subject headings when appropriate. The following databases were electronically searched using a subset of key terms: PubMed, Embase, CINAHL, Web of Science, Scopus, and the ProQuest Environmental Science Collection. Covidence [20], a web-based software platform, was utilized to manage and streamline the scoping review process, specifically supporting tasks such as title and abstract screening, full-text review, citation management, data extraction, and collaboration among reviewers. Covidence also automatically searched through journal citations for additional relevant articles. The full search strategy was registered on the Open Science Framework (OSF), and full details for replication can also be viewed in Appendix A. Articles were uploaded to Covidence for review in August 2023.

This scoping review followed a structured identification and screening process to select relevant studies. The identification phase began with searching multiple databases and registers, yielding 8092 studies from sources including Scopus (1826), Web of Science (1458), Embase (1414), PubMed (1222), ProQuest Environmental Science Collection (959), citation searching (959), and CINAHL (254). No additional references were identified through other sources, citation searching, or grey literature. After removing 3904 references due to duplicates—3889 identified by Covidence and 15 identified manually—a total of 4188 studies remained for screening. During the screening phase, 4188 studies were initially screened, with 3804 studies excluded at this stage. Each title and abstract were screened independently by two reviewers to exclude publications that did not meet the inclusion criteria. The remaining 384 studies were sought for retrieval and underwent assessment for eligibility. At this stage, 370 studies were excluded for various reasons: 86 were not in the appropriate year range, 70 had an inappropriate study design, 50 had wrong outcomes, 43 had unrelated interventions, 36 had wrong comparators, 31 had irrelevant settings, 32 were opinion articles or letters to the editor, 18 did not have full text available, 3 were not in English, and 1 was a duplicate. Two reviewers independently assessed each article against the inclusion and exclusion criteria. Any discrepancies between reviewers were resolved by a third reviewer. Following this comprehensive screening and assessment process, 14 studies were ultimately included in the final review. This approach ensured that only the most relevant and appropriate studies meeting all inclusion criteria were incorporated into the analysis. The PRISMA flowchart details the entire process in Figure 1.

2.2. Extraction, Critical Appraisal, and Data Synthesis

Eligible full-text articles (n = 14) were categorized based on their study design. To facilitate data extraction, the standard data extraction template two from Covidence was used, which is designed to be more flexible for reviews that are not systematic in design. The findings of each study were summarized in tabular format by two independent reviewers, and the workgroup voted on which to include. There were no discrepancies between reviewers/voters during this process. Themes for outcomes were identified to enable comparisons across different study types during the final synthesis. The findings were categorized into measurable outcomes regarding best practices for environmental sustainability.

3. Results

3.1. Summary of Studies

The 14 articles originated from nine different countries, including five from the United States, two from the United Kingdom, and one from each of the following countries: Australia, Belgium, Canada, Denmark, Germany, India, and the Republic of Korea. None of the studies reported any conflicts of interest. The study settings were mostly hospitals (n = 4) and, specifically, operating rooms (n = 5), but also included education (n = 3), dentistry (n = 1), and pharmacy (n = 1). The articles also represented a variety of levels of evidence. Most (n = 10) of the studies had no financial support to report, but two reported internal funding from the institution or department [12,21], one reported funding from the FDI World Dental Federation [10], and one reported funding from the German Job Agency (project KUREM) and the Association for the Advancement of Pro-Environmental, Healthy and Safe Behaviour [8]. Full article details can be viewed in

Table 1. Summary of 14 included articles.

Authors	Country	Design	Aim(s)	Setting	Population/ Sample
Bathish et al., 2022 [3]	United States	Cross sectional	Identify current sustainability practices of clinical simulation education centers in the United States.	Education	77 respondents from 75 unique healthcare simulation education institutions, representing 31 states and four countries (USA, India, Dominican Republic, and Canada)
Vogt & Nunes, 2014 [8]	Germany	Case control study	Review factors influencing recycling behavior.	Hospital (non-OR)	616 nurses, ward managers, medical doctors, civil servants, and others who worked in six selected hospitals chosen based on size and recycling systems
Martin et al., 2021 [10]	United Kingdom	Scoping review	(1) Answer the research question “What is the current state of environmental sustainability in general dental practice?”; (2) Provide baseline data for general awareness, barriers, and challenges for the implementation of sustainable practices.	Dentistry	128 articles total consisting of original research (n = 60), literature reviews (n = 25), reports on policy and/or legislation (n = 4), and expert opinion articles (n = 39)
Wyssusek, Keys, & van Zundert, 2018 [11]	Australia	Systematic review	(1) Quantify and qualify current OR waste; (2) Understand existing practices of waste segregation in ORs in Australia, and how these compare with international practices; (3) Investigate best practices in waste management; (4) Understand the financial implication of these initiatives; (5) Determine potential barriers to greening initiatives and how these can be improved.	Operating room (OR)	84 articles total consisting of original research (n = 45), review articles (n = 30), editorials/ personal reflections (n = 7), and letters to the editor (n = 2)
Kheirabadi & Sheikhi 2022 [12]	United States	Expert opinion	Review the recent advances in recycling and reusing biomedical materials, discuss challenges associated with each practice, and outline prospects for future research.	Education	Healthcare
Xiao et al., 2021 [21]	Canada	Literature review, unspecified type	(1) Survey the current landscape of plastic use and disposal in the perioperative setting; (2) Outline evidence-based “reduce, reuse, recycle, rethink, and research” recommendations toward building environmental sustainability for plastics in the OR.	OR	Not described
Ma & Han, 2024 [22]	United Kingdom	Literature review, unspecified type	Identify and suggest changes that can be made in hand surgery for more sustainable practices.	OR	Not described
Linstadt et al., 2020 [23]	United States	Expert opinion	Educate and motivate emergency providers to action by providing a guide to sustainable healthcare and an approach to creating a climate-smart emergency department.	Hospital (non-OR)	N/A
Joseph et al., 2021 [24]	India	Expert opinion	Detail the need for recycling medical plastics, current recycling techniques, and their limitations within the framework of available data.	Hospital (non-OR)	Healthcare facilities producing plastic medical waste
Kleber & Cohen, 2020 [25]	United States	Expert opinion	Focus on the health effects of plastic medical waste and how nurses can be leaders in changing the way these products are used and disposed of.	Hospital (non-OR)	Nursing (inpatient or outpatient)
Harding et al., 2021 [26]	Belgium	Mixed Method— Observation	Investigate waste creation in the operative room to identify design opportunities to promote waste reduction according to the circular economy.	OR	8 surgical observations and 5 expert witnesses
Azouz et al., 2019 [27]	United States	Educational intervention	Identify barriers to recycling, implement a recycling improvement educational program, and examine the personnel attitudes toward recycling in the OR.	OR	524 OR personnel from four Mayo Clinic campuses (Phoenix, Rochester, Eau Claire, and Florida)
Mallick et al., 2022 [28]	Denmark	Non- randomized experiment	Describe how to design and implement a take-back system for single-use or disposable medical devices, specifically the ReturpenTM insulin pen.	Pharmacy	66 of the 73 pharmacies in the three participating municipalities (37 in Copenhagen, 21 in Aarhus, and 8 in Kolding)
Choi et al., 2022 [29]	Republic of Korea	Cross sectional	(1) Determine how the recognition and attitude of zero waste affected student behavior; (2) Understand the change in plastic use caused by the pandemic; (3) Lay the foundation for the development of programs that promote zero-waste behaviors.	Education	196 university students recruited via social networking sites

, which is arranged by level of evidence. After summarizing and synthesizing, findings were grouped into three uniting themes. The sustainability recommendations from each article can be viewed in

Table 2. Sustainability Recommendations from 14 Included Articles.

Authors	Transferable Concept(s)/Recommendation(s) Relevant to Sustainability
Bathish et al., 2022 [3]	-Advancing sustainability efforts in simulation centers will likely benefit from more formal planning, resource support, and partnership with other institutions. -Partnerships must be formed with vendors and industry partners to collectively create and encourage the use of carbon-neutral packaging and products. -Innovation is needed throughout the lifecycle of simulation supplies, from purchasing to reuse, recycling, and disposal, to make further waste reduction feasible and convenient. -Reuse may be the most feasible implementation strategy to combat supply chain shortages. -Recycling, environmentally preferable purchasing, and sustainable disposal are not immediately cost saving and may require investment without a guarantee of financial return. -Supply chain and waste stream assessment can potentially decrease costs; simulation centers may identify additional opportunities for waste reduction within the current infrastructure that only require further education and uptake. -Students should be taught to be environmentally conscious, resourceful, and judicious with supplies, as well as why these actions are important.
Vogt & Nunes, 2014 [8]	-The European Eco-Management and Audit Scheme (EMAS) is a voluntary instrument of the European Union that can be used by businesses and organizations to improve their environmental performance. -EMAS-certified hospital employees were significantly more satisfied with waste handling compared to those at non-certified hospitals. -Older employees self-reported more pro-environmental behavior at home, which correlated with fewer problems with waste handling observed on the wards -Modifiable changes can focus on improvement of waste handling. -Management should provide staff with information about the waste, the recycling process, and its outcomes. -Recycling bins should be solid, closed, and cleaned mechanically to reduce the risk of injury, with designated and sufficient space for bins on the wards. -People are motivated to separate waste if it is made easy, with clear labeling and feedback given on the outcome. -Cost-benefit analysis data may increase employers’ interest in ecological issues through feedback on the outcome.
Martin et al., 2021 [10]	-The Centre for Sustainable Healthcare in the UK has produced a guide for dental practices that highlights travel, supplies, energy waste management, biodiversity and green space, cost, return on investment, environmental benefit, and ease of implementation of each suggestion as factors to consider. -High knowledge, a positive attitude, and effective infrastructure are key to implementing effective waste management, but these are often lacking due to a lack of education, financial support, and appropriate supportive legislation. -Broad sustainability aims and guidance are beginning to be introduced into healthcare contracts, but these are neither sufficiently pervasive nor enforceable by the employer or law, and should be strengthened.-The disposal of plastic waste contributes a small percentage to the overall impact on pollution and CO2 emissions that arise from plastic usage in healthcare, so focus should be on the major contribution coming upstream in the supply chain from manufacturing, processing, distribution, and logistics. -Coordinating the procurement of products that use plastic as a container or packaging with waste management that can recover and recycle this waste can create significant financial gains by mapping procured plastic (at all levels of packaging) to sustainable recovery and recycling technologies, and a focus on sustainable purchasing leads to lower costs and environmental and health benefits. -There is a growing need to educate staff and students on sustainability using a range of media and resources. -Effective life cycle analyses can provide baseline data for key restorative materials and subsequently identify ways to minimize their use and facilitate recovery.
Wyssuse, Keys, & van Zundert, 2018 [11]	-Ensure waste is labeled and segregated into different waste containers to ensure that each type of waste is disposed of appropriately. -Segregation at the source of generation reduces the volume of clinical waste requiring special treatment. -Reducing paper towel waste can be achievable using hand dryers or hand sanitizers. -Teams can use a “just-in-time” model to prevent overage. -A redesign of standard kits to include only the necessary equipment to avoid waste and save money. -Do not automatically open all packages as some may not be used. -By physically documenting overage, staff were more inclined to reduce overage, thus reducing waste and associated costs. -Non-hazardous waste can be donated to schools for art projects, medical or veterinary schools for teaching purposes, or to developing countries -Legislation for healthcare waste management can provide a framework for prioritizing waste management to achieve the best environmental outcome. -Best practice is to limit waste altogether, followed by recycling, then diversion to landfill. -Regular education and mentorship to team leaders is recommended to help mitigate the barrier of staff attitudes. -Greening interventions should occur in small steps because acceptance by staff members is more likely to occur when changes take place gradually. -Greening efforts are intricate and require multidisciplinary collaboration between all healthcare personnel and hospital management, adequate leadership and guidance, implementation of an environmental greening team, staff education, and a predilection for new and novel environmentally friendly technologies. -Every small step counts toward reducing the ecological footprint.
Kheirabadi & Sheikhi 2022 [12]	-Reprocessing multiuse devices and recycling plastics is encouraged, with consideration to the specific material compatibilities and the potential risks of various sterilization methods (thermal, radiation, and chemical). -Both mechanical and chemical recycling can be useful to recover valuable materials from medical waste. -Machine learning for waste classification and public awareness campaigns can address the lack of standardized waste sorting. -Economically viable recycling processes, bio-based plastics to reduce environmental impact, and strict adherence to established protocols can ensure safety and efficiency in recycling practices.
Xiao et al., 2021 [21]	-The Sustainability Roadmap and the HospiCycle toolkit are valuable, vendor-neutral resources that can help institutions set up recycling programs. -Implementing a consistent color scheme for waste bins helps reduce ambiguity and prevents the mixing of waste streams. -Consider donating open-but-unused supplies to developing nations through reputable programs such as the REMEDY program or Not Just Tourists. -Reformulate standardized kits and remove items that are routinely left unused. -Sharps containers should only hold items capable of puncturing the skin, not empty syringes themselves, to limit overfilling with waste that could be recycled in some jurisdictions; for safe sharp disposal, consider reusable sharp containers with a needle adaptor that can lock the needle and automatically twists it off the syringe, allowing the disposal of only the needle instead of the entire syringe and needle unit. -Preferentially purchase supplies and equipment from companies that align with the hospital’s sustainability goals. -When optimizing their supply chain decisions, end users should pressure manufacturers for more environmentally conserving packaging and extended producer responsibility, where manufacturers of the product are responsible for the take-back, remanufacturing, recycling, and end-of-life management of the product. -Before starting recycling operations, conduct a prospective waste audit (internally or with third-party auditors) to benchmark the waste stream and determine what portions can be targeted by a recycling program. -Institutions can create a “Waste Wizard” sorting tool that guides proper recycling and disposal practices. -Measure program performance through periodic audits and provide measurable results, such as disseminating waste reduction outcomes regularly (e.g., in hospital newsletters) to energize and engage staff members. -Sustainability committees should comprise the following: (1) senior leadership (authority to approve capital investment and equipment purchases); (2) representatives from support services such as facilities, environmental services, and procurement to manage operational infrastructure for sustainability practices; (3) a sustainability officer whose primary responsibilities are to lead environmental initiatives and collect statistics; and (4) multidisciplinary clinical champions (e.g., front-line healthcare providers, surgeons, anesthesiologists, and nurses) to liaise communication efforts between environmental services and departments and coordinate staff education and action plans.
Ma & Han, 2024 [22]	-The 5 R’s help to positively impact our carbon footprint—Reduce, Reuse, Recycle, Research, and Rethink. -End users should collaborate with vendors who focus on producing greener materials and creating kits that reduce waste of unnecessary equipment. -A just-in-time model can be used to prepare only the necessary equipment and supplies to reduce waste. -Staff education on recycling practices promotes recycling of materials. -Teamwork promotes a common culture committed to working toward a carbon-neutral environment.
Linstadt et al., 2020 [23]	-Minimizing the amount of waste produced is the primary goal, which can be accomplished through more sustainable procurement practices. -Improving purchasing patterns includes working with suppliers to request and support development of environmentally preferred products and redesigning products to minimize waste. -Staff education is critical to waste reduction programs. -Decreasing disposable single-use devices in favor of reusable medical equipment can decrease waste and reduce the need for additional procurement. -Although recycling is an element of climate-smart healthcare and helps minimize the total volume of landfill waste produced, its overall contribution is minor.
Joseph et al., 2021 [24]	-Medical professionals should be educated on the value of recycling. -Programs should ensure that recyclers understand not all the materials being sent are contaminated or hazardous. -Materials must be segregated and categorized at the source, with the preparation of the internal collection system at each source. -Correct separation of medical plastics is important for efficient recycling. -Staff must be properly trained in handling and sorting recyclable materials. -Reuse products after sterilization whenever possible. -Unused medical supplies can be donated to non-profit organizations.
Kleber & Cohen, 2020 [25]	-Nurses can lead sustainability efforts by example through actions such as informing colleagues, friends, and family about sustainability efforts and supporting legislation to incentivize recycling and reduce emissions. -Information about sustainability efforts should be shared with other departments, administrators, and at conferences. -Nurses should advocate for green purchasing, recycling, and waste diversion. -Personal actions to promote sustainability efforts include communicating using electronic devices, printing double-sided, and using only necessary supplies. -Creating green initiatives, green teams, recycling workflows, and visual reminders can boost sustainability efforts. -Nursing-led interventions can result in reduction of wasted supplies. -Healthcare organizations should have a financial incentive to facilitate and encourage proper waste sorting, wherein local, state, and/or federal fines may be imposed if materials are not separated correctly. -Health Care Without Harm provides resources, including sample policies, to help clinicians jumpstart environmentally preferable purchasing programs. -Recycling bins should be readily available. -Demonstrating institutional cost savings is advantageous when engaging nursing and hospital leadership in waste reduction. -Supplies that can no longer be used can be donated to organizations that sort and distribute the supplies to healthcare systems in need around the world. -Purchasing single-use emesis basins, urinals, and bedpans made from 100% recycled molded pulp allows sewer disposal, reducing plastic waste, fossil fuel use, and hospital solid waste costs.
Harding et al., 2021 [26]	-Extending the lifetime and/or reuse of materials has higher value than recycling, but both interventions should be combined, as reuse is not always possible. -Clear labeling assists with communication of cleanliness of reusable instruments for future use. -The composition of supply sets should be reconsidered to reduce waste. -Availability of different recycling receptacles should be convenient and varied.
Azouz et al., 2019 [27]	-Most participants were concerned about the amount of garbage produced at their hospital, had a positive attitude toward recycling, and were active recyclers in their homes/community -Many respondents stated that proper training and labeling of recyclable materials would be most effective in improving operating room waste management. -Signs describing proper disposal of sharps were created and placed on each sharp container in the operating room to improve waste management. -A cost savings of 10.3% was achieved in sharp waste disposal expenditure, savings that could offset monetary intervention costs such as printing recycling signs.
Mallick et al., 2022 [28]	-Industries should take proactive measures to contribute to a more circular economy for disposable medical devices. -Companies can envision internal and/or reputational value to be recognized as a “green leader” or see financial value from reusing post-consumer recycled materials in the company’s own production; establishing a reverse value chain can contribute to envisioned value. -Collaborative partners and stakeholders are important contributors to a project’s success and may include state and local government, distributors and wholesalers, and relevant associations. -Designing a user-centric, workstream-based approach can provide a practical framework for the development and implementation of take-back programs. -Workstreams should identify recycling solutions in terms of recycling technology and infrastructure, in line with the broader take-back strategy, and find end markets for the recycled materials. -Logistics solutions need to be lean and utilize the existing setup to the greatest extent possible. -Additional workstreams on program management, business modeling, and Life Cycle Assessment may be needed. -Cultural norms matter; if the target group is already accustomed to the idea of sorting other wastes at home and the benefits of recycling are already anchored, incentivizing is not required (in Denmark, there is innate trust in authorities, and thus also in waste sorting obligations). -Communication and marketing plans can increase engagement by identifying where users want to learn about take-back, which tools and media to use, and where users would like to hand in their devices. -A visual identity image can explain the life cycle of the product.
Choi et al., 2022 [29]	-Recognition of the adverse link between microplastics and health was a major factor promoting zero-waste awareness and behavior, but participants showed low recognition regarding the health effects of microplastics; students must be offered more education to help them acquire reliable information, promote zero-waste behaviors such as segregation of disposables, and foster thinking on minimizing environmental pollution or microplastic usage. -Collaborative systems with universities should be built and operated to provide zero-waste-related education programs and campaigns for students. -More promotions and exciting public relations campaigns are required to encourage people to change their habits and inculcate zero-waste behaviors. -Companies should develop various alternative products that customers can use conveniently.

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3.1.1. Theme 1: The 5 R’s

Adapted from the traditional “reduce, reuse, recycle” model, the 5 R’s of sustainability now refer to “reduce, reuse, recycle, research, and rethink” [22]. The original three R’s are still included to represent the lifecycle of the product itself through creation, use, and disposal. The two additional R’s represent strategies to determine the leanest creative approaches for waste reduction. Ma and Han emphasize that rethinking, an essential component in shaping effective, sustainable practices, plays a pivotal role in influencing the other R’s and promoting long-term, carbon-neutral environmental strategies. These combined concepts also shift the mindset to consider the overall impact on the carbon footprint in addition to the reduction of physical waste.

Reduce, Reuse, and Recycle

Suggestions for reduction included decreasing the purchasing of single-use devices, purchasing reusable products, and/or purchasing products made of recyclable or compostable materials when appropriate [22,23]. Reduction can also refer to lessening the use of standard packages or kits that may contain unnecessary items. Ma and Han [22], as well as Wyssusek et al. [11], suggest the use of a “just-in-time” model to prepare only the necessary equipment and supplies immediately before they are needed to reduce waste rather than having wasteful standardized kits containing equipment for multiple different procedures, a concept from the operating room setting that could easily be applied in the educational setting. Documentation of waste being produced may also bring awareness and serve as a waste reduction strategy by simply drawing attention to the issue [11]. Waste reduction efforts in healthcare simulation centers can also occur outside of managing medical supplies; for example, Wyssusek et al. [11] suggest the use of hand dryers rather than paper towels to reduce waste from both the towels and the garbage bags needed for disposal, though consideration must be given to the overall carbon footprint over time, energy efficiency, chemical use during resource production, and the biodegradability of paper products. Collaboration with vendors who focus on producing greener materials, thereby purchasing products that inherently reduce waste from unnecessary equipment packaging, can also be an effective reduction strategy [21,22,23].

Reuse is cited as the most common waste reduction strategy already in use within healthcare simulation centers [3] and is generally preferable to recycling, which is often complicated by recycling restrictions [24]. Reuse may be internal, such as having students reuse catheterization kits for practice rather than opening a new sterile kit each time, or external, such as having an affiliated hospital system donate expired fluid bags that would otherwise be discarded to the simulation center. Healthcare simulation centers can also donate their unused supplies to non-profit organizations that can assist with redistribution, such as the Afya Foundation, the Recovered Medical Equipment for the Developing World, and Not Just Tourists at Yale University programs [11,21,24,25], or to local schools/art centers as supplies [11]. Communication of the cleanliness and/or intended future use of reusable instruments (e.g., labeling) is also a good facilitator of reuse efforts [26].

Recycling was often discussed in the articles as one of the most difficult strategies to implement. Many articles cited that the ease of recycling can determine whether that strategy is successful or not. However, some strategies were suggested within the articles to improve the ease and use of recycling practices. Recycling bins should be available in convenient locations, particularly close to the area of product use [27]. Clear signage further creates an impact on recycling. While one study focused on isolation rooms in hospitals, implementing recycle bins in each room and minimizing supplies entering the rooms are practical steps toward this goal, which are transferable to educational settings. Much like reuse, clear labeling of recyclable materials has also been identified as a strategy to improve recycling efforts [8,11,21,27] and properly separate waste from recyclable materials [25]. Visuals on recycling bins that show the products’ life cycles and what other products could be produced from the recycled waste may also be helpful to explain and encourage recycling practices [28]. Bins should also be sufficiently large and/or emptied regularly to avoid overflow [8]. However, recycling may not save money initially due to upfront costs, which should be considered by those trying to implement recycling plans within their facilities [3].

Research and Rethink

The concepts of “research” and “rethink” are often intimately linked to participatory efforts within the previous three R’s. The inclusion of “Research” implies the need to conduct studies evaluating the impact of environmental interventions that are implemented to objectively determine if they were successful [22]. However, in the included articles, “research” was largely contextually focused on completing an internal assessment of waste within one’s own facility, known as a waste audit [3,21]. Additionally, due to the difficulty with recycling and the differences in recycling capability by location, it is necessary to research the life cycle analysis of recycling available in one’s own area/state/country before attempting to implement a recycling program [3,10]. Mallick et al. [28] identified that workstreams should identify recycling solutions in terms of recycling technology and infrastructure, in line with the broader take-back strategy, and find end markets for the recycled materials. Similarly, the concept “rethink” often refers to creatively approaching one of the other three R’s by changing common or dogmatic practices, such as not pre-packing or opening unnecessary supplies ahead of time [11,21,22,26]. Implementing sustainable changes with new products and/or practices often requires a shift in thinking as well as a personal willingness to change to ultimately be successful [25]. While understanding the 5 R’s provides a framework for sustainability practices, implementation requires effective strategies to engage stakeholders at all levels.

3.1.2. Theme 2: Getting People Motivated

There are several themes that emerged when trying to get people motivated to use the 5 R’s and engage in other sustainability efforts. These themes are important for institutional buy-in from all stakeholders to make permanent change.

Education and Acceptance

To boost motivation for using the 5 R’s, it is crucial to educate and engage people in sustainability efforts [27]. For example, major obstacles that continue to be a barrier to recycling include a lack of knowledge about what and how to recycle. Education on how to further reduce the environmental footprint begins with understanding how innovative products, like single-use molded pulp paper items, can further reduce the environmental footprint [25]. These products, derived from recycled newspaper, are ground and disposed of via the sewer system, decreasing the volume of nonbiodegradable waste and reducing reliance on fossil fuels. Understanding the process from start to finish can help boost an individual’s feeling that the task being asked of them is worth their time and effort.

Lack of knowledge as a barrier applies not only to contaminated materials but also to inconvenient bin locations, insufficient incentives, and time constraints [27]. Azouz et al. [27] noted that 89.6% of survey participants from four Mayo Clinic campuses reported recycling home items, indicating that there is learning and action occurring regarding recycling in general. By viewing sustainability efforts as a lifestyle change rather than a workplace requirement, the recognition of the adverse links between microplastics and health can promote behavioral changes in lifestyle for both locations [29]. Further education is warranted for understanding the value of recycling, knowing that not all materials are hazardous, and to train staff on the proper handling and sorting of recyclables in workplace settings [24].

Setting Clear Standards of Practice

According to Kleber and Cohen [25], nurses can be the leaders for change by creating environmental sustainability practices. A nurse-led standardization effort providing clear standards of restocking in the intensive care unit led to a waste reduction of supplies by 45–80% [25]. Similarly, Vogt and Nunes [8] discussed the importance of clear recycling guidance for handling recycling waste disposal. Providing information about waste and how it is to be recycled helps motivate people. People are motivated to recycle waste if it is made easy with bins that have clear labeling, and feedback is given on how the cost and benefit make a difference [8].

Emphasizing Cost Savings

Cost savings are also important to recognize, particularly when considering that annual savings can offset the initial monetary costs of sustainability interventions. Azouz et al. [27] found a 10.3% savings in sharp waste disposal expenditure post-intervention compared to the pre-intervention data of the year prior. Healthcare organizations have strong financial incentives to promote proper waste sorting, as non-compliance with local, state, and federal regulations can result in fines [25]. Simulation training for staff can further reinforce these practices [27]. Demonstrating these savings is beneficial for garnering support from nursing and hospital leadership for broader waste reduction initiatives.

Internal Collaborative Efforts

Three areas important to sustainability include teamwork and collaboration, creating committees, and student champions. Teamwork and collaboration should occur with vendors who focus on producing greener materials and creating kits that reduce waste from unnecessary equipment [22]. Xiao et al. [21] discuss the importance of creating committees capable of coordinating successful action plans with senior leadership who have approval authority for capital investments and equipment purchases. Additional committee membership should include a dedicated sustainability officer from support services, who can lead initiatives and gather relevant data, as well as multidisciplinary clinical champions who facilitate communication between environmental services and clinical departments [21]. Student champions can also be important and active members of these committees. Teaching students to be environmentally conscious, resourceful, and judicious with supplies and the reason behind why sustainability practices are important can lead the charge to creating a sustainable healthcare environment [3].

3.1.3. Theme 3: Larger External Collaboration

Effective sustainability practices in healthcare require more than just internal policies and individual efforts. Exploring how healthcare organizations, including simulation centers, can achieve greater environmental impact through external partnerships, regulatory engagement, and system-wide initiatives is important to overall sustainability efforts.

Interdisciplinary Partnerships and External Engagement

Interdisciplinary collaboration within hospitals and with external stakeholders is essential for advancing sustainability and waste management practices. Initiatives such as Returpen™ and operating room greening programs rely on diverse expertise, shared goals, and partnerships across sectors [11,28]. Effective communication, coordinated efforts, and engagement with regulatory bodies, industries, and local communities are critical for designing and implementing successful programs that reduce environmental impact [11,28]. Expanding on these concepts, Xiao et al. [21] indicated that purchasing supplies and equipment from companies that align with recycling and sustainability goals influences manufacturers to be innovative and environmentally responsible. A collaborative approach between partners and stakeholders that includes local government, distributors, and wholesalers is important to creating change. Mallick et al. [28] proposed a framework based on their experience piloting a take-back system for single-use medical devices to encourage a more circular economy within the healthcare industry.

Technological Solutions

The intersection of external sustainability initiatives and emerging technologies presents promising opportunities to advance medical waste reduction efforts. Machine learning applications have shown potential for enhancing waste management systems [12]. These applications enable computers to analyze data patterns and optimize performance through algorithmic learning [30]. Development of specialized algorithms for medical waste reduction, including intelligent sorting systems, could better distinguish and separate mixed recyclable materials in healthcare settings.

Regulatory Frameworks and Compliance

Legislation can drive efforts to make sustainability practices a priority within healthcare facilities and education. Effective recycling initiatives require collaboration among stakeholders, policy changes, and incentives, such as augmented taxes or supplier-led programs, to ensure participation and long-term sustainability [10,11]. Legislation can play a critical role in regulating waste management and shaping recycling practices, as seen in frameworks like the United Kingdom’s Health Technical Memorandum 01–05 and Australia’s Waste Reduction and Recycling Regulation, which prioritize safety and environmental outcomes but often lack sustainability considerations [10,11]. Healthcare organizations can face financial penalties, such as fines for improper waste disposal, highlighting the importance of adhering to regulatory frameworks and guidelines to ensure compliance and avoid costly repercussions. For example, in 2016, two hospital systems in Pennsylvania were fined for improper disposal of medical waste [25]. Effective waste management and recycling programs, supported by staff education and strategic planning, are essential to meet regulatory requirements and promote sustainable practices within healthcare settings [28].

National Policies and Strategic Initiatives

Mallick et al. [28] and Martin et al. [10] underscore the importance of national support, policies, and collaborations in advancing environmental sustainability within healthcare, as seen in initiatives like the United Kingdom’s Control of Substances Hazardous to Health regulations and Denmark’s Returpen™ program, a collaborative take-back initiative for single-use or disposable medical devices in homecare settings. Economic realities and even regulations may create forces that inhibit effective sustainability practices. Martin et al. [10] explore the role of national guidelines in promoting sustainability in dentistry, emphasizing the challenges of balancing infection control measures, such as increased use of single-use plastics and personal protective equipment, with environmental sustainability goals. Suggested solutions include eco-friendly curricula, policy changes, and international collaboration to address these complexities and improve sustainable practices in dental care [10]. Implementing standard procedures, such as purchasing and incentivizing returns, would reduce waste in the clinical learning setting. Effective sustainability efforts require supportive regulatory frameworks, stakeholder partnerships, and educational reforms to drive meaningful change and ensure compliance with environmental goals [10,28].

4. Discussion

This scoping review is intended to synthesize best practices related to environmental sustainability in healthcare education simulation centers. In recent years, healthcare simulation centers have begun to incorporate sustainability into their operational practices. Sustainable practices, such as reusing consumables and recycling materials like intravenous tubing and solution bags, have been implemented to reduce waste within simulation environments [31]. The integration of eco-conscious initiatives aims to minimize the environmental impact of healthcare education while maintaining high-quality training experiences [31,32]. Furthermore, the commitment to sustainability aligns with the broader goals of promoting environmental responsibility within the healthcare sector. Simulation centers can act as hubs for climate action by adopting sustainable practices and contributing to a more sustainable healthcare system [31].

4.1. Implications for Practice

Three themes emerged from this review: the 5 R’s, getting people motivated, and larger external collaboration. The implications for practice include cultural change, cross-sector collaborations, integration of sustainability practices into existing workflows, and advocacy for policy development. Bathish et al. [3] discussed the importance of fostering a culture of sustainability through education and leadership in healthcare simulation settings. Partnering with external stakeholders such as waste management firms can address systemic challenges and promote sustainability efforts [25]. Embedding sustainability practices into everyday workflows, such as waste segregation, can improve adherence [26]. Additionally, advocacy for healthcare professionals to engage in policy-making is critical to drive systemic change and secure funding for sustainable initiatives [11]. While not included in this review due to publication after the search was completed, an international survey completed by Marsack et al. [33] showed differences in sustainability efforts and success rates across different nations, indicating larger implications for international collaboration and the sharing of best practices. Overall, the disposal of healthcare plastic waste has a small relative impact compared to efforts that occur upstream in the supply chain. Focus should be placed on sustainability efforts related to manufacturing, processing, distribution, and logistics, as they have a larger impact on plastic use and disposal [10]. Healthcare simulation centers can aid in these efforts by pressuring suppliers to engage in more sustainable practices, such as recycling and/or taking-back materials, eliminating restocking fees to encourage the return of unused products, and generating plastic products more responsibly with recycled plastic or less carbon dioxide emissions.

To effectively promote environmental sustainability within healthcare simulation centers, it is crucial to incorporate sustainable healthcare practices into healthcare education curricula. Environmentally sustainable practices must be adopted by as many institutions as possible to retain and promote planetary health. Integrating sustainability principles into nursing curricula would also align with educational competencies outlined in the American Association of Colleges of Nursing Essentials Domain 3, which emphasizes the impact of climate change on health and population [34]. Early introduction with consistent incorporation of content related to sustainable healthcare would emphasize its significance in shaping the professional identity of healthcare education students. This integration can enhance the capacity of future healthcare professionals to adopt sustainable practices and positively contribute to planetary health [35].

4.2. Action Items—What Simulation Centers Can Do Now

There are relatively simple changes that can be adopted within healthcare simulation centers to boost environmental sustainability efforts without external assistance, as suggested by the healthcare simulation sustainability framework (Figure 2). Reuse is by far the most accessible option, with common items for reuse including IV tubing and bags, syringes, prepackaged kits such as straight catheter kits, and mock medication vials and bags. Maintaining fidelity can be a challenge, but adopting practices that reduce waste from reusable supplies can maintain realism when reusing supplies. Reduction of supplies can also result from changes in standard practices. For example, some healthcare simulation centers prepare kits for each student to take home, including new sterile packages for each item they may need to practice with. If students do not use those items, they become unnecessary waste. These kits can either be avoided entirely, or students can be instructed to return unused items at the end of the term.

Externally, healthcare simulation centers should inquire into local recycling practices and restrictions to determine the recycling capacity in their own area. While not every item used in a simulation center is recyclable, such as intravenous tubing, which contains multiple types of plastic and gets tangled in processing lines, other items such as emesis basins, may be readily recyclable. Signs on recycling bins and education within the institution should be updated to easily show which items are recyclable and which must be discarded. Partnering with local healthcare systems can result in limiting expired supplies entering the waste system by donating these supplies for safe use within healthcare simulation centers. This maintains fidelity and avoids unnecessary waste of products that cannot be utilized in the healthcare setting.

Guidelines also exist from institutions and larger organizations for healthcare simulation centers to utilize. Some universities and clinics have posted specific guides for campus environmental sustainability on their websites, such as the Mayo Clinic [36], the University of Minnesota [37], and the University of Michigan [38], to make referencing sustainability practices easier. A governmental example is the National Health Service Trust in England [39], which aims to provide implementable strategies such as virtual simulations, reusable packaging, and teaching modules. Calls for action have also emphasized the importance of identifying a “sustainability champion” within your organization to keep processes organized and moving forward [40].

4.3. Future Directions

Strategic cross-disciplinary partnerships represent one key avenue for progress. Collaborations with engineering and other technical fields could accelerate the development and implementation of innovative waste reduction solutions, such as those involving machine learning. Additionally, systematic literature reviews examining sustainability practices across different industries and workforce sectors may reveal transferable approaches that could be adapted for healthcare environments.

To achieve widespread impact, sustainability principles must be embedded within the foundational guidelines of major healthcare organizations. Incorporating these best practices into established frameworks such as INACSL’s Healthcare Simulation Standards of Best Practice^® would ensure consistent distribution of sustainability principles across diverse healthcare simulation programs. This integration has the potential to fundamentally transform how healthcare simulation education addresses environmental responsibility, establishing sustainability as a core component of simulation practice standards rather than an optional consideration. These developments collectively position sustainability as an integral element of healthcare simulation’s evolution, moving beyond isolated initiatives toward systematic, evidence-based environmental stewardship that can be scaled across the healthcare education sector.

4.4. Cost Implications

Simulation centers must grapple with the cost of recycling materials, which is often more expensive than simply discarding them [23]. Return on investment may factor into initiatives where the cost to recycle impacts decisions. Kleber and Cohen [25] discussed the significant upfront costs associated with purchasing reusable equipment as well as establishing recycling programs. One way to mitigate these expenses is to work with other departments or nearby hospital systems to share the cost of recycling pickup. While one building or department alone may not produce enough waste to justify this cost, sharing the cost and producing a larger total volume of recyclables is beneficial for all parties involved. Although negative economic impacts may be more apparent, long-term cost savings and the hidden costs of non-sustainability should be considered when advocating for environmental sustainability practices. Ma and Han [22] demonstrated through cost analysis that investing in sustainable practices can yield long-term financial savings despite initial expenses. Hidden costs of non-sustainability regarding waste mismanagement include environmental cleanup and health implications [29].

These efforts are also starting to be recognized and encouraged through incentives from large organizational bodies. The Joint Commission helps healthcare organizations reduce their carbon footprint by offering certification that aligns them with sustainable practices [41]. This certification benefits healthcare organizations by minimizing their environmental impact, potentially qualifying them for cost-saving tax incentives, attracting like-minded individuals to enhance community engagement, and, most importantly, contributing to improved health outcomes for the population.

4.5. Additional Sustainability Initiatives

A number of other interesting ideas arose from the literature review that, while beyond the scope of the PICO question, are tangentially related to the goal of increasing environmental sustainability in healthcare simulation education. For example, nurses and midwives in Australia collected vial caps for creative projects to create pens with the waste [40]. Increasing the use of virtual and/or extended reality would also inherently reduce the use of real plastic materials [42]. Other articles proposed donating simulation waste for use in construction materials [43,44,45]. Research findings could also inform the development of regulatory policies aimed at reducing the environmental impact of microplastics [46]. It may be more practical to collaborate with local resources on such initiatives rather than undertaking the work independently.

4.6. Limitations

While this scoping review was conducted following rigorous standards of practice, it does have limitations. The literature search was restricted to specific dates, which may have resulted in missing relevant data published before or after the selected timeframe, especially given the rapid growth of this field. Additionally, the exclusion of gray literature and COVID-19-focused materials, deemed too niche for this review, may have further limited search results during data extraction. However, broad search terms were used across multiple databases to mitigate these limitations and ensure a comprehensive scope. Lastly, the study team reviewed only articles written in English despite the global nature of these efforts. Nonetheless, the inclusion of studies from nine countries provides some insight into international initiatives in this area.

5. Conclusions

This scoping review compiles best practices for environmental sustainability in healthcare simulation education. However, the limited research in this area highlights significant opportunities for improvement and future exploration. While barriers to implementing sustainable practices exist, this review has identified practical next steps and solutions to address some of these challenges. With growing interest in sustainability and technological advancements, progress in related areas, such as machine learning for recycling optimization, may extend to reducing medical waste.

Education and stakeholder engagement will remain critical to the success of sustainability efforts. While individual actions in environmental sustainability are important, this review’s findings highlight that meaningful waste prevention cannot be accomplished by these efforts alone, nor can recycling be relied upon as the sole solution. Sustainability must be addressed at a systemic level, with lawmakers and medical suppliers playing key roles in recycling, material take-back programs, and adopting sustainable production and shipping practices. The ultimate goal should be a collaborative approach to environmental stewardship, where every stakeholder, from supply chain manufacturers to educators and students, actively contributes to the sustainability of healthcare education. By working together, we can ensure a more sustainable future for healthcare simulation and beyond.