Regulation of Health Professionals’ Work as a Climate Mitigation Strategy: Opportunities, Responsibilities, and Challenges

Abstract

Background: The climate impacts of health professionals’ work are significant. The potential role and opportunities for regulators of health professionals’ work to drive behavioural and practice change have not been adequately explored in the literature. The objective of this research was to examine regulators’ perspectives on the potential role of health professions’ regulatory bodies in advancing the adoption of climate-conscious professional practice. Methods: Semi-structured interviews with 19 regulators overseeing the practice of health professionals in medicine, nursing, pharmacy, and dentistry in Canada were undertaken. Constant comparative data analysis using nVivo v15 was undertaken to identify common themes. The COREQ framework was applied to ensure the quality of the research processes used. Results: Participants highlighted their belief that there are only limited opportunities for health professions’ regulators to lead climate-positive practice change, despite their personal beliefs in the importance of the topic. The use of educational approaches, rather than legal or regulatory tools, was emphasized. Concerns were raised regarding regulatory overreach, practitioner blowback, and practical/logistical considerations. Coalition building across different facets of a profession (including educational institutions, unions, workplaces, and professional/advocacy groups) was identified as potentially most impactful. Conclusions: Previous research had highlighted practitioners’ beliefs that regulators had significant legal and practice-directed levers that could drive behavioural change towards more climate-friendly health care work. This research has highlighted regulators’ discomfort with assuming a legalistic role. Instead, they favoured persuasive techniques such as education and coalition building that may nudge, rather than compel, practitioners towards more climate-friendly practice.

1. Introduction

The climate impacts of health care work have been well described and highlight the reality that, in the name of healing, health care professionals’ work creates significant environmental burdens. It is estimated that the health care sector contributes 4.6% of all global greenhouse gas (GHG) emissions [1]. Prescribed and over-the-counter medications alone account for more than 1% of GHGs [2]. Harms resulting from “pharmaceutical pollution” contributes to biodiversity loss, drives antimicrobial resistance, and threatens both planetary and human health [3]. The auxiliary supplies and equipment used by health care professionals (such as alcohol swabs, disposable needles, single unit-of-use containers, and sterile packaging) further compound negative climate impacts, produce additional GHG emissions, and create legacy chemical and plastic pollution [4,5].

The fact that health care professionals who aim to heal are actually contributing to ill health through the polluting facets of their work has been noted across many different professions, including medicine, nursing, pharmacy, and dentistry [6,7,8,9]. Diverse groups within and across these professions have emerged, advocating for the “climate-conscious practice” of professions that ensures that patients are protected from possible harm or infection risk, and that planetary health is also a top-of-mind consideration in the day-to-day work for professionals.

Ranging from grassroots organizations of concerned professionals to profession- and industry-wide affirmations and commitments, momentum within health professions to mitigate the climate impacts of their work appears to be growing [10]. Given the size of the health care sector globally, there are numerous points in the research, development, manufacturing, distribution, procurement, storage, and disposal processes where opportunities may exist to reduce climate impacts [10]. Climate-conscious practice typically focuses on the decisions and work of front-line patient-facing health professionals rather than on the choices or decisions made by large employers, organizations, or health systems [10]. The adoption of climate-conscious practice by front-line health care professionals appears to be frustratingly slow in gaining traction [10], particularly in community-based primary care or outside large organizations such as academic health centres.

Recent research examining the pharmacy profession highlighted significant barriers to enacting meaningful change towards climate-conscious practice at the community level [11]. This research, undertaken with front-line primary care/community-based pharmacists highlighted the challenging realities faced by “average” health professionals primarily concerned with ensuring the health and well-being of their patients. While all participants in this study were aware of and accepted the realities of climate breakdown in general, few truly understood the ways in which their own work as health care professionals contributed negatively to climate outcomes. The polluting effects of health care practices that are widely used and generally accepted were rarely, if ever, the subject of mindful or intentional practice change. For example, consider the routine use of an alcohol swab prior to the administration of a vaccine by injection. This practice is rarely if ever questioned or reflected upon by health professionals. The notion that alcohol swabbing prior to administration of an injection is necessary to prevent infections is widely accepted and expected by patients, despite ambivalent evidence of its value and effectiveness [12]. Such “hygiene theatre” is replicated literally billions of times daily by health professionals around the world, leading to the negative climate impacts of health care work. Participants in this study noted that they are extremely busy and overburdened in simply providing primary care services to their patients and have neither the time nor the intellectual bandwidth required to meaningfully engage in climate-conscious practice change, despite their acceptance of its importance and value. They noted that in an increasingly cost-constrained, competitive, and resource-depleted health system, workplaces, managers, and organizations were also unlikely to lead change in this area. Of interest, most participants in this study suggested that one group within every profession could (and potentially) should provide the kind of change required, change that would then compel all professionals to practice in a more climate-conscious manner: regulators.

Professions such as medicine, nursing, pharmacy, and dentistry are often referred to as “regulated health professions” as these roles can only be performed by qualified individuals who have been vetted for competency by an external non-employment-based agency—a regulatory (or licensing) body [13]. Regulatory bodies oversee the work of health professionals and are mandated to focus on the protection of the public’s best interests. Regulatory bodies do not function to advocate for professions or professionals but instead to serve and protect the public and patients’ rights. As part of this public protection mandate, regulatory bodies use a system of registration (or licensure) that requires prospective health professionals to prove they are competent and can provide safe and effective care to patients. Competence is assessed through (for example) completion of an accredited education/degree program at a recognized post-secondary institution (college or university), completion of a pre-qualification in-service clinical training program (e.g., an internship or residency), successful completion of post-education program tests (e.g., licensing examinations), and other requirements. Members of the public who feel they have been harmed by a health professional are free to file formal complaints, which are then investigated, and, where warranted, will be the subject of a disciplinary process. Regulatory bodies also have the power to require compulsory continuing education or other activities designed to ensure that professionals maintain their competence over a lifetime of work. Regulatory bodies also have the ability to develop and enforce regulations—legal instruments that compel licensed professionals to behave in a specific manner with specified sanctions or penalties should they breach these regulations. The role of a regulatory body in the life of a health professional is significant, and regulators have a strong steering effect on both individual professionals and on professions through the variety of roles and responsibilities they have. Thus, it is not a surprise that health professionals themselves identified regulators as having a potentially large and currently unfulfilled role in driving climate-conscious practice in professions.

There is currently scant research examining the role of health professions’ regulators in driving climate-positive professional practice. The objective of this research was to explore regulators’ perspectives on their opportunities, responsibilities, and challenges in leading climate-conscious practice changes within professions. This is based on health professionals’ beliefs that regulators of health professionals’ work may have a significant but unrealized role to play in this area. This research aims to examine regulator’s perceptions and beliefs about their potential role in supporting carbon reduction goals through use of regulatory tools designed to drive climate-conscious professional practice.

2. Materials and Methods

Given the paucity of the extant literature on the topic of health professionals’ regulators’ roles in driving climate-conscious practice change, an exploratory qualitative research method was selected. This approach has been identified as most appropriate when little is known about a topic of inquiry [14]. As an initial exploration of the topic, semi-structured interviews with regulators were identified as a useful initial research approach to learn more about their perspectives. Semi-structured interviews provide researchers with opportunities to more authentically engage with research participants and follow their lead while still maintaining a central research theme focus [15]. To ensure quality, indicativeness, and trustworthiness of the research, the consolidated criteria for reporting quality research (COREQ) checklist was utilized [16]. This widely used qualitative research tool is a 32-item checklist for interviews that guides researchers in ensuring their work meets expectations with respect to quality and reliability and provides reassurance that researchers’ inherent subjectivities and biases do not disproportionately distort research processes, data interpretation and analysis, or reporting.

For this project, four professions in Canada were selected: medicine, nursing, pharmacy, and dentistry. While there are many more and different health professions that exist, these four professions are amongst the largest, most common, and therefore most potentially impactful of health professions, particularly in primary care. All four of these are regulated health professions with well-established regulatory bodies that oversee the practice of individual professionals. Through a search of publicly accessible websites of regulatory bodies for these professions across Canada, key informants (regulatory staff members) involved in the provision of professional practice guidance to practitioners/clinicians were identified. Invitations to participate in this research were then emailed to these individuals, along with a description of this study.

The regulation of professions in Canada is undertaken on a provincial rather than federal basis; as a result, across these 4 professions, there are a total of 42 regulatory bodies in Canada. Information about this study was sent to each of the 42 regulatory bodies, along with an invitation to learn more about participation. Invitations were sent to the registrar/chief executive officer of the regulatory body.

A semi-structured interview protocol was developed and pilot tested [see Appendix A]. Four individuals participated in the pilot test and provided feedback with respect to the clarity and appropriateness of questions used during the interview; modifications to the initial protocol were made based on this feedback. Initially, the protocol consisted of 16 question prompts, but these were reduced in number and consolidated based on pilot testing. The final version of the protocol was designed to be sufficiently open-ended in its approach to allow each participant to more freely describe their experiences and perspectives while still retaining a central focus on the opportunities, responsibilities, and challenges faced by regulators with respect to climate-conscious professional practice. Interviews would be undertaken to thematic saturation, the point at which the research team believed no new or meaningful information resulting in new codes, categories, or themes being identified, was derived from additional interviews. All interviews were undertaken virtually using the Zoom platform. With participants’ permission, interviews were recorded, and verbatim transcripts were produced using Zoom’s automatic transcript function. The subsequent review and cleaning of these Zoom-produced transcripts was undertaken by the interviewer to ensure accuracy and clarity. Participants were offered the opportunity to review the transcript of their interview if they wished.

All transcripts were reviewed by two researchers who undertook independent coding and categorization of data using the constant comparative data analysis method [17]. Data were managed and analyzed using nVivo v15. After independent review and analysis, researchers met to achieve consensus on themes. Transcript data were referred to throughout the process to ensure an evidentiary basis for identified codes, categories, and themes. Throughout the process, the 32-item COREQ checklist was used to ensure all processes and methods conformed to quality expectations for participant-focused interview-based data collection.

This study received research ethics board approval from the University of Toronto, Canada.

3. Results

A total of 42 invitations to participate in this research were sent to regulatory bodies in Canada in the professions of medicine, nursing, pharmacy, and dentistry. Of these, 26 agreed to receive more information about this study and 19 agreed to participate in the interviews. All 19 who agreed to be interviewed were scheduled for a 45 min Zoom-based meeting with a researcher, scheduled based on mutual convenience. Of these 19 individuals who agreed to participate, there were 5 participants from each of the professions of nursing, pharmacy, and dentistry, and 4 participants from the profession of medicine, representing all 10 provinces in Canada. Key themes that emerged from this research included the following:

1.

Regulators’ awareness of health care-related climate impacts and principles of climate-conscious professional practice was highly variable.

2.

Regulation of climate-conscious practice is neither feasible nor appropriate at this time.

3.

Regulators prefer educational approaches that “nudge” rather than mandate climate-conscious practice change.

4.

Regulators believe that coalition building is vital and their key leadership role.

“Of course human-led climate change is a significant concern, not just for me as a regulator but for me as a human being, a parent. And I do wonder, worry…what can or should I be doing in my role as a regulator to reduce climate change impacts? I just…well, it’s so complicated, right? There’s only so much regulators can do using regulation, legal means. I know it sounds like we’re passing the buck, but there you have it.”

All participants in this study fully accepted the notion that human activity was leading to climate breakdown. All participants were aware of global political and social movements aimed at establishing thresholds for climate goals and accepted the notion that carbon reduction was essential at meeting national and international commitments. No participants expressed skepticism towards the notion of human-induced climate breakdown; all participants also noted that, in both their professional and personal lives, they had become increasingly mindful of climate impacts of everyday life and that, in their own way and within their own spheres of influence, they were attempting to reduce climate impacts they themselves generated (e.g., electing to take public transit to work rather than driving, or reducing the amount of printing of documents they undertook at their workplace). As a starting point, these results suggest that regulators themselves have a good understanding of the scientific consensus and realities associated with climate breakdown.

The degree of awareness associated with the climate impacts of health care work itself was much more variable. Some regulators in some professions had some awareness that health care work was polluting, or that GHGs that resulted from certain pharmaceutical products (e.g., anaesthetic gases and inhalers used for the treatment of asthma) were problematic, but no participants identified the scale or the magnitude of climate impacts of health care work. This lack of awareness of the size of the problem, or the connection between health professionals’ daily practice and increased GHG/carbon emissions leading to health-related problems such as asthma, antibiotic resistance, or chronic obstructive pulmonary disease was prevalent across all participants in this study.

Regulators’ understanding of the concept of “climate-conscious practice” was similarly highly variable. Typically, regulators described it in terms of personal or organizational strategies that are similar to those that members of the public undertake—for example, having recycling bins available in the workplace, or replacing incandescent bulbs with LED bulbs, or reducing the amount of paper-based printing required in the workplace. Few regulators could identify profession-specific practice changes that could lower carbon footprints and environmental impacts (for example, eliminating alcohol swabbing prior to the administration of vaccinations, or switching to lower carbon-impact inhalers for asthma or lower GHG impact anaesthetic gases for medical or dental procedures). Participants in this study generally interpreted “climate-conscious practice” as a simple extension of the personal responsibility they themselves took to be more mindful about environmental impacts rather than interpreting it as something focused on the actual work and practice of the profession they regulated. As a result, few regulators were able to identify opportunities for regulatory intervention to support more climate-friendly professional practice. Those able to identify a potential opportunity for regulatory intervention most frequently highlighted “de-prescribing” as a valuable initiative. De-prescribing is the process of rationally evaluating a patient’s medication regimen to identify opportunities to stop prescription medications that may not have any discernible function or purpose [18]. De-prescribing is valuable since prescribers will often initiate medications to deal with a short-term situation (e.g., insomnia or anxiety) but, once the short-term condition has resolved or been managed, they simply forget to discontinue it, or they avoid stopping the medication for fear of “rocking the boat” and upsetting the patient. The value of de-prescribing from an environmental perspective is clear: discontinuing an unnecessary medication is not only safer for the patient, it also means one less polluting substance that needs to be manufactured, distributed, stored, dispensed, and consumed.

The variable level of knowledge and awareness of climate-conscious practice amongst regulators raises several important points. First, the generally high level of knowledge about climate change in general, along with acceptance of the need for personal responsibility and collective action required to meet climate change goals, suggests that regulators in this study are not climate change deniers or skeptics. Rather, they are open and interested and recognize the importance of action to mitigate climate breakdown. Participants’ general unawareness of profession-specific climate-conscious practice raises important opportunities for the further education of regulators themselves but also highlights how those who oversee professions and their practice may be unaware of opportunities to reduce the climate impact of health professionals’ work. Without this awareness of climate-conscious professional practice, the ability of regulators to actually change the practice of the professions they oversee may be limited.

5.

Regulation for climate-conscious practice is neither feasible nor appropriate at this time.

“There’s just this general environment right now where everyone—I mean the public, especially government, but also professionals themselves—everyone is really cynical about the role of regulators, the value of regulation. I don’t think this is the time to be thinking about expanding regulation, or introducing new rules—the blowback and controversy would be just too much.”

All participants in this study expressed concern at the notion that regulatory bodies could or should provide leadership with respect to climate-conscious practice change. They noted that regulation is a “blunt instrument”, a highly legalistic tool for directing the behaviour of professionals and therefore should be reserved for exceptional cases. To most participants in this research, the use of regulation represented, in some ways, a failure of other approaches, most notably education, in driving practice change. Most participants cited the evolving notion of “right-touch regulation” as a philosophy of regulatory practice. Right-touch regulation means regulating only that which can only be managed through regulation, and using other means (e.g., education, incentives, persuasion) in most other circumstances.

Many participants also noted that in the current political environment, “regulation” as a concept was under siege as never before. Importantly, this research was undertaken at a time when regulation was being actively politicized and weaponized; for example, in the United States, the Department of Government Efficiency (DOGE) was working to systematically de-regulate across a wide swathe of industries in the name of enhancing cost effectiveness and efficiency of service delivery. Even in Canada at the time of this study, questions about regulatory overreach and concerns about unelected regulators imposing costly and unnecessary burdens on the public or workers were growing in frequency and intensity.

The concern about the “scope creep” of regulators was a central concern for participants in this study, as were general worries about how “new” or “additional” regulations would be accepted by both members of a profession and members of the public. Reticence to use the regulatory lever unless absolutely necessary emerged as a common cultural theme amongst all regulators in this study, regardless of profession or geographic location. This reticence was expressed in different ways. For some, there was a need for “overwhelming evidence” of the value, impact, and success of climate-conscious practice changes before regulators would consider using legislative or legal tools to require it. For others, there were concerns that climate-conscious practice is not the purview of a regulatory body but instead the remit of a professional society or educational institution, and that regulators needed to “stay in their lane” on this issue. For yet others, there was a belief that regulation was simply unworkable in this context, and would lead to litigation, poisoned relationships with members of the profession, and ultimately would further erode the reputation of regulators in the process.

The feasibility and appropriateness of regulators leading climate-conscious practice change was first identified in previous research examining practitioners’ views on the topic [11]. In that study of primary care community pharmacists, participants (who were all front-line health care professionals) expressed their concerns that employers and workplaces had limited interest in supporting climate-conscious practice due to the expense and logistical encumbrances associated with the idea. They also noted that individual practitioners are already overworked and under-resourced and lacked the bandwidth to implement it without support. From their perspective, regulators were the only group with a profession who had both the clout and the mandate to advance the idea: if regulators required climate-conscious practice, employers, workplaces, and individual professionals would have no choice but to comply in order to remain licensed as a professional. It would also level the economic playing field: costs and logistical encumbrances associated with climate-conscious practice change would be borne by everyone at the same time. Regulators were the only group within any profession who would make this happen, and, as a result, professionals themselves felt this was an appropriate and feasible approach for a regulator to take in order to actually effect climate-positive change within professions.

Regulators themselves rejected this premise and these arguments and instead highlighted potential risks to regulatory bodies themselves as a reason to avoid regulatory approaches in this context. Participants in this study did not necessarily rule out regulatory responses altogether but noted how important it would be to address these reputational and other risks to regulatory bodies prior to regulatory action. Several participants noted how the entire culture of regulation (not just in health care but across society) had changed very quickly over the past few years. Until recently, they noted, regulation was seen as both a public good and a political priority, an essential tool for safeguarding public interests and well-being particularly in the context of large corporations intent on maximizing shareholder value. Today, there is a prevailing political and cultural belief that regulation itself is problematic: it stymies innovation, increases costs, decreases accessibility, and ultimately creates unhelpful bureaucratic tangles. In today’s prevailing environment, regulators themselves appear very wary of extending regulatory power into new domains or areas as a way of countering concerns of regulatory overreach.

6.

Regulators prefer educational approaches that “nudge” rather than mandate climate-conscious practice change.

“Rules, regulations—that’s not the only tool we regulators have. One of the most important things we can do is bring together different parts of the profession—employers, professionals, unions, advocacy groups. They all connect with us in a unique way, so these kinds of coalitions can be led or at least initiated by regulators, but can then do so much more together than each individual group by itself. And this way, well, maybe together we can all encourage, or nudge individual professionals to change their practice instead of using a really blunt instrument like regulation.”

All participants in this study accepted the realities of human-caused climate change and expressed support for the need for action at the personal and organizational levels in order to meet carbon reduction targets and goals. While they rejected the notion of “regulation” as a tool or lever to accomplish this within professions, all participants noted that regulators have other approaches they could use in order to “nudge” professionals towards climate-conscious practice. The use of educational approaches and strategies was frequently identified as the preferred regulatory option, and one that fit within the remit of regulatory bodies and their public safety/protection mandate.

As noted previously, regulatory bodies have within their purview the ability to prescribe requirements for health professionals in order to ensure they continue to maintain competency across their entire working lifetimes. The model of health professions’ regulation invests considerable time and resources in assessing competency at entry-to-practice; prior to being awarded an initial license to be a doctor, nurse, pharmacist, or dentist, candidates must earn degrees from challenging university programs, undertake clinical placements and internships, and pass difficult licensing exams, all designed to ensure they are ready to provide safe and effective care and service to the public. Once licensed and regulated, there are limited requirements for re-testing or re-certification in most health professions. As a result, a person licensed as a dentist may work for 30, 40, or even more years and is generally “trusted” to maintain their competency over this time frame.

Most health professions recognize this as a potential public safety and protection risk and as a result use their regulatory powers to mandate some form of continuing education or continuous professional development. For example, in some professions, health care professionals are required to complete a minimum of 20 h of continuing education learning each year and provide documentation of successful completion of post-learning quizzes or tests as a pre-condition for renewing their license each year. Regulatory bodies that mandate continuing education or continuing professional development could use this platform to “nudge” or encourage climate-conscious practice through requirements that some portions of this compulsory requirement are focused on this topic.

Alternatively, in some professions, as part of the annual renewal of a license, there could be a requirement that individual professionals complete some kind of self-assessment audit that requires them to reflect upon and document their approaches to climate-conscious practice. By linking this educational activity to the annual renewal of a license that is required to continue to work in that profession, the regulatory body has the opportunity to “nudge” practice change without necessarily resorting to the blunt instrument of new regulation per se.

In yet other professions, maintenance of the competency of individual health professionals is evaluated through an on-site visit by a practice inspector. At this time, the practice inspector sent by the regulatory body observes the day-to-day work of the professional and offers education and coaching to help improve that person’s practice. Another educational approach within the remit of the regulatory body would be to focus this kind of practice inspection process on climate-conscious practice change. This education, coming from the regulator, could be potentially impactful and well-received by members of the profession, and in a way that does not require new legalistic or regulatory interventions.

Participants in this study expressed their belief that such educational interventions would be both more appropriate and feasible than regulatory or legal interventions and would still be aligned with the regulatory mandate to ensure safe and effective professional practice. They also felt this educational “nudge” would be more acceptable by members of the profession itself and less likely to cause blowback or raise concerns about regulatory scope creep. Regulators believed that educational interventions such as this could and would translate into actionable practice change, even without the weight of laws and regulations compelling it. They noted that professionals are typically highly motivated to do what is best for their patients, regardless of the presence of regulation or the threat of punishment. Using the regulator’s reach to bring education to all members of a profession is not a new or threatening process; most professionals will have experienced this already in some other context.

7.

Regulators believe coalition building is vital and their key leadership role.

“At the end of the day regulators don’t have as much power as people might think we do. If we over-reach with regulation, we lose the profession’s and the public’s trust and faith and…well, that’s where we seem to be with the public today. Instead we have to be part of, maybe lead, groups, a ‘coalition of the willing’, where different parts of the profession—including the unions and the employers for example. If we can bring everyone to the table so the profession as a whole can discuss and debate and decide how to proceed—then regulators have done a really important thing for their profession.”

The impetus behind this study were findings from a previous study [11] that front-line health care professionals believed that regulators of health professionals were best situated and well-suited to lead progressive changes towards climate-conscious practice. Lef to themselves—and without the regulatory “stick”—health professionals have limited time, bandwidth, or resources to enact this change. Employers, workplaces, and corporations have limited incentives to support such change given the time, costs, and logistical encumbrances that may evolve. As noted above, regulators appear skeptical and unwilling to assume this leadership role using regulation and regulatory bodies as the driver of practice change. Participants in this study did note, however, that there is a kind of leadership that they could support, related to building coalitions, that mobilizes different facets of the profession.

Regulators noted that regulatory bodies occupy a unique niche and powerful role within every profession; they are the only group that connects all members of a profession together. While some professionals may have studied at different universities and colleges, and other professionals work in different practice settings or for different employers, every single member of a profession is—by definition—a member (or “registrant”) of a regulatory body. One cannot be regulated as a health professional without being part of the regulatory body that governs that profession. As a result, within every profession, the regulatory body is the only group that connects every individual profession to itself. This reach provides both unique opportunities and responsibilities for regulators and gives them a powerful springboard to build even more trans-professional coalitions. Specific groups identified as potentially joining a regulator-led “coalition of the willing” included unions, employers, professional advocacy groups, patient groups, health systems administrators, educators, accreditation agencies, and student groups.

Participants in this study were accepting of the realities of climate breakdown and mindful of the enormity of the work required to meet climate change targets and goals. They expressed their concerns that regulatory bodies by themselves and on their own could not accomplish the objective of shifting professions towards climate-conscious practices. These participants noted that regulated health professions are composed of different organizations, each of which have distinct roles and complementary objectives. Educational institutions are distinct and have an enormous role in the life of professionals. Similarly, professional advocacy groups that represent professions to governments and the public have important roles, access to resources and political networks, and other tools at their disposal. In some professions, unions have a powerful platform and role to play. Participants in this study described how, in most professions, these different “arms” of a profession with complementary roles and distinct mandates sometimes have difficulty communicating with each other and building consensus across an entire profession, or amongst multiple professions. Because regulatory bodies are uniquely composed of every single member of a profession, they can serve an important convening role in bringing together educators, unions, professional advocacy groups, employers, and other groups within a profession to discuss issues of common interest—such as climate breakdown.

While the “regulating” role of regulatory bodies in the context of climate breakdown may not be feasible or appropriate, all participants in this study suggested the idea that a convening and coalition-building role, led by regulatory bodies, could be both powerful and impactful. The scale of climate breakdown and the response of health professionals to it is an enormous and wicked problem that defies simple solutions or unilateral action by one group or agency. Instead, the entire profession must find a mechanism to come together and find consensus to make actionable changes. This is where regulatory bodies are uniquely positioned to lead such coalitions, enable such consensus building, and find alignment of interests amongst disparate parts of a profession.

In assuming this convening role, regulators could bring specific strengths to unlock potential action. First, the fact that regulators are leading and convening such discussions commands attention and respect from all parts of a profession: a union, or educational institution leading such discussion may not necessarily garner the same degree of attention, interest, and respect from employers or corporations. Second, regulators have access to data and resources they could potentially bring to this discussion. Participants in this research noted that regulatory bodies generate their own funding through the levying of an annual licensing fee on individual professionals; they also issue requirements for annual renewal of a license to practice a profession, and this provides a unique point of leverage with every single member of a profession. This could also allow regulators to measure and monitor impact of any changes that are evolving in a way that would be more challenging for a professional advocacy group or union. Third, regulatory bodies have historically been viewed as neutral and primarily interested in the public interests and patients’ safety—not in maximizing shareholder value or self-promotion of the professional. This stance brings an authenticity to the convening role that may be challenging for an employer, a corporation, or a professional advocacy group to demonstrate.

Participants highlighted the need for such a convening role within their respective professions. Across medicine, nursing, pharmacy, dentistry and most other health professions, there is a patchwork of different groups who claim to represent interests of the profession or professionals or patients, and this cacophony makes it challenging to know who speaks for the profession as a whole. Regulator-led convening of interests and building of a profession-wide consensus with respect to climate breakdown and climate-conscious practice has significant potential for positive outcomes while still avoiding risks associated with regulatory scope creep.

4. Discussion

As noted above, the impetus for this research was the findings from a previous study that suggested health professionals themselves believe—and want—their regulatory bodies to assume a more direct, active, and muscular approach in regulating and mandating climate-conscious practice. Without the power and heft that comes with being a regulator in a regulated health profession, these front-line professionals believed the shift to climate-conscious practice would be difficult or impossible to enact. These professionals and those interested in reducing climate impacts of health professionals’ work may be disappointed but not surprised by the findings of this study. On one level, it appears to be a case of crossed signals, mixed messages, and the left hand and the right hand each pointing at one another: professionals want regulators to lead, and regulators say they cannot, and the profession itself needs to lead. In this reading of the data from the study, a disheartening conclusion that real progress towards climate-conscious practice is not possible may be understood.

A closer reading of the results of this study points in a different and perhaps more optimistic direction. First, the personal commitments and awareness of regulators themselves is aligned with mainstream climate science. Regulators are not climate change deniers or skeptics and accept the scientific consensus regarding the realities of climate breakdown. They also accept personal responsibility for small, individual, and incremental changes and, in their day-to-day lives, are trying to change their own behaviours. Regulators believe in climate science and understand the urgency and importance of actionable changes in their professions. Where there are more opportunities for education and professional development for regulators is with respect to the details and specific dimensions of climate-conscious practice in professions such as medicine, nursing, pharmacy, and dentistry. Climate-conscious practice is not about light bulbs and recycling bins but instead about using the power of regulated health professional work to reduce climate impacts of health care. Climate-conscious practice involves awareness of hygiene theatre, and the long-established but scientifically questionable practices health care professionals use daily that they think keep patients safe but in reality may not achieve anything more than adding to the carbon footprint of their work. Climate-conscious practice is a way of looking at the unique scopes, roles, and activities that each health professional has and identifying opportunities to reduce climate impacts. The poor understanding of profession-specific climate-conscious practice principles demonstrated by regulators in this study highlights significant opportunities for education and professional development for regulators themselves; better understanding of the concept itself may unleash more creative regulatory options in the future.

Regulators’ perspectives on the use of legislation and regulation to compel climate-conscious practice are important to acknowledge and respect. As noted by all participants in this study, public faith in regulation in general is wobbly at best. In many jurisdictions, regulation has become politicized, weaponized, and the subject of systematic dismantling, despite the reality that regulation exists in the first place to protect the public. Regulators noted their concerns that regulation in the name of climate change may further politicize and alienate some constituencies within and outside of professions, and this risk is substantial and real enough to warrant the avoidance of regulation as an option at this time.

Instead, participants in this study highlighted the power of education and coalition building to unleash the potential of both individual professionals and professions writ large. The enormity of the climate change problem in health care is such that no single arm of a profession could possibly tackle it on their own; instead, an entire profession, and consortia of multiple different professions, will be needed to reduce climate impacts of health care work. In this respect, education and coalition building are two particular strengths that align well with both regulatory expertise and the regulatory mandate. Importantly however, those front-line health professionals who first suggested that only regulatory bodies had the power and authority to drive climate-conscious practice had also noted that well-intentioned efforts focused on education, “nudges”, or other techniques that lacked the strength of actual regulation were unlikely to succeed due to time and resource pressures faced by professionals and employers/corporations alike.

The findings of this study do raise some uncomfortable questions for those who recognize the importance of health care professionals addressing the hidden carbon footprint of health care work itself. Regulators in this study could be interpreted as shifting or avoiding the responsibility to act that comes with the authority granted to them as regulatory bodies. Similarly, front-line professionals could be seen as being unprofessionally passive and not taking control of their own practices to address an issue of urgency and importance and instead awaiting or expecting other forces to do it for them. Employers and corporations could be seen as also being complicit in this inaction, as they are not providing the support and resources necessary to address issues of societal and global concern. Ultimately, in the case of health professional work, there may be uncomfortable echoes of the broader public experience of mitigation of climate related harms; everyone in the system appears to want to wait for someone else to lead, make the difficult decisions, and endure whatever blowback may result, even if the overall objective (carbon and GHG emission reductions) is clear and, seemingly, tantalizingly attainable.

There are limitations to this study that may limit the generalizability of its findings. The qualitative research method utilized, while appropriate for exploratory research such as this, should not be interpreted as being applicable to all potential stakeholders. The sampling method used was non-representative and therefore caution must be used in interpreting the findings. A strength of this study was the use of the COREQ approach to ensure quality in qualitative research. Techniques such as double coding of transcripts, opportunities for participants to review their interviews and confirm accuracy, and application of the constant comparative analytical method align with COREQ requirements. Still, as an exploratory project it was not designed to be conclusive or final in its pronouncements but simply to raise questions and highlight opportunities for further research.

This study highlights the nature of the wicked problem [19] that exists in attempting to address climate-related harms associated with the work of health professionals. Based on these participants’ perspectives, incremental regulatory nudges focused on education and coalition building may be the only feasible or realistic option at this point, but whether these will produce any meaningful advances towards more climate-conscious practice remains unclear.

Future Directions

This study has highlighted regulators’ reluctance to use the blunt instrument of regulation to compel practitioners to adopt climate-conscious practice. Instead it has highlighted their interest in exploring the use of persuasive techniques that may “nudge” rather than force practitioners to reflect on their practice and adopt more carbon-neutral practices. Three particular ideas raised by research participants warrant further exploration: coalition building, regulators’ use of education strategies, and enhancing trustworthiness of regulators themselves through avoidance of regulation. Further work is needed to determine how best to build profession-wide and interprofessional coalitions of employers, unions, practitioners, advocacy groups, patient groups, and other interested parties in a manner that allows discussion, debate, but ultimately action towards climate-conscious practice. Coalition building by regulators is not widely researched or well-understood given the historical role of regulators within professions; this study highlights an opportunity to consider its place in the toolkit used by regulators.

Traditionally, regulators have been distinct from educators and assumed different responsibilities. This study has highlighted the potential role of regulators AS educators, using continuing education requirements connected to annual renewal of licensure as a potential pathway to increase practitioner awareness of climate-conscious practice. This idea has not been widely studied or described in the literature; further research and pilot-testing may be necessary to ensure its acceptability, viability, feasibility, and value.

Finally, this study has raised questions regarding the role of regulation within professions and the appropriateness of legal rules-based approaches to solving problems such as climate change. Further research is needed to better understand regulators’ perspectives on this issue, but also to understand how professional themselves, the public they serve, and other interested groups (for example, government, employers, or unions) perceive rules-based regulation in the context of pushing forward behavioural changes. Determining the desirability and acceptability of regulator-imposed change on professional practice will require further research and careful deliberation.

5. Conclusions

The climate impacts associated with the work of health care professionals are becoming increasingly well-understood and coming under greater scrutiny. In the name of healing and helping patients, health care professionals are contributing to greenhouse gas emissions, carbon footprints, and environmental pollution that is adversely impacting patient and planetary health. Previous research had suggested there may be a role for the regulatory (licensing) bodies of health professionals to assert greater legalistic authority in advancing the spread of climate-conscious practice in health care. Findings from this study suggest this may not be feasible or appropriate at this time, and, instead, regulators in this study highlighted alternative pathways focused on education and coalition building. Whether these non-legalistic initiatives will actually result in change or evolution is debatable. In the meantime, additional research is required to identify options and opportunities to advance climate-conscious practice in health care work.