A Cross-Cultural Validation of the Italian Version of the Nurse’s Environmental Awareness Tool (NEAT)

Abstract

The healthcare sector significantly impacts environmental sustainability, with nurses contributing to waste and energy use while also being positioned to lead change through sustainable practices. However, only one validated tool, the Nurses’ Environmental Awareness Tool (NEAT), is currently available to assess their environmental awareness. This study aimed to adapt the NEAT into Italian and evaluate its psychometric properties. The Italian version was developed using a five-phase approach, followed by a cross-sectional validation study to assess its validity and reliability. A sample of 382 nurses and nursing students was included. The Italian NEAT demonstrated optimal content and face validity indices, satisfactory goodness-of-fit indices confirming the original six-subscale structure (Comparative Fit Index 0.85–0.92; Tucker–Lewis Index 0.80–0.90; Standardized Root Mean Square Residual 0.05–0.08; Root Mean Square Error of Approximation 0.06–0.14), and good reliability values (Cronbach’s α 0.77–0.90; omega-ω ≥ 0.80). Construct validity results were likewise satisfactory. The participants’ scores suggested limited knowledge but adequate environmental awareness and ecological behaviors. The Italian version of the NEAT is designed for screening purposes, guiding educational interventions, and supporting research in both clinical and academic contexts. By contributing to the advancement of knowledge on sustainability in healthcare, it promotes environmentally responsible practices within the nursing profession.

1. Introduction

1.1. Environmental Impact of Healthcare

The healthcare sector plays a crucial role in environmental sustainability, significantly contributing to climate change and public health outcomes. With a global climate footprint nearing 5% of net greenhouse gas emissions, healthcare is a major consumer of energy and natural resources [1]. This is due to the extensive energy required by hospitals and healthcare facilities for heating, cooling, and medical equipment, further intensifying their environmental impact.

In addition to high energy consumption, the sector generates vast amounts of waste, including biomedical, pharmaceutical, and general waste. In particular, single-use, non-biodegradable plastic products contribute to microplastic pollution [2]. Improper disposal of these materials exacerbates pollution and poses long-term ecological and health risks.

1.2. Nurses’ Roles in Sustainability

Addressing these challenges requires the implementation of sustainable healthcare practices, with a key role played by healthcare professionals (HCPs), especially nurses [3]. As the largest workforce in the healthcare sector, nurses are well positioned to influence environmental sustainability. Environmental considerations have been central to nursing principles since its inception [4], and remain highly relevant today, as nurses contribute to achieving the Sustainable Development Goals [5]. However, despite their awareness in health promotion, nurses also contribute to environmental harm through daily practices that involve energy use, waste production, and reliance on disposable materials [6,7].

Although nurses play a pivotal role in promoting sustainable practices, there is limited understanding of their actual environmental awareness in clinical contexts [8]. Few tools are available to assess this construct, and validated instruments for use in non-English-speaking contexts are particularly scarce. To address this gap, this study focuses on the adaptation and validation of a tool capable of evaluating nurses’ environmental awareness in the Italian healthcare context. In Italy, this topic remains relatively understudied; one recent qualitative study reported that nurses expressed concerns about environmental exposures and emphasized the need for targeted training on environmental disease types, exposure pathways, preventive measures, health promotion, and environmental impact [9]. These findings highlight the need for validated instruments that can effectively assess these concepts in the Italian setting.

1.3. The Role of Environmental Awareness in Sustainable Healthcare

Environmental awareness is a multidimensional concept that encompasses knowledge, beliefs, values, and behaviors related to sustainability [10,11]. The International Council of Nurses has reinforced the profession’s responsibility to meet sustainability standards, emphasizing the importance of environmental education [5,12]. Achieving ecological sustainability in healthcare requires balancing conservation efforts with patient care, ensuring the well-being of current and future generations [1,5,6].

The COVID-19 pandemic further highlighted the urgent need for structured assessments of nurses’ environmental awareness, as the level of awareness remained low despite a significant increase in waste production. This gap reinforces the importance of evaluating nurses’ ecological consciousness to inform effective sustainability initiatives and reduce the climate footprint of healthcare systems [5]. Recent studies further emphasize that climate-related competencies among nurses and nursing students are increasingly recognized as being critical to sustainable healthcare delivery. For instance, nursing students have shown high levels of environmental awareness and literacy, underlining the importance of integrating environmental health content into both nursing curricula and ongoing professional training [13,14]. At the same time, HCPs report recognizing the relevance of climate change but feeling inadequately informed or equipped to address it in clinical practice, often due to time constraints, limited information, and insufficient training materials [15]. Together, these findings underscore a global need for targeted interventions and validated instruments to assess and enhance environmental awareness and climate literacy within the nursing profession.

1.4. Existing Tools for Assessing Environmental Awareness

Although the recent literature emphasizes the need for assessing and enhancing climate literacy and environmental behaviors among nurses [5,12], few validated tools exist to support such evaluation efforts. A dedicated questionnaire could provide valuable insights into nurses’ knowledge, attitudes, and behaviors, guiding sustainable improvements in nursing practice. However, few validated questionnaires have been developed to specifically assess nurses’ perceptions of the environmental impact of healthcare. The existing instruments were created in the United States [16,17], and only the Nurses’ Environmental Awareness Tool (NEAT) has undergone cross-cultural validation in Spanish [18].

1.5. Theoretical Frameworks Underpinning the Nurses’ Environmental Awareness Tool

Given the complexity of environmental awareness, the NEAT offers a structured, theory-informed tool grounded in the Integrated Change Model and the EWT-E Wheel [16,19]. These frameworks allow for the assessment of both cognitive and behavioral aspects of sustainability, aligning well with the multidimensional role of nurses in healthcare. In Italy, where nurses actively support sustainability efforts but lack a validated assessment tool [9], an Italian version of the NEAT is needed to support education, policy, and practice.

The NEAT questionnaire was developed to measure and evaluate environmental awareness among nurses, addressing two key constructs: awareness of the environmental impacts of nursing practice, and ecological behaviors [20]. Originally developed and tested by Schenk et al. (2015), the questionnaire is grounded in two complementary theoretical frameworks: the Integrated Change Model and the EWT-E Wheel [16]. The Integrated Change Model proposes that behavior change is influenced by awareness, motivation, and perceived ability to act, highlighting the importance of understanding beliefs and attitudes as precursors to ecological behaviors [19]. This framework supports the NEAT’s focus on both awareness and behavioral domains. In parallel, the EWT-E Wheel provides a practical lens for categorizing environmental impacts within healthcare, organized into four domains: energy, waste, toxicants, and engagement [16]. These domains are reflected in the NEAT’s subscales, which assess nurses’ awareness of how daily clinical practices intersect with resource consumption, pollution, and opportunities for sustainability engagement. Together, these models provide a solid theoretical foundation for the NEAT and support its application in evaluating nurses’ environmental awareness.

1.6. Using the Nurses’ Environmental Awareness Tool

The NEAT questionnaire serves as an essential tool for assessing and comparing nurses’ environmental consciousness across different settings, and has been the subject of prior validation studies in English [20] and Spanish [18], highlighting its relevance for cross-cultural adaptation and broader international use. Except for the validation conducted in Spanish [18], an assessment of the psychometric properties of the instrument has never been carried out in languages other than English [20]. Furthermore, to be used in non-English-speaking countries, the NEAT must undergo cross-cultural adaptation to verify its measurement properties, as well as its semantic and conceptual equivalence with the original version [21].

Therefore, the aim of this study was to adapt the NEAT into Italian and assess the psychometric properties of the tool.

To guide this process, the following questions were considered:

-

Does the Italian version of the NEAT demonstrate adequate content and face validity, as evaluated by expert judgment and pilot testing?

-

Does the factor structure of the Italian NEAT reflect the dimensionality identified in previous validation studies?

-

Does the Italian NEAT show satisfactory reliability, as measured by internal consistency across its subscales?

-

Do the correlations among subscales support its construct validity in the Italian context?

2. Materials and Methods

This cross-sectional validation study was conducted in five phases. The determination of the sample size and the reporting of the study process were performed following the Consensus-based Standards for the Selection of Health Status Measurement Instruments (COSMIN) guidelines [22]. Between September 2022 and October 2023, a convenience sample of nurses and nursing students was recruited from the Azienda Sanitaria Locale Città di Torino and the University of Torino. Both nursing students and registered nurses were included to reflect the continuum of nursing education and practice, ensuring the tool’s applicability across different levels of professional development. Participants met the following criteria: nurses or nursing students with previous clinical experience with patients; aged 18 or older; and native or Italian speaking. Individuals without direct clinical experience or those unable to speak Italian were excluded.

2.1. The Nurses’ Environmental Awareness Tool

The NEAT is a self-administered tool designed to provide a comprehensive assessment of nurses’ ecological awareness and behaviors across both professional and personal contexts. It is structured into three interconnected scales, each consisting of 11 items. The first scale, the Nurse Awareness Scale (NAS), assesses nurses’ awareness of ecological issues and their role in reducing environmental harm. This scale includes two response levels for the same items: NAS I, which measures familiarity with ecological issues, and NAS II, which evaluates the perceived connection between ecological issues and human health. The second scale, the Nurse Professional Ecological Behaviors (NPEB) scale, captures ecological actions performed by nurses in professional settings. Similar to the NAS, it has two response levels: NPEB I, which measures the frequency of ecological behaviors at work, and NPEB II, which assesses the perceived difficulty of implementing these behaviors in clinical settings. The third scale, the Personal Ecological Behaviors (PEB) scale, examines ecological behaviors adopted by nurses at home. It includes two response levels, one measuring the frequency of ecological behaviors at home (PEB I), and the other assessing nurses’ perceived barriers and facilitators to adopting ecological behaviors in their domestic environment (PEB II).

All six subscales—NAS I, NAS II, NPEB I, NPEB II, PEB I, and PEB II—use a 5-point Likert scale, tailored to each construct. Response options for NAS I range from 1 = No, I have never heard of this before, to 5 = Yes, I have definitely heard of this, while NAS II ranges from 1 = Never related, to 5 = Always related. In the NPEB scale, responses for NPEB I range from 1 = Never or almost never, to 5 = Always or almost always, measuring the frequency of ecological behaviors at work, while responses for NPEB II range from 1 = Very difficult, to 5 = Very easy, assessing the perceived ease or difficulty of implementing these behaviors in a professional setting. Similarly, PEB I responses range from 1 = No, I have never heard of this before, to 5 = Yes, I have definitely heard of this, while PEB II is rated from 1 = Never or almost never, to 5 = Always or almost always, evaluating the frequency and perceived difficulty of adopting ecological behaviors in the home environment.

For each scale, item scores are averaged, producing six response levels per participant (NAS I, NAS II, NPEB I, NPEB II, PEB I, and PEB II), with total scores ranging from 11 to 55. A cut-off value of 33 indicates a sufficient score, providing a benchmark for evaluating environmental awareness and ecological behaviors among nurses.

2.2. Translation and Cross-Cultural Validation

The cross-cultural validation process of the Italian Version of the NEAT followed the five consecutive phases (

Table 1. Synthesis of the five phases of the translation and cross-cultural validation.

Phase	Description
Phase I—Forward translation	Translation from the source language to the target language
Phase II—Synthesis	Comparison and merging of the translated versions into a single consensus version
Phase III—Backward translation	Translation of the synthesized version back into the source language
Phase IV—Expert evaluation	Review by a panel of experts to assess semantic, conceptual, and cultural equivalence
Phase V—Preliminary testing	Face validity assessment through a pilot study

) recommended by Sousa and Rojjanasrirat [23].

2.2.1. Phase I—Forward Translation

The translation of the NEAT and its instructions from English to Italian was carried out after obtaining permission from the authors of the original version [20]. Two independent translators, both native Italian speakers, were involved—one working in a clinical setting and the other as a nurse educator in a university setting. The two translated versions included a colloquial version, preserving the concepts of the original version while ensuring natural readability, and a literal translation incorporating both medically and culturally appropriate terminology.

2.2.2. Phase II—Synthesis

The research team assessed both translations of the NEAT, assembling, summarizing, rechecking, and reviewing the final version of the instrument. Any inconsistencies were resolved through discussion, and agreed-upon adaptations were shared with the team. None of the items included from the original NEAT were excluded.

2.2.3. Phase III—Backward Translation

A certified English translator, whose native language is English, translated the final Italian version of the NEAT back into English. The translation was then submitted to the original author of the instrument to confirm the conceptual equivalence of the Italian version. This phase concluded with the original author’s authorization to administer the definitive Italian version of the NEAT.

2.2.4. Phase IV—Expert Evaluation

The Italian NEAT was presented to a group of 26 experts, composed of professionals in healthcare and basic sciences, to assess the content validity of the instrument. The expert group included chemical engineers (n = 2), environmental engineers (n = 3), public health physicians (n = 2), nurses (n = 8), head nurses (n = 2), nurse educators (n = 5), and nursing students (n = 4). Most experts were female (n = 19; 73%), with a mean age of 34.8 years (SD ± 9.4), and an average work experience of 9.1 years (SD ± 8.9). Content validity refers to the extent to which the items on the Italian NEAT was objectively representative of issues and behaviors related to environmental awareness. Experts independently rated each item of the instrument using a four-point Likert scale, ranging from 0 (not representative) to 4 (strongly representative), and were invited to suggest new items if they identified missing areas of content. Based on their input, two new items related to healthcare waste minimization and segregation were proposed. These topics are closely aligned with environmental awareness, as effective healthcare waste management is considered a core component of safe and sustainable care, in line with WHO recommendations [24]. The research team drafted the items based on the experts’ suggestions and refined them through iterative review before incorporating them into the NPEB subscale. Notably, these items were part of the original NEAT developed by Schenk et al., but were removed during the validation [16,20]. After obtaining authorization from the original authors, the two items were reintroduced in the Italian version and included in subsequent pilot testing and psychometric evaluation. All items in the Italian NEAT met the 0.78 cutoff value, indicating acceptable validity, while the full instrument achieved a content validity index/average (CVI/Ave) score of 0.92.

2.2.5. Phase V—Preliminary Testing

The face validity of the Italian NEAT was evaluated in a pilot study. Face validity refers to the extent to which the instrument appears to measure nurses’ environmental awareness. A sample of 16 nurses and nursing students who met the inclusion criteria but were part of the validation study completed the Italian NEAT to assess whether the items, at face value, were an appropriate measure of environmental awareness. Each item was evaluated using a ten-point Likert scale, ranging from 0 (not appropriate) to 10 (strongly appropriate). The Italian NEAT achieved a face validity score of 9.8 out of 10 and was approved as appropriate for psychometric testing.

2.3. Procedure

Participants were contacted by the researchers via institutional email at ASL Città di Torino and the Bachelor’s Degree in Nursing program at the University of Torino. Email addresses for nurses were obtained from the ASL Città di Torino mailing list, while those of nursing students were provided by the program coordinators. The invitation email included information about this study’s purpose and provided a direct link to an online platform where participants could complete a sociodemographic questionnaire and the Italian NEAT. The online survey was created using LimeSurvey, for which the University of Torino held a private license, hosted on a dedicated protected server. The researchers provided direct contact information in case participants had any questions about this study. Before accessing the questionnaires, the participants were required to sign an online informed consent form on a separate webpage.

The sociodemographic questionnaire collected basic information on participants’ age, sex, and education. The Italian NEAT was administered in the version approved following pilot testing. The researchers sent reminder emails every three weeks until the target sample size was achieved.

The sample size was determined based on methodological recommendations for factor analysis, which suggest a minimum of 5 to 10 participants per item of the instrument [25]. Given that the NEAT consists of 33 items, a sample of approximately 330 participants met the aforementioned criterion, allowing for a robust assessment of dimensionality and internal consistency [26]. This approach has also been consistently applied in previous cross-cultural validation studies of the NEAT, such as the Spanish version [18,22]. To account for potential incomplete or missing questionnaire responses, an additional 10% was added, resulting in a final target sample size of 363 participants.

2.4. Data Analysis

Initially, data from the sociodemographic questionnaire and the Italian NEAT results were analyzed using descriptive statistics, including means, standard deviations, and frequencies.

Factor validity and reliability analyses were then used to test the psychometric properties of the NEAT. Sample adequacy for factor analysis was supported by the Kayser–Meyer–Olkin (KMO) test and Bartlett’s test. The threshold value of 0.80 for the KMO was considered satisfactory as an indication of an adequate sample, while a significance level of <0.05 for Bartlett’s test was indicative of homogeneity in item variances [27]. We used a combined approach to assess the factorial validity of the NEAT, using an initial exploratory factor analysis (EFA) followed by a confirmatory factor analysis (CFA) to test the theoretical structure of the instrument.

Due to the non-normal item distribution already shown in the previous validation study of the NEAT [18], a maximum likelihood estimator and a Promax oblique rotation of the factors were used to perform the analyses when testing it in the Italian context. This decision was further supported by the assessment of skewness and kurtosis in our dataset, indicating deviations from normality in several items (Supplementary Table S1).

In the EFA, factors with an eigenvalue ≥1 were retained, and a visual inspection of the scree plot was used to support the determination of the number of factors to extract. A minimum factor loading coefficient of 0.30 was required to keep each item in the scale. Items that had more than one factor loading with a coefficient ≥0.30 were removed [28,29].

For CFA, model fit was assessed using the following criteria: Comparative Fit Index (CFI; 0.80–0.90 = moderate fit, 0.90–0.95 = acceptable fit, ≥0.95 = good fit), Tucker and Lewis Index (TLI; 0.80–0.90 = moderate fit, 0.90–0.95 = acceptable fit, ≥0.95 = good fit), Root Mean Square Error of Approximation (RMSEA; 0.05 = well-fitting model, 0.06–0.08 = moderate fit, 0.1 = poor fit), and Standardized Root Mean Square Residual (SRMR; ≤0.08 = good fit). Along with the above indices, the traditional chi-squared test (χ2) was used [30,31,32].

Reliability, intended as internal consistency, was tested using multiple coefficients considered for the factorial model for the Italian NEAT. Since multiple factors were represented by the Italian NEAT, internal consistency was assessed using McDonald’s composite omega-ω (values ≥0.6 are considered adequate) [33,34]. Cronbach’s α coefficient was also calculated for the total scale (values ≥0.70 were considered adequate).

The correlation between the scores of the resulting factors and the item summary was also assessed using Spearman’s Rho coefficient (ρ). Values of ρ ≤ 0.20 were considered very weak, 0.20 to 0.39 was considered weak, 0.40 to 0.59 was considered moderate, 0.60 to 0.79 was considered strong, and 0.80 to 1.00 was considered very strong [35].

A ≤0.05 level of significance was used. Statistical analyses were performed using SPSS version 29.0.2 (IBM, Armonk, NY, USA), except for EFA and CFA, which were performed using Mplus version 8.1.

2.5. Ethical Approval

The author of the original NEAT granted authorization for its use and validation. The Bioethical Committee of the University of Torino approved this study (Resolution No. 0368357/2022), and the directors of the Azienda Sanitaria Locale Città di Torino and the Bachelor’s Degree in Nursing program at the University of Torino provided written authorization.

Eligible participants were informed both verbally and in writing about this study’s objectives, procedures, data confidentiality, and the strictly voluntary nature of their participation. They provided informed consent by completing a dedicated form within the digital survey.

3. Results

A total of 382 participants were recruited, including 115 nurses and 267 nursing students. The mean age was 28.6 years (SD ± 11.7), with 307 females (80%) and 73 males (19%). Among the nurses, 6 held a vocational diploma (5%), 85 had a bachelor’s degree (74%), and 24 (21%) had a postgraduate qualification. The average time to complete the questionnaire was 9.1 (SD ± 1.3) minutes. The participants completed the Italian version of the NEAT, with an item-by-item English translation provided in

Table 2. Items included in the Italian NEAT with the original English version.

#	Item—Italian	Item—English
A1	I report internazionali indicano che, dopo l’industria alimentare, il settore sanitario è il secondo più grande consumatore di energia.	According to the EPA, in-patient healthcare ranks as the second largest commercial energy user after the food service industry.
A2	Le strutture sanitarie utilizzano più del doppio dell’energia per metro quadrato rispetto ai normali uffici.	Hospitals use 2.5 times as much energy per square foot as typical office buildings.
A3	Gli idrocarburi costituiscono la maggior parte dell’energia consumata in Italia, tra cui quella destinata all’assistenza sanitaria.	Most of US energy, including that of healthcare, is fossil fuel-based.
A4	Quasi l’80% degli italiani guida per recarsi al lavoro. Questa energia può eguagliare o superare quella necessaria per far funzionare la struttura in cui si lavora (incluse quelle sanitarie).	Over 70% of Americans drive to work alone. The energy used can equal or exceed the energy required to run a workplace building (including a hospital).
A5	L’energia utilizzata per il trasporto di prodotti medici, alimenti e forniture rappresenta una parte significativa dell’energia totale utilizzata in sanità.	Energy used in the transportation of medical products, foods, and supplies accounts for a significant part of the total energy used in healthcare.
A6	Ogni anno, in Italia vengono prodotte 140.000 tonnellate di rifiuti sanitari, di cui 95.000 vengono incenerite.	US hospitals produce over 6000 tons of waste per day.
A7	Le sostanze chimiche tossiche utilizzate nell’assistenza sanitaria hanno contribuito ad accumulare nell’ambiente mercurio, diossina e ftalati.	Toxic chemicals used in healthcare have contributed to accumulations of mercury, dioxin, and phthalates in our environment.
A8	È possibile osservare livelli elevati di sostanze chimiche potenzialmente tossiche nei liquidi corporei del personale sanitario.	When bio-monitored, nurses show elevated levels of numerous potentially toxic chemicals in their body fluids.
A9	Alcuni prodotti chimici come i plastificanti presenti in alcuni device di uso comune (ad esempio negli aghi cannula) possono essere responsabili di disfunzioni ormonali.	Plasticizers, chemicals which soften plastics for easier use (in IV tubing for instance), are suspected to be hormone disruptors.
A10	Il Triclosan, una sostanza chimica spesso presente nei saponi ospedalieri e nei liquidi usati per il lavaggio delle mani, è stato correlato a disfunzioni ormonali.	Triclosan, a chemical often in hospital soaps and hand-washing liquids, has been linked to hormone disruption.
A11	Gli alimenti serviti negli ospedali contengono spesso residui di pesticidi ed erbicidi.	Foods served in hospitals often contain pesticide and herbicide residues.
B1	A lavoro, spengo consapevolmente le luci quando non sono in uso.	At work, I consciously turn off lights when not in use.
B2	A lavoro, spengo il monitor del computer o gli apparecchi elettromedicali (come le pompe infusionali, le pompe nutrizionali o l’ecografo) quando non sono in uso.	At work, I turn off computer monitors when not in use.
B3	A lavoro, cerco di differenziare i rifiuti.	At work, I recycle.
B4	A lavoro promuovo la raccolta differenziata.	At work, I lead recycling efforts.
B5	A lavoro, mi impegno a ridurre l’uso di sostanze chimiche tossiche (come mercurio, DEHP o triclosan).	I work to reduce the use of toxic chemicals in the hospital (such as mercury, DEHP, or triclosan).
B6	Ricerco sul web o in letteratura evidenze sulle sostanze chimiche tossiche usate nell’assistenza sanitaria.	I do literature or web searches on toxic chemicals used in healthcare.
B7	Informo il personale sanitario sulle sostanze chimiche tossiche presenti sul posto di lavoro.	At work, I help educate other staff about toxic chemicals in our workplace.
B8	Informo i pazienti sui rischi correlati all’esposizione ambientale a sostanze chimiche tossiche o inquinamento.	At work, I educate patients about the risks of environmental exposure such as to toxic chemicals or pollution.
B9	Al lavoro, incoraggio il nostro servizio di ristorazione a servire cibi locali.	At work, I encourage our food service to serve local foods at my hospital.
B10	Al lavoro, cerco di ridurre la quantità di rifiuti prodotti.	/
B11	Al lavoro, cerco di separare i diversi componenti dei rifiuti (ad esempio imballaggi composti da carta e plastica).	/
C1	A casa, tengo traccia di quanti kWh di elettricità consumo al giorno o al mese.	At home, I track how many kWh of electricity per day or month I use at home.
C2	A casa, cerco di limitare consapevolmente il consumo d’acqua.	Each year, I check my plumbing for water leaks and make necessary repairs.
C3	A casa, scelgo di comprare prodotti riciclati.	At home, I buy recycled content products.
C4	A casa, cerco di adattare i miei acquisti per evitare un’eccessiva produzione di rifiuti.	At home, I make purchasing decisions based on avoiding the production of waste.
C5	A casa, non uso pesticidi e / o erbicidi.	At home, I do not use pesticides and/or herbicides.
C6	A casa, acquisto prodotti biologici.	At home, I buy organic produce.
C7	A casa, evito di usare prodotti per la cura personale che contengano sostanze chimiche tossiche.	At home, I avoid using personal care products that contain toxic chemicals.
C8	A casa, uso detergenti ecologici.	At home, I use green cleaners.
C9	Mi informo sui media a proposito delle problematiche associate all’ambiente e alla salute umana.	I read about issues associated with the natural environment and human health in the popular media.
C10	Svolgo attività di volontariato a sostegno dell’ambiente.	I volunteer for efforts to support a healthy environment (board member, community drive, etc.).
C11	In quanto sanitario, discuto delle tematiche riguardanti l’ambiente naturale e la salute umana con i miei amici e familiari.	As a nurse, I discuss issues about the natural environment and human health with my friends and family.

NAS—Nurse Awareness Scale; NPEB—Nurse Professional Ecological Behaviors Scale; PEB—Personal Ecological Behaviors.

. A detailed synthesis of the descriptive characteristics of each item is provided in the Supplementary Materials—Table S1.

3.1. Exploratory Factor Analysis

The normality and sphericity of each of the six NEAT subscales were assessed using the KMO and Bartlett’s sphericity tests. The KMO values were 0.87 and 0.89 for NAS I and NAS II, respectively; 0.80 for both NPEB I and NPEB II; and 0.84 and 0.81 for PEB I and PEB II, respectively. Bartlett’s test yielded a p-value of < 0.01 for all subscales. Therefore, the sample was considered suitable for factor analysis.

3.1.1. Nurse Awareness Scale (NAS I and NAS II)

The NAS I and NAS II subscales exhibited a two-factor structure, accounting for 47.3% and 59.7% of the total variance, respectively. Items A1 to A7 formed the first dimension, titled “Awareness of Energy Expenditure and Pollution”, while items A8 to A11 constituted the second dimension, “Awareness of Chemicals”. The factor loadings for each item in the NAS I and NAS II subscales are provided in

Table 3. Factor loadings for the 11 items in the Nurse Awareness Scale (NAS I and NAS II).

Items	Factor 1 NAS I	Factor 2 NAS I	Factor 1 NAS II	Factor 2 NAS II	Name of Factor
A1_NAS1_NAS2	0.712		0.801
A2_NAS1_NAS2	0.715		0.843
A3_NAS1_NAS2	0.572		0.810
A4_NAS1_NAS2	0.631		0.681		Awareness of Energy Expenditure and Pollution
A5_NAS1_NAS2	0.702		0.755
A6_NAS1_NAS2	0.669		0.607
A7_NAS1_NAS2	0.578		0.511
A8_NAS1_NAS2		0.369		0.595
A9_NAS1_NAS2		0.811		0.858	Awareness of Chemicals
A10_NAS1_NAS2		0.903		0.958
A11_NAS1_NAS2		0.498		0.793
Explained variance	47.3%		59.7%

.

3.1.2. Nurse Professional Ecological Behaviors Scale (NPEB I and NPEB II)

The NPEB I and NPEB II subscales showed a two-factor structure, explaining 42.9% and 41.8% of the total variance, respectively. The first dimension, “Energy Saving and Waste Management”, comprised items B1 to B4 and B10 to B11, while the second dimension, “Attention to Chemical Products and Reduction”, included items B5 to B9. The two newly added items demonstrated acceptable psychometric properties, with satisfactory factor loadings, supporting their inclusion in the NPEB subscale (see Supplementary Table S1). The factor loadings for each item in the NPEB I and NPEB II subscales are presented in

Table 4. Factor loadings for the 11 items in the Nurse Professional Ecological Behaviors Scale (NPEB I and NPEB II).

Items	Factor 1 NPEB I	Factor 2 NPEB I	Factor 1 NPEB II	Factor 2 NPEB II	Name of Factor
B1_NPEB1_NPEB2	0.426		0.304
B2_NPEB1_NPEB2	0.310		0.338
B3_NPEB1_NPEB2	0.813		0.874
B4_NPEB1_NPEB2	0.819		0.928		Energy Saving and Waste Management
B10_NPEB1_NPEB2	0.502		0.302
B11_NPEB1_NPEB2	0.749		0.702
B5_NPEB1_NPEB2		0.366		0.405
B6_NPEB1_NPEB2		0.805		0.731
B7_NPEB1_NPEB2		0.836		0.917	Attention to Chemical Products and Reduction
B8_NPEB1_NPEB2		0.693		0.700
B9_NPEB1_NPEB2		0.608		0.574
Explained variance	42.9%		41.8%

.

3.1.3. Personal Ecological Behaviors Scale (PEB I and PEB II)

The PEB I and PEB II subscales revealed a two-factor structure, accounting for 35.1% and 33.4% of the total variance, respectively. Items C1 to C4 and C9 to C11 constituted the first dimension, labeled “Limiting the Environmental Impact”, while items C5 to C8 formed the second dimension, “Avoiding Chemicals”.

Table 5. Factor loadings for the 11 items in the Nurse Personal Ecological Behaviors Scale (PEB I and PEB II).

Items	Factor 1 PEB I	Factor 2 PEB I	Factor 1 PEB II	Factor 2 PEB II	Name of Factor
C1_PEB1_PEB2	0.302		0.460
C2_PEB1_PEB2	0.532		0.564
C3_PEB1_PEB2	0.522		0.611
C4_PEB1_PEB2	0.483		0.672		Limiting the Environmental Impact
C9_PEB1_PEB2	0.578		0.321
C10_PEB1_PEB2	0.311		0.310
C11_PEB1_PEB2	0.474		0.339
C5_PEB1_PEB2		0.420		0.427
C6_PEB1_PEB2		0.709		0.488	Avoiding Chemicals
C7_PEB1_PEB2		0.668		0.566
C8_PEB1_PEB2		0.938		0.781
Explained variance	35.1%		33.4%

presented the factor loadings for each item in the PEB I and PEB II subscales.

3.2. Confirmatory Factor Analysis and Reliability

The model goodness-of-fit indices for each subscale of the Italian NEAT are provided in

Table 6. Fit indices from confirmatory factor analysis for the Italian NEAT subscales.

Subscale	X2 (pX2)	CFI	TLI	SRMR	RMSEA	RMSEA 90% CI
NAS I	162 (<0.001)	0.92	0.90	0.05	0.08	[0.07–0.09]
NAS II	383 (<0.001)	0.86	0.82	0.07	0.14	[0.13–0.15]
NPEB I	151 (<0.001)	0.91	0.88	0.08	0.06	[0.06–0.09]
NPEB II	237 (<0.001)	0.85	0.80	0.08	0.10	[0.09–0.12]
PEB I	145 (<0.001)	0.90	0.87	0.05	0.07	[0.06–0.09]
PEB II	135 (<0.001)	0.90	0.86	0.05	0.07	[0.06–0.09]

NAS—Nurse Awareness Scale; NPEB—Nurse Professional Ecological Behaviors Scale; PEB—Personal Ecological Behaviors Scale; X²—Chi-square; CFI—Comparative Fit Index; TLI—Tucker and Lewis Index; SRMR—Standardized Root Mean Square Residual; RMSEA—Root Mean Square Error of Approximation; CI—Confidence Interval.

.

3.2.1. Nurse Awareness Scale (NAS I and NAS II)

The NAS I and NAS II subscales were designed to encompass two dimensions: Awareness of Energy Expenditure and Pollution, which includes knowledge of energy consumption and waste production in healthcare facilities; and Awareness of Chemicals, which pertains to the presence of chemical substances in HCPs’ body fluids, medical devices, and food.

The model’s goodness-of-fit indices (Table 6) indicated a good fit for NAS I, while NAS II demonstrated an acceptable SRMR and moderate other indices. The NAS I had a Cronbach’s α coefficient of 0.85, while NAS II obtained 0.90. The omega (ω) coefficient was 0.85 for NAS I and 0.91 for NAS II.

3.2.2. Nurse Professional Ecological Behaviors Scale (NPEB I and NPEB II)

The NPEB I and NPEB II subscales were formed by two dimensions: Energy Saving and Waste Management, which includes turning off lights and medical devices when not in use, as well as behaviors aimed at waste reduction and recycling; and Attention to Chemical Products and Reduction, which encompasses actions performed to minimize chemical use, inform colleagues and patients about the risks associated with chemicals and pollutants, and encourage hospital canteens to serve locally sourced food.

The model’s goodness-of-fit indices (Table 6) showed a good fit for NPEB I, while NPEB II demonstrated an acceptable SRMR and moderate other indices. The Cronbach’s α coefficient was 0.77 for NPEB I and 0.81 for NPEB II, while the omega (ω) coefficient was 0.77 for NPEB I and 0.82 for NPEB II.

3.2.3. Personal Ecological Behaviors Scale (PEB I and PEB II)

The PEB I and PEB II subscales comprised two dimensions: Limiting the environmental impact, which includes behaviors aimed at reducing environmental impact in the household, acquiring information, and discussing environmental issues with others; and Avoiding chemicals, which encompasses behaviors focused on reducing chemical use and pesticide exposure.

The model’s goodness-of-fit indices (Table 6) indicated a good fit for both PEB I and PEB II. The PEB I had a Cronbach’s α coefficient of 0.79, while PEB II obtained 0.77. The omega (ω) coefficient was 0.85 for PEB I and 0.80 for PEB II.

3.3. Construct Validity

Table 7. Correlation among NEAT subscales.

NAS I	Mean (SD)	NAS I	NAS II	NPEB I	NPEB II	PEB I	PEB II
NAS I	27.5 (±9.6)	-	0.181 **	0.311 **	0.113 **	0.363 **	0.178 **
NAS II	40.4 (±8.6)	0.181 **	-	0.120 *	−0.052	0.267 **	0.165 **
NPEB I	34.5 (±7.1)	0.311 **	0.120 *	-	0.591 **	0.421 **	0.231 **
NPEB II	34.4 (±7.5)	0.113 *	−0.052	0.591 **	-	0.159 **	0.365 **
PEB I	33.8 (±7.7)	0.363 **	0.267 **	0.421 **	0.159 **	-	0.597 **
PEB II	34.7 (±7.5)	0.178 **	0.165 **	0.231 **	0.365 **	0.597 **	-

NAS—Nurse Awareness Scale; NPEB—Nurse Professional Ecological Behaviors Scale; PEB—Personal Ecological Behaviors; * p < 0.05, ** p < 0.001.

presents the mean scores for each Italian NEAT subscale. With the exception of NAS I, participants scored above the cut-off of 33 on all subscales, suggesting a lack of knowledge about the environmental impact of healthcare. However, the results indicate that, on average, participants engage in environmentally responsible behaviors and exhibit a moderate level of environmental awareness.

Most subscales of the Italian NEAT demonstrated weak to moderate positive ρ-correlations, with particularly strong associations observed between paired behavioral domains (NPEB I and NPEB II; PEB I and PEB II). A non-significant correlation was observed between NAS II and NPEB II, reflecting distinct underlying constructs (Table 7).

4. Discussion

This study aimed to adapt the NEAT to Italian and evaluate its psychometric properties. The cross-cultural adaptation process followed the necessary steps to tailor the original NEAT to the Italian context. The Italian version demonstrated good validity indices, an adequate construct, and satisfactory reliability, making it a promising instrument for assessing nurses’ environmental awareness from undergraduate education to clinical practice.

The translation process of the Italian version of the NEAT followed the same rigorous five-phase procedure used for the cross-cultural validation of the Spanish version [18,23]. It was approved by the developers of the original scale, confirming the conceptual equivalence of the instrument. Regarding the end-users of the Italian NEAT, our results on content and face validity indicate strong consistency with the environmental theme, as well as excellent comprehensibility and readability of the tool. During the cultural adaptation of the instrument, two items related to waste minimization and segregation were added to the NPEB subscale. These topics align closely with environmental awareness, as healthcare waste management is a fundamental prerequisite for safe and high-quality healthcare, as identified by the WHO [24]. Notably, discussions with the developers of the original NEAT revealed that these items were initially included in first version but later removed after validation in English [16]. Their reintroduction in the Italian version is supported by positive psychometric performance and allows for the assessment of these aspects within the specific context of Italian nursing practice.

The structural evaluation of the Italian version of the NEAT was conducted through an initial exploratory analysis, following a confirmatory assessment of the original structure of the instrument, consistent with previous validation studies. The EFA revealed a preliminary two-dimensional structure for each subscale of the Italian NEAT, differing from previous validations. It is important to highlight that identified dimensions align with environmental awareness and ecological behavior, confirming the theoretical underpinning of the instrument. Further psychometrical investigations of this substructure in larger populations could refine the Italian NEAT by reducing the number of items or developing more targeted subscales focused on specific aspects. While the CFA supported the overall structure identified in previous validation studies [18,20], two subscales (NAS II and NPEB II) showed moderate fit indexes. This may suggest that certain items within these subscales did not perform as strongly in the Italian context. A possible explanation could involve cultural and systemic differences in how Italian nurses and nursing students perceive the environmental impact of healthcare, particularly regarding institutional-level environmental practices (NAS II) or challenges in carrying out professional ecological behaviors (NPEB II). In particular, organizational structures, policy environments, and interprofessional dynamics in Italian healthcare may differ from those in the contexts where the original NEAT was developed and validated. Further research should explore whether the refinement of these subscales or cultural adaptation of specific items may enhance model fit and conceptual relevance.

The Italian version of the NEAT demonstrated good reliability, with Cronbach’s α coefficients ranging from 0.77 to 0.90 and an omega (ω) coefficient exceeding 0.8 [36]. These findings, together with evidence supporting the construct validity of the NEAT subscales, confirm the internal consistency of the instrument. With the exception of one non-significant correlation, possibly reflecting distinct underlying constructs between NAS II and NPEB II, the remaining correlations were mostly weak to moderate and consistent across dimensions, thereby limiting the risk of conceptual overlap. These results are consistent with those obtained in the English and Spanish versions of the instrument [18,20], confirming its good performance in the Italian context. Overall, the findings align with the Integrated Change Model and the EWT-E Wheel [16,19], as the structure and correlations among NEAT subscales reflect the expected links between awareness, motivation, and ecological behaviors across key environmental domains. This indicates that the Italian NEAT represents a reliable instrument for measuring environmental awareness and ecological behaviors across a broad nursing population, from education to daily clinical practice.

The scores obtained from the NAS I subscale in this study highlight that nurses’ knowledge of the environmental impact of healthcare remains limited, consistent with findings from other studies conducted in the United States and Spain [18,20]. Despite this, participants demonstrated awareness of how their care practices affect human health, engaged in sufficient ecological behaviors, and perceived few barriers to implementing such behaviors. As the largest group among HCPs, nurses have the potential to drive meaningful change toward sustainability [37]. Targeted interventions to enhance their environmental awareness and ecological behaviors could have a significant and widespread impact, beginning in undergraduate education and extending throughout their professional careers [11]. Education could play a crucial role in fostering a culture of sustainability in nursing practice. In this regard, multicomponent educational interventions integrating theoretical knowledge, practical training, and institutional support have proven their effectiveness and could raise awareness and reduce the ecological footprint of healthcare [38]. Strengthening environmental education at all levels of nursing training and practice can lead to long-term behavioral change, ensuring that nurses are not only equipped with the necessary knowledge but also empowered to implement sustainable practices [39]. By investing in structured and comprehensive interventions, healthcare institutions can amplify nurses’ role as key agents of sustainability, ultimately minimizing the environmental impact of healthcare and promoting a healthier future for both patients and the planet.

The psychometric robustness of the Italian NEAT supports its use not only as a research instrument but also as a practical tool in nursing education and policy development. For instance, subscales such as NAS I, which focuses on awareness of sustainability concepts, and NPEB I, which measures engagement in professional ecological behaviors, can be particularly valuable for identifying knowledge gaps and behavioral trends among nursing students and professionals [8]. These insights can inform the design of targeted educational interventions, such as integrating sustainability modules into nursing curricula or simulation-based training focused on eco-conscious clinical decision-making. In academic settings, the NEAT could be administered at different stages of nursing education to monitor progress and evaluate the impact of environmental health content [40]. In clinical contexts, it could serve as a component of continuing professional development, informing staff training programs aimed at reducing the environmental footprint of healthcare practices. At a broader level, the NEAT may also contribute to national or institutional sustainability strategies by offering a standardized method to assess and monitor nurses’ awareness and engagement with environmental issues over time.

This study has some limitations. The inclusion of participants from a restricted area in the north-west of Italy may limit the generalizability of our findings, particularly given regional differences in healthcare provisions and resources. Additionally, the inclusion of both nurses and nursing students could have influenced the results, as participants may have been either more closely engaged with clinical practice or more familiar with knowledge acquired during undergraduate education. Moreover, the inclusion of nursing students likely contributed to the relatively young mean age of the participants. With regard to the representativeness of the sample, the participating nurses were drawn from a variety of clinical settings, ensuring diversity in terms of working environments. However, they shared a relatively homogeneous educational background. Similarly, the nursing students had completed internships across different care contexts, which contributed to capturing diverse perspectives on environmental awareness in healthcare. The decision to analyze students and nurses as a single group was guided by the aim of validating a tool that can be used in both educational and clinical contexts to assess environmental awareness and support sustainability-related policies in nursing. Furthermore, this study used a convenience sampling approach, which may introduce selection bias and limit the generalizability of the findings. Participants were recruited from specific academic and clinical settings, and may not fully represent the broader population of Italian nurses and nursing students. As a result, the sample may be skewed toward individuals with a particular interest in sustainability, or those more available to participate in research. While the diversity of clinical contexts adds some variability, caution is warranted when extrapolating the results to the entire nursing workforce. Future studies employing probabilistic sampling methods could help to strengthen the external validity of the NEAT’s psychometric properties. Finally, a test–retest reliability assessment should be conducted to evaluate the instrument’s stability over time. The lack of longitudinal data in the present study represents a methodological limitation, as temporal stability is an essential component of construct validation. Future research should assess the NEAT’s reliability over time to confirm its consistency and usefulness for repeated measurement in educational or clinical interventions. However, we followed the COSMIN guidelines and included a substantial multidisciplinary sample to assess content validity. Despite the mixed composition, our sample adhered to the rule of thumb of five to ten participants per item in the Italian NEAT subscales.

5. Conclusions

This study adapted and psychometrically validated an Italian version of the NEAT, supporting its use in the Italian context. The instrument demonstrated satisfactory validity and reliability, confirming its potential for assessing environmental awareness among both nursing students and professionals. By capturing both cognitive and behavioral dimensions of sustainability, the NEAT represents a valuable resource for evaluating educational needs and monitoring the impact of interventions aimed at promoting environmentally responsible practices in healthcare.

The findings have important implications for nursing education and policy. The NEAT can be used in academic settings to guide curriculum development and in clinical contexts to inform professional training and sustainability initiatives. Furthermore, the instrument provides a foundation for future research exploring the factors that influence environmental awareness in nursing and its relationship to practice change.

While the use of a convenience sample limits generalizability, the inclusion of a diverse population across educational and clinical settings enhances the ecological relevance of the findings. Future studies should consider broader and more representative samples to further validate the tool and support its international application.

In conclusion, the Italian NEAT is a theoretically grounded and psychometrically sound instrument that can contribute to building sustainability competencies among nurses, paving the path toward achieving environmentally responsible healthcare.