Interim Report August 2015: A Delphi study and thematic analyses of curricula to identify opportunities for embedding sustainability in nursing curricula

Output O2: A Delphi study and thematic analyses of curricula to identify opportunities for embedding sustainability in nursing curricula


Activity 2 is linked to project objective 2 and directly  feeds into project objective 3:

  • Project Objective 2. Identify examples of good practice and opportunities for integrating sustainability into the nursing curricula (…also barriers)
  • Project Objective 3. Develop and agree SLC framework linked to professional profiles within nursing


  • To scope the nursing curriculum (and CPD) in partner organisations in order to identify current sustainability content and opportunities for integrating SLC.
  • To conduct a broader participatory (e.g. Delphi survey) thematic analysis of curriculum opportunities in order to identify (how to integrate) key SLC issues and examples of good practice in the nursing curricula of the partner organisations, but also in nurse education in general via project stakeholders
  • To provide a thematic overview of SLC curriculum opportunities (including didactical approaches) for nurse education

 Main sub-activities

  • Thematic curriculum analysis: Thematic scoping and analyses of programmes in Plymouth, Jaen and Esslingen.
  • Broader expert Delphi study SLC curriculum content

Note: A third but minor activity carried out under Activity 2 is the review of nursing professional body standards for education in each partner country to interpret and identify curriculum opportunities to address SLC. The review is completed for The Netherlands and Germany. The reviews for the UK and Spain will be completed by mid-September, results will be collated and discussed in the final O2 project report.


Activity 2 main milestones and expected deadlines

  • Initial thematic curriculum analyses: completed
  • Transnational meeting Plymouth-Maastricht to finalise Delphy survey outline: completed
  • Detailed thematic curriculum analyses: completed
  • Delphi survey: round 1 completed, round 2 completed
  • Collated activity 2 report and submitted paper: report due in September, paper due in October

Feeding into: project meeting in Maastricht-> agree on SLC framework (month 12)

Extra activities carried out:

The Delphi survey was translated into a student survey for the student focus groups carried out in Plymouth, Jaen and Esslingen.

Achievements and future action

All tasks have completed as per project plan and according to time-scales.

Findings will be discussed at the Transnational meeting in Maastricht in September in order to inform the construction of the Sustainability Literacy and Competency Framework.

A final report will be produce (end October) and paper prepared for submission to a peer-reviewed journal.


Curriculum Scoping



The main aim of this scoping process is to identify examples of good practice and opportunities/barriers for integrating sustainability into the nurse education. For this, the NurSus team developed a comprehensive scoping template and associated interview guide. The initial curriculum scoping (milestone 3) and the detailed curriculum scoping (milestone 5) was carried out simultaneously, as this approach was less demanding on the interviewed teaching staff.


The scoping included a total of 18 selected informants from the different programmes: 6 in Plymouth, 6 in Jaen and 6 in Esslingen. In the programmes in Jaen, none of the selected informants could (after reviewing the SLC topic guide) identify sustainability-related topics within their nursing curricula. Within the programmes in Plymouth and Esslingen, several sustainability-related education examples were identified (see Table 1 and 2 for examples).


Findings and action


The scoping outcomes fed into the Delphi-survey among European experts as well as the development of the NurSus education materials in the second project year. The scoping results will be included and discussed in the Activity 2 report, due end of September.


Table 1: Main characteristics identified SLC education examples in Plymouth programmes

SLC education examples Plymouth programmes
Short describing title Programme Course Free key words topic Free key words education format Study load
1. Sustainability and Health skills: natural resources[Health and Sustainability Skills: Scenarios for healthcare resources use] BScNursing and Midwifery Clinical SkillsYear 2  Sustainable use of healthcare (clinical) resourcesAppropriate waste segregationImpact of healthcare on the environment

Problems of reliance on items made from scarce natural resources

Interactive scenario-based learning[integrated the session into nursing skill]  . This is a one-hour session that
2. Sustainability and Health skills: impact of climate change on health / healthcare[Leadership and Management] BScNursing and Midwifery Clinical SkillsYear 3  Impact of climate change on healthImpact of natural disasters on healthClimate change and public health Scenario-based learningGroup discussion One hour session in leadership and management module
3. Sustainability skills in Midwifery Practice/ Health promotion BSc (Hons) Midwifery MID 226 Midwifery Practice /Health PromotionMID 117 Resource managementWaste managementHealthy living Scenario based workshopInteractive discussionPractice linked Year 2 – 40 minutesYear 1 – 200 hours (healthy promotion) = 7-8 ECTSPractice – 10 – 15% practice time
4. Resource management[using legal and ethical viewpoints] BScNursing and Midwifery Healthcare law and ethics ADN302Year 3 Links between sustainable resource management, healthcare, ethics and law Student seminars; build on and is informed by preceding sessions on law and ethics in healthcare 2 hour student seminar session
 5. Sustainability skills in clinical nursing practice BSc Hons Nursing Child Health Clinical Skills yr 2 and 3 Clinical wastePlasticsRe-use/ Recycle

Practical skills

Interactive discussionScenario based learning Skills modules  16 hours
6. Sustainability skills: links between environment and mental health BSc(Hons) Mental Health Nursing NRS406 Skills & practice for nursingMHN302 Psychosocial Interventions to meet complex mental health needs WellbeingResourcesReflective practice


ScenarioReflective practice discussionsLecture 4 hours
7. Sustainability skills / Sustainability & Health BSc (Hons) Nursing: Adult NRS406/ ADN204/ ADN303(Skills & Practice for Nursing)ADN405 Core Concepts in Health / ADN201

Promoting Health & Public Policy

Links between sustainability and healthEnvironmental healthEvidence based practice


WorkshopDiscussionScenario problem solving 4-5 hours

Table 2: Mapping of identified SLC education examples in Esslingen programmes against the scoping SLC topic guide (Knowledge)

SLC topic Number SLC education example
1 2 3 4 5 6
Sustainable development/sustainability and nursing
Sustainable development concept and definition (approaches)
An understanding of the link between providing nursing care and sustaining the global environment. X
Consider government, professional and local philosophies and standards/targets linked to sustainability
Identify and understand key sustainability challenges, e.g. climate change, ecosystem services
Healthcare impacts of climate change
Sustainable resource and waste management (including energy and food) X
Identify the limited global resources used in nursing care
Sustainable Waste Management  (including toxic/polluting materials) X
Sustainable resource management, including energy use (e.g. reducing CO2 emission), commissioning; sustainable procurement
Review the sourcing, access, choice, distribution and waste of nutrition especially in Hospitals
Explore strategies to minimise healthcare waste in nursing practice
Health Promotion, including Active Travel x
Considering  transport systems and access to services and the most economically sustainable use of these resources x
Explore own understanding and philosophy of environmental sustainability and its application to healthcare delivery and health promotion x
Ecological Public Health (integrated/holistic approach toward health determination, including global health) X X
Concepts of Health: Individual – Society; Illness – Wellbeing; Biomedical approach; Biopsychosocial approach; self-help approach; ecological public health X X
Explore how the health of individuals, communities and populations is affected by social, political and environmental factors, e.g. the direct and indirect health impacts of climate change, within the ‘social determinants of health’ approach X X X
Population health X X
Health inequalities X X
Healthy communities X X
Health in a globalised  world,  including global determinants of health X
Ability to discuss the nature of the growing global population including local application and its dependence on global ecological systems X
Environmental health X
Consider government, professional and local philosophies and standards/targets linked to sustainability X
Environmental Impact (on health) X
Ecology, healthy environment important for healthy life X
How nursing activities effect the environment X
Environmental awareness (i.e. awareness of environmental issues) X
Understand changes required in nursing practice in order to sustain a stable ecological environment  X


Expert Delphi survey



The Delphi approach is a method for structuring a group communication process for soliciting expert opinion, using two or more (survey)rounds; each follow-up round builds on the results of the previous one. The main aim of the NurSus Delphi-study is to sense the opinion experts (nurse educators/professionals) about the most important sustainability knowledge, skills and competence to be included/achieved in nurse education.  As such, the survey will be employed for ‘issue identification and priorization’ regarding the main content of the NurSus SLC framework.  The NurSus Delphi study approach was discussed during the first transnational meeting (October 2014, Plymouth), resulting in a Delphi study protocol document. It was agreed that that the Delphi study would encompass three main phases.


Phase 1: Preparation

  • Topic generation procedure: Generate ideas on potential topics/components SLC framework; group topics under relevant headings Structure the field and formulate possible SLC topics. Desk research based on literature review, activity 1 and activity 2 scoping. SLC topics were categorized according to: Knowledge; Skills; Cognitive and functional competences; Personal and ethical competences
  • Selecting the expert panel: The list of possible expert participants was selected based on 1) Project partners network, 2) Review of relevant literature, websites and conference programmes, 3) EFN members (European federation of nures Associations) and 4) ENNE members (European network of Nursing in Higher Education).


Box 1: Selection criteria Delphi expert panelSelected panel members should have the requisite knowledge and/or experience to respond appropriately; they do not have to be experts in sustainability in nursing…

–      From as many European countries as possible (ensuring variation)

–      4 EU regions, minimum of 5 per per region

–      Plan to recruit between 30 and 40 respondents (note: the field is still relatively small in Europe)

–      Minimum of 15 educators

–     Sample as whole 50-50%: 50% nurse educators and curriculum developers, 50% other participants (People in practice/directors of nursing, authors publishing relevant research/ Policy: professional organisations/networks, guideline developers, policy development, hospital managers)


Phase 2: First round of the Delphi survey

  • Agree on outline: Agreed at the second transnational meeting (February 2-3, 2015, Plymouth),
  • Formulation of the different SLC-topics: building on activity 1 literature review and the scoping topic guide, we developed an extensive list of relevant SLC topics in 4 categories (knowledge, skills, cognitive and functional competences, ethical and personal competences)
  • Drafting and piloting of round 1 survey
  • Revisions and translation into online version
  • Administration, monitoring response, sending reminders (April 15th0-may 8th)
  • Analyses of round 1 results; and prepare feedback for round-2 survey


Phase 3: Second round of the Delphi survey

  • Agree on outline; based on outcomes phase 2, including feedback results and possibly additional questions (see also Box 2).
  • Drafting and piloting of round 2 survey:
  • Revisions and translation into online version
  • Administration, monitoring response, sending reminders (June 3oth-august 13th)
  • Analyses of round 1 results; and prepare feedback for round-2 survey
Box 2: Round 2 Feedback formatsTwo types of feedback will be included

1)    provide percentages or graphics from the accumulated round 1 data in a similar way as in the first round questionnaire & provide opportunity to review their scoring in view of average (range) round-1 outcomes

2)    provide graphics from the accumulated round 1 data followed by reflexive questions


Findings and action (selection of key outcomes)

Expert Panel

A total of 52 experts from different European regions participated in the first round of the Delphi survey. In the second round, the response rate was about 80% compared to the first round.


Importance sustainability education in nursing curriculum

Within the NurSus project, we define sustainability in health care as follows: ‘Designing and delivering health care that meets today’s health and health care needs of individuals and populations without compromising the ability of future generations to meet their own health and health care needs; this requires the provision of health care that recognizes and respects the dependence of our health on the earth’s ecosystems, without resulting in unfair or disproportional impacts within society’. Based on this definition, we asked respondents how important they believed it is to integrate sustainability-related education into the nursing curriculum.  The average score of the expert panel was 5.08 on a scale from 1 to 6, where 1 means “very unimportant” and 6 means “very important” .

Perceived barriers for integrating sustainability into the nursing curriculum

The participating experts were also asked to score a set of predefined possible barriers on their importance, on a scale from 1 to 6, where 1 means “very unimportant” and 6 means “very important.”


The round 2 survey closed on August 13th, 2015. The analyses and synthesis of results is ongoing and results will be included in the Activity 2 project report (due end of September). The results of the Delphi survey (round 1 and round 2 combined) will be translated into scientific publication, including recommendations for integrating sustainability in nurse education.


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