Content area
Background
Health systems must be strengthened to mitigate and adapt to climate change-related health challenges, and nursing program accreditors are beginning to require climate health competencies (American Association of Colleges of Nursing). Since these recommendations are recent, more information is needed for faculty to build competence in content related to climate and health in nursing program curricula.
Method
A literature review was conducted to explore how climate-change environmental and population health implications are being incorporated into nursing education. Literature was reviewed using the Global Consortium on Climate Change and Health Education competency outcomes as a guide to evaluation.
Results
Educators used three types of strategies: (1) integration of content throughout the existing curriculum; (2) embedding a stand-alone course; and (3) educational activities directed toward climate health education.
Conclusion
The strategy that provided education on the greatest number of competencies was the integration of content throughout the existing nursing curriculum. [J Nurs Educ. 2025;64(4):227–234.]
Full text
The Intergovernmental Panel on Climate Change (IPCC) (2022) reports with high confidence that climate change has adversely affected the physical and mental health of people around the globe. The IPCC projects that both near-term and long-term ill-health and premature deaths will significantly increase because of climate change and extreme events. The IPCC recommends strengthening health delivery systems and improving system resilience to mitigate and adapt to changing circumstances affecting human health and service delivery.
Strengthening health systems involves a shift in how health care professionals think about and respond to climate-related health problems. Improving understanding of both the direct and indirect effects of climate change on human health is essential. Important considerations include the social and behavioral factors as well as the environmental and institutional contexts that influence exposure pathways and health outcomes (United States Global Change Research Program [USGCRP], 2016). Increases in temperature, precipitation extremes, extreme weather events, and sea level rise expose populations to extreme heat, poor air quality, reduced food and water quality, changes in infectious agents, and population displacement (IPCC, 2022; USGCRP, 2016). How those exposures translate into adverse health outcomes is affected by social determinants and behavioral choices as well as infrastructure conditions, geography, agricultural and livestock use, and ecosystem changes (USGCRP, 2016).
The importance of educating health care professionals on the implications of climate change on health has been gaining widespread support during the past 5 years. In 2018, the International Council of Nurses called for national nurses' associations to embed climate change-related knowledge into nursing curricula and continuing education. The American Medical Association (2024) has declared climate change a public health crisis and adopted a policy in 2019 supporting education on the basic science of climate change beginning in undergraduate training. The American Nurses Association (ANA, 2023) issued a position statement calling on nurses to “integrate the science of climate and health into nursing education, research, and practice” (p. 1).
Nursing, as the largest health care profession in the U.S. with 4.7 million RNs (American Association of Colleges of Nursing [AACN], 2024), is well positioned to positively affect health systems. According to Gallup polls (Brenan, 2023), nurses are the most trusted profession, allowing for considerable influence on the individuals, families, and communities they serve. The profession is ethically bound to provide interventions that protect vulnerable populations (ANA, 2015). Nurses are systems experts with holistic perspectives and are experts at forming relationships across disciplines (ANA, 2023). These attributes are identified as essential in both mitigating and adapting to the effects of climate change (USGCRP, 2016).
The ANA (2023) position statement on climate change and health encourages schools of nursing to prepare nurses to educate patients and the public about climate health and mitigation strategies, ready them to participate in disaster and climate adaptation preparedness, train them in caring for those affected by climate change, support decarbonization of the health sector, and integrate climate and sustainability content in all levels of nursing curricula. Nurses respond to human health needs and advocate for just and equitable health care in all settings. The changing planetary conditions require nursing education to respond by preparing the workforce for the challenge of mitigation and adaptation with a commitment to equity and social justice.
Core concepts to guide educational and curricular program development in climate health for health professions were developed by the Global Consortium on Climate and Health Education (GCCHE; 2023). The model was established in 2017 as an outgrowth of needs identified at the 2015 COP-21 conference in Paris and has had several iterations since then. Because the model was developed for the education of all health professionals, it is particularly well suited to serve as a guide for curriculum development for nursing. The framework is organized using broad educational domains. Each domain outlines overarching concepts reflecting foundational climate and health skills knowledge accompanied by a brief statement describing a learning objective. The goal is to provide a flexible framework that allows students to understand known challenges and adapt their practice to the climate change challenges they may encounter. Because this framework is housed in a living document under frequent review by experts to keep abreast of science and best practices, it can serve as a model for assuring balanced and complete curricular content to develop competencies in prevention, mitigation, and response to the health effects of climate change.
The most recent revision of the Commission on Collegiate Nursing Education's (CCNE) framework for the preparation of baccalaureate-prepared RNs includes a competency for preparedness to protect population health that includes understanding the effect of climate change on population and environmental health (AACN, 2021). The framework is the accreditation guide for thousands of baccalaureate programs with national accreditation through CCNE.
Because the effect of climate change on health has only recently been added to essential nursing education, baccalaureate nursing program curricula often do not address climate change-related health management competencies. Amerson et al. (2022) surveyed 21 schools of nursing and found that 81% of respondents do not include the health implications of climate change in their curriculum. Barriers to the integration of climate change and health in health professions curricula include a lack of faculty expertise, the faculty time and support to develop course content, the lack of teaching materials, and a lack of space in already dense curricula (Breakey et al., 2023). More information is needed for faculty to develop and incorporate meaningful, competence-building content related to the health effects of climate change in nursing curricula.
Aims
Aim 1
The first aim was to conduct a literature review of climate change-related population health competency development in nursing education to answer the question, “How are climate-change population and environmental health implications currently being incorporated into prelicensure nursing education?” Literature included met the following criteria:
Discussed climate change-related population and environmental health implications in nursing. Provided content relevant to teaching undergraduate nursing students competencies in the management of population and environmental health issues connected with climate change. Were relevant to nursing programs in the U.S. and Canada.
Aim 2
The second aim was to synthesize and evaluate the literature to inform content integration recommendations in the baccalaureate nursing curriculum to meet the need to improve nurses' management of health implications related to climate change.
Method
Inclusion Criteria
Inclusion criteria included full-text articles published in English that reported climate-change topics relevant to GCCHE Climate and Health Core Concepts for Health Professionals (2023) competencies and methods of embedding those topics in higher education curricula. English language policy documents, professional organization documents, governmental publications, and published and unpublished literature relevant to the study aims were included.
Literature published before 2008 was excluded due to the rapidly changing scientific knowledge of the health effects of climate change. Literature not published in the English language also was excluded.
Search Strategy
A comprehensive search strategy was used to identify English-language literature relevant to the topic. Specific databases that were searched included CINAHL® Complete™, PubMed®, Scopus®, and MEDLINE® as these databases house the bulk of literature specific to health care and health care education. The following search terms were used: (1) Nurs* and Educ* and climate change and (2) climate change and curricul* and (college OR universit*). An English language filter was used, and results were limited to studies published from 2008 until 2024.
Study Selection
All studies identified in the searches were selected if they met the eligibility criteria. Studies identified in the search were uploaded to EndNote™, a bibliographic management software. Studies then were transferred to Covidence, a systematic review software, to facilitate the removal of duplicates and screening of studies meeting the inclusion criteria. The author performed all searches, screening, and evaluation independently.
Results
The initial search of all included databases and other literature yielded 1,575 documents. After the removal of duplicates, the initial pool included 659 articles. A title and abstract screening further reduced the pool to 162 articles. Following the full-text screening, 116 articles were excluded, primarily because they did not include methods of embedding climate change topics in higher education curricula. Studies included in the review (n = 41) underwent data extraction using a data extraction form developed by the author to identify the geographical area of the study, the student study population (i.e., undergraduate nursing, graduate nursing, medical, and health professions), the study aims, the type of educational strategy (i.e., program curriculum, stand-alone course, a module within another course, and learning activity), and the methods used for content integration.
Each type of educational strategy was then evaluated to assess if and to what extent the strategy succeeded in meeting the GCCHE core competencies for health professionals. Of the 41 studies selected, 23 were conducted in North America, 15 in European countries, one in the Middle East, and two in Australia. Although the focus of this query was undergraduate nursing curriculum related to climate change, other health professions' climate change curricular strategies were included. Eighteen studies discussed undergraduate nursing education, 17 were related to medical education, six were focused on graduate nursing, and five included all health professions (Figure 1).
Integrating Climate Change and Health Education Throughout Existing Curriculum
This category of studies included 10 articles describing the academic content or philosophy of curricular design for an entire program of study. Five of the articles described nursing curricula, four described medical curricula, and one described health care education in general. Two of the studies limited the topic to issues regarding sustainability; the remaining eight articles had a much broader range of climate change topic inclusion.
Several models were used to structure climate and health topics for inclusion in the curricula. Models included the GCCHE model (2023), the Planetary Health education framework (Faerron Guzman & Potter, 2021), the NurSus TOOL-KIT evidence-based sustainability competencies (University of Plymouth, 2024), and several models developed in-house. None of the studies included a robust evaluation of the efficacy of their curricular approach.
GCCHE model. The GCCHE (2023) model was used in two of the studies. The core concept framework is intended to be used as a guide in developing climate and health education for health professions programs. Concepts are related to five domains: (1) knowledge and analytical skills; (2) communication and collaboration; (3) policy; (4) public health practice; and (5) clinical practice.
Simmonds et al. (2022) incorporated the GCCHE competency domains into an advanced practice Doctor of Nursing (DNP) program. Using a step-wise approach, they introduced concepts in the knowledge and analytical skills and policy domains in the first semester, built on that knowledge through assignments in the second semester, and then in the third semester, reflected on their roles in influencing public health systems change, specifically related to social and racial inequities, and climate change. Their approach appeared to be focused primarily on the development of the professional's awareness of the effects of climate change on vulnerable populations and their voice in advocacy and policy.
Quinn Griffin et al. (2022) used a crosswalk approach, linking the AACN core competencies for professional nursing practice with GCCHE domains and competencies in a DNP program. The GCCHE domain of Knowledge and Analytical skills fits well in courses on theory as well as concepts and contemporary issues. Courses on population health work well with the GCCHE domains of Communication and Collaboration, Policy, and Public Health Practice. Clinical Practice domain topics would fit well in coursework devoted to quality and safety and person-centered care. Courses devoted to scholarly inquiry can incorporate Communication and Collaboration domain topics, as well as Policy Public Health Practice topics. At the DNP level, the authors recommend the integration of climate change topics throughout the DNP coursework.
Planetary Health education framework. The Planetary Health education framework was developed by the Planetary Health Alliance based at the Harvard T.H. Chan School of Public Health (Faerron Guzman & Potter, 2021). Published in 2021, this framework is the culminating effort of many professionals participating in task forces beginning in 2017. It is designed to provide an organized interpretation of Planetary Health education for institutions, curriculum, and course design using a constructivist approach to achieve transformational learning. The concept of man's interconnection with nature is at the core, with the topics of The Anthropocene and Health; Movement Building and Systems Change; Equity and Social Justice; and Systems Thinking and Complexity entwined with the core concept, all embedded within local conditions and the wider global agenda and priorities.
Navarette-Welton et al. (2022) and Flaten et al. (2023) also used a crosswalk approach for their curriculum. Navarette-Welton et al.(2022) linked their guiding educational principles with the Planetary Health education framework (Faerron Guzman & Potter, 2021) core competencies and developed planetary health learning objectives with course objectives within existing courses in their medical curriculum. Their approach touched on all the GCCHE domains except Domain 2, the Communication and Collaboration domain. Flaten et al. (2023) linked the Planetary Health core competencies with the AACN nursing competencies and embedded activities, meeting both competencies with in-class learning activities in their population health coursework.
NurSus TOOLKIT evidence-based sustainability competencies. The University of Plymouth (2024) houses a curriculum toolkit, NurSus TOOLKIT, designed to be used with nurses and midwives to build sustainability competence. Although the curriculum aligns with the GCCHE competence knowledge and analytical skills, the materials and methods appear to be heavily focused on environmental sustainability with minimal alignment with the other four GCCHE domains. Studies citing the NurSus TOOL-KIT curriculum focused on student activities during clinical practice designed to bring awareness and encourage problem-solving focused on medical waste reduction and were conducted in the United Kingdom (Jersby & Ridley, 2023; Richardson et al., 2019).
Other models. Two studies did not rely on existing climate change competencies; instead, the studies used lists of climate change and health outcomes created specifically for the studies (Liu et al., 2022; Sullivan et al., 2022). In these two studies, the overarching climate change curriculum goals were determined by an in-house committee, which then aligned those goals to the existing educational framework and integrated climate-specific outcomes in multiple existing curricular settings.
Integrating Climate Change and Health Education Through a Stand-Alone Course
The inclusion of climate change and health curriculum was accomplished through the development and implementation of courses dedicated to the topic in 13 studies. Three of the studies described courses identified as mandatory in the curriculum of study; six were course electives, and four were elective mini-courses.
Mandatory courses. Cadet (2022) described the creation of a stand-alone mandatory course in an advanced practice RN (APRN) curriculum using a crosswalk of the National Organization of Nurse Practitioner Faculties' (NONPF) competencies with a list of concepts related to climate change health issues derived from a literature review. Their approach appears to align with all of the GCCHE Domains with the exception of Policy. No evaluation of outcomes was provided.
Müller et al. (2023) described a mandatory 28-hour elective course on climate change and health for preclinical medical students in Germany. Their curriculum appeared to align well with GCCHE Knowledge and Analytical Skills and Clinical Practice, with a small application in Communication and Collaboration. The study included an evaluation of student environmental knowledge and awareness outcomes, which showed improvement in basic climate change knowledge but no appreciable change in environmental behavior.
Gundacker and Himmelbauer (2023) repurposed an existing medical ecology course included in the core curriculum of first-year medical students in Austria. The course objectives were limited to those aligning with the GHCCE Domain Knowledge and Analytical Skills and Public Health Practice, specifically biodiversity loss and disease emergence. Course evaluation indicated students achieved the learning objectives of the course.
Elective courses. Elective courses included online, hybrid, and in-person options. Fülbert et al. (2023) described an in-person medical education course that featured lecturers from various disciplines within and outside of medicine speaking on topics on planetary health identified in Germany's recently updated competencies in medicine. Another German study described a hybrid course for first-year medical students with both online and in-person requirements (Lemke, et al., 2023). Both courses appeared to be organized around three GCHHE domains: (1) Communication and Collaboration, with a focus on communication with patients; (2) Clinical Practice, with a focus on applying climate and health knowledge to patient care; and (3) Policy, with a focus on transformative action at the personal and sociopolitical level. Both courses received positive student evaluations.
An online offering that appears to encompass all of the GCHHE domains in the brief description provided was discussed by Hatfield et al. (2022). The multidisciplinary course was designed to engage students through online discussion of required readings and recorded mini-lectures by experts. This was one of two studies with an interprofessional focus. Although not explicitly stated, the authors' list suggests the students were in medicine, nursing, human nutrition studies, and public health programs. The other online interprofessional elective course (Rogers et al., 2023) described an 8-week course on public health emergency preparedness touching on all of the GCCHE concepts except clinical care of patients and advocacy. Student evaluations exceeded averages for all interprofessional education courses.
Wasco (2019) stated the goals of an online course developed for RNs seeking a baccalaureate nursing degree were to educate students about the health effects of climate change and to help them develop “a sense of responsibility for the global population and its collective health” (p. e7). The course topics appeared to touch on concepts in two GCHHE domains: (1) Knowledge and Analytical Skills and (2) Communication and Collaboration. Student evaluations indicated satisfaction with the course.
Mini courses. Williams and Downes (2017) described a 3-day seminar for graduate nursing students on the nursing role in complex humanitarian emergencies related to the changing climate. The course used online modules developed through Sphere (2023), didactic components, and participatory group exercises. The narrow focus on humanitarian emergencies appears to limit the GCCHE components to some concepts in the Knowledge and Analytical Skills and Clinical Practice domains. High student satisfaction was reported.
Capetola et al. (2022) discussed a mini course that resulted in a micro-credential for graduate students using a 6-week online format that appeared to touch on all of the GCCHE Domains except Clinical Practice. Moustafa Saleh and Elsabahy (2022) used a 4-week online format for nursing students; from the limited information available, the content appeared to be limited to environmental sustainability. Jonas et al. (2023) also used a 4-week format, offered both online and in person, for third-year medical students that focused on the health consequences of climate change in children, fulfilling the GCCHE domain of Clinical Practice. All of the studies reported positive student feedback.
Integrating Climate Change and Health Education Through Learning Activities
Nine studies described the creation of educational content designed to integrate climate change and health learning. Online modules were created to deliver content in three studies, and other methods of content delivery were devised in three studies. In the remaining three studies, the authors described hands-on student activities in simulations.
Modules. Linton et al. (2020) embedded a 4-week instructor-created module focused on sustainability in a 16-week nursing synthesis course for RNs seeking a baccalaureate degree. Dunne et al. (2022) delivered a similarly constructed stand-alone online module for third- and fourth-year medical students. Both models appeared to meet sustainability concepts found within the GCCHE Knowledge and Analytical Skills domain. and both models used a pretest-posttest method of evaluation that suggested the interventions were successful in improving student attitudes toward sustainability. Keating et al. (2022) constructed an online module with asynchronous and synchronous content delivered one time to Doctor of Nursing Practice students in an epidemiology course. The course objectives indicated the content was limited to a couple of concepts in the GCCHE Public Health Practice domain. Student feedback suggested more climate change content was needed in their program of study.
Embedded learning materials. The creation of climate change and health course material designed to be used at-will in existing courses was used in three studies. Luo et al. (2023) developed slides to provide planetary health content that aligned with the Canadian Federation of Medical Students Health and Environment Adaptive Task Force (2021) Planetary Health Educational Competencies in a form easily embedded in existing lectures. This model closely aligned with the GCCHE Core Concepts for Health Professionals. After receiving the content, participants' planetary health knowledge scores improved.
Moro et al. (2023) created planetary health facts and planetary health solutions that were embedded into an introductory physiology course PowerPoint® slide to match the week's topic; no other teaching was provided. Survey results indicated moderate improvement in students' knowledge of planetary health. Topics appeared to encompass the GCCHE domains of Knowledge and Analytical Skills and Clinical Practice concepts.
Abebe et al. (2022) created a film and a toolkit to reflect on emotional and psychological concerns arising from climate change. The investigators embedded this content in an existing interprofessional undergraduate course on the health effects of climate change; the content falls within the GCCHE domain of Clinical Practice. The authors had not completed the evaluation of their toolkit at the time of publication.
Simulations. Three studies described active learning activities in simulations. Ramkumar et al. (2021) used a standardized patient exposed to wildfire smoke in a simulation delivered at a simulation center. The simulation evaluated medical students' application of knowledge of climate and environmental risks in patient care, falling within the GCCHE Clinical Practice domain. Results indicated students' knowledge of the health effects of climate change improved after the simulation. Rosencranz et al. (2023) used a tabletop simulation in a 90-minute workshop to teach policy and advocacy concepts to medical students. Results indicated improvement in the GCCHE domain of Advocacy Skills. Kueter (2020) conducted a simulation of a climate change-induced disaster for nursing students at a simulation center to learn about a Nicaraguan coastal community affected by climate change before taking students to the community during a study-abroad experience. No outcomes evaluation was provided.
Opportunities for Curricular Revision in Undergraduate Nursing Programs
Many nursing programs are undergoing major curricular revisions due to the updated AACN (2021) essential competencies for professional nursing education. AACN accreditors have moved to a competency-based evaluation strategy requiring many nursing programs to evaluate their current curriculum for alignment with the new requirements. Curricular revision is always a complicated process in baccalaureate professional nursing programs due to the density of content required to matriculate a minimally safe nurse. Because many programs are already engaged in the curricular re-tooling process, it is an opportune time to integrate climate change health content. If the goal is to produce nurses imbued with the values and skills necessary to strengthen health delivery systems and improve system resilience to mitigate and adapt to climate changes affecting human health and service delivery (Intergovernmental Panel on Climate Change, 2023), a comprehensive effort should be made to align the GCCHE concepts with AACN essential competencies and incorporate climate change health learning objectives into the curriculum.
Climate change health content currently is being delivered in a variety of ways in health professions curricula. The methods that appear to provide an opportunity to cover all the GCCHE Domains, if not all of the concepts housed in the domains, include the integration of content in appropriate existing courses across the curriculum and the delivery of a stand-alone mandatory full-length course. In already dense curricula such as medicine and nursing, there were several mentions of the difficulty in carving out additional room to add yet one more course. The exception to this would be in those programs that require interprofessional education coursework; those courses could be tailored to meet many of the goals of climate change health education.
The ready-made materials described by several authors provide nursing faculty who may not have any education in climate change health with high-quality resources ready for course integration. Available resources mentioned in the literature are listed in Table 1.
| Reference | Description | Link |
|---|---|---|
| Canadian Federation of Medical Students (2024) | Open source modules, slides, and info for climate health education | |
| Global Consortium on Climate and Health Education (2024) | Links to educational content and resources on climate and health topics | |
| Harvard T. H. Chan School of Public Health (2025) | Collections curated to support teaching and learning about climate change and health | |
| Alliance of Nurses for Healthy Environments (2025) | Presentations, recommendations, advocacy strategies, lesson plans, and an environmental health in Nursing e-textbook | |
| University of Plymouth (2025) | Opensource teaching materials related to planetary health and sustainability | |
| Planetary Health Alliance (2025) | Downloadable planetary health presentations, curriculum design support, videos, cases studies | |
| Sphere (2023) | Videos and other materials for training on humanitarian disaster responses |
Model for Implementation of Curricular Change
Curricular change requires thoughtful planning. The Lewin Change Model (Lewin, 1947) states that the first step in organizational change is to unfreeze or set the stage for change. As previously discussed, there is a confluence of factors setting the stage for climate change and health education, including international, national, local, professional, and personal imperatives. Moving is the second step or creating needed changes through group consensus. The third step is refreezing, or implementing and sustaining the changes. Figure 2 incorporates Lewin's Change Model (Lewin, 1947) in planning for the integration of climate change and health content in undergraduate nursing curricula.
Recommendations Based on Existing Literature
Evaluate the GCCHE (2023) and the Planetary Health Alliance (2025) models for best fit within the existing mission and values of your institution.
Construct a crosswalk aligning the competencies required by the nursing program's accreditation agency and the climate health competencies in the model chosen with the program's course offerings, ideally teaching climate health within existing course student learning outcomes. Construct an evaluation strategy.
Work with course faculty to provide resources and additional training needed to build instructor confidence and expertise in climate health. Use available resources.
Embed existing content or construct new content on climate health, building in robust evaluation methods. Use available resources.
Implement the changes.
Evaluate student outcomes and keep the data.
Write up findings and disseminate new knowledge.
Discussion
Because the incorporation of climate health goals in nursing education is relatively new, there are few published studies on curricular incorporation and none that include an evaluation of climate health competencies acquired through a nursing program. The bulk of the literature found in the initial search was centered on the need for climate health education in health professions education. Evaluation of the efficacy of the different educational methods was either missing or very limited to student feedback in most of the literature reviewed. The small number of applicable studies is a limitation of the review, requiring a more subjective evaluation of the efficacy of curricular approaches than would occur with more mature topics.
Another limitation of this inquiry is the lack of a second reviewer. This was a systematic review, and a thorough review requires at least two reviewers to reduce the risk of bias in the selection of reports, identification of relevant data, and interpretation of the data.
Regardless of the limitations, this is an important addition to nursing knowledge. Nursing faculty throughout the U.S. are in the process of curricular revisions necessitated by the major AACN changes in the essential components of nursing programs seeking accreditation. Nursing faculty often are tasked with all aspects of the nursing curriculum, including program learning outcomes, student learning outcomes, and evaluation strategies, along with the design, development, and delivery of course content. It is difficult to have time to do everything well, thus reviews such as this one serve as an informed time-saver for nurse educators.
The World Health Organization (2023) has called climate change the single biggest health threat facing humanity. There is a call for nurse educators worldwide to prepare the nursing workforce to adapt to climate change and care for people affected by climate change (Butterfield et al., 2021; Dupraz & Burnand, 2021; International Council of Nurses, 2018; Leffers, et al., 2017). Scholarly inquiries such as this literature review provide one step forward in realizing the goal of mobilizing nurses, the nation's largest health care workforce, in meeting this public health challenge.
Conclusion
The incorporation of climate change and health content in nursing curricula is occurring all over the world in a variety of ways. Very few nursing programs report using a mature framework to guide the embedding of the complex content needed for the well-informed health care professional. Two well-researched and reputable guides to curricular development and the inclusion of climate health competencies in nursing programs are the GCCHE (2023) and Planetary Health Alliance (2025) frameworks. The alignment of existing nursing competency outcomes with climate health outcomes can facilitate the embedding of climate health content within an already dense curriculum. Many well-constructed and applicable educational materials are available to help nursing faculty improve their understanding of climate health concepts and assist in course development and delivery.
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