Upscaling sustainability: nurse leadership key

• Aug 16, 2023

Speaking at the headquarters of the Florence Nightingale Foundation (FNF), Charlotte McCardle, the Deputy Chief Nursing Officer for England, recently highlighted the vital role nurses have within sustainable healthcare. Climate change will have an “incalculable toll on human health”, she warned, but nurses have an opportunity to help protect our planet – to become “champions of change”. She called for all healthcare sectors to work collaboratively.

“We have to tackle climate change with the same vigour and gusto that we show around patient safety. Crucially, I think there is hope. By acting now, we can really make a difference,” she asserted.

Her speech was part of the graduation event of the first Green Healthcare Leadership Programme which celebrated nurse-led initiatives aimed at driving improvements in environmental sustainability. The Florence Nightingale Foundation and Nuffield Health previously announced a multi-year partnership, in 2022, with the launch of the ‘Green Healthcare Leadership Programme’. In the first year, the initiative saw 18 nurses – from the independent sector – each develop a nurse-led quality improvement project.

Designed to offer a supportive learning space to help develop leadership skills, the programme is empowering nurses to influence sustainable practice on the frontline of care. The event, held in London, provided a spotlight on their achievements.

The Clinical Services Journal spoke to the teams behind the programme to learn more about the innovation taking place, the support available to help nurses reduce the carbon footprint of their organisations, and the inspiring stories of projects that are currently making an impact. Some of the many initiatives introduced by the nurses, enrolled onto the pilot, included: 

• Reducing carbon emissions associated with single-use procedure packs.
• Tackling overuse of single-use plastic aprons.
• Reducing unnecessary usage of IV sets in oncology.
• Reducing unnecessary sterile equipment in theatre packs.
• CE marking for Begas as a plastic alternative for sterile equipment.
• A move to prescribing greener inhalers.
• Eliminating unnecessary use of couch covers (blue/white paper).
• Reducing surgical site infection (which in turn reduces carbon footprint), through improved nutrition.

The hope is to spread green practice and learning, across the healthcare sector and beyond. 

Lucy Brown, the Director of Nursing and Midwifery Leadership Development at the Florence Nightingale Foundation, described the impact of the pilot programme as “phenomenal” and “exceeding all our expectations”. 

“Working with the Centre for Sustainable Healthcare, we support and empower successful applicants on a transformational leadership journey,” she explained. “It is about giving nurses and midwives a voice to challenge practice and ultimately lead change. Nurses can struggle to have their voices heard and often suffer with imposter syndrome. At the FNF, we hold up a mirror to show our nurses and midwives how incredible they are; that they do have a voice, and that they can challenge and change practice. 

“Nurses are the largest profession in healthcare – they have great ideas and understand what does and doesn’t work. But often they do not speak up. Our programmes, including the programme with our partner Nuffield Health on sustainability, are about empowering these individuals to lead change back in their organisations, to influence others and manage upwards and across the frontline,” she continued.

The programme

Successful cohorts complete an eight-session programme, which starts with a reflection on the legacy of an inspirational role model, Florence Nightingale – one of many ultimate pioneer and nurse leaders. The programme initially focuses on building self-awareness and emotional intelligence. 

“This is your superpower; if you know yourself, you can lead others. We start to empower individuals by encouraging them to look within and recognise their strengths and also work on their blind spots,” Lucy explained. 

On the second session, the nurses learn about quality improvement and how they can take their idea forward – how they can frame it, measure it, and make sure it has an impact. “It is about how they can lead that change and embed it across multiple practice areas,” she commented.

Participants then go on to attend the Royal Academy of Dramatic Arts (RADA Business) – which Lucy described as “a life-changing experience” for those taking part.

“It is about building confidence, having clarity in delivering key messages to a range of audiences, and ‘bringing people along with you’. It is transformational,” she exclaimed. 

She revealed that participants also spend time with the King’s Fund, looking at how they can have greater influence and authority, including presenting to the board and building a business case to obtain funding and resources. This is in addition to time spent with the Centre for Sustainable Healthcare, which provides useful information on the climate change agenda, how to measure carbon emissions and sustainable healthcare methodologies. 

“You can see the spark in their eyes when they recognise that their projects could be replicated and scaled up at pace. Small, incremental changes can have such an impact on our carbon emissions which is very exciting,” Lucy continued. “At the last check-in, this group of 18 nurses had successfully saved over 6,821 tonnes of carbon. There are approximately 20 million nurses globally, imagine what could be achieved collectively; we could change the trajectory of our planet.”

Jonny Groom, Paediatric Anaesthetic Consultant, at the Royal London Children’s Hospital and Associate Medical Lead for Sustainability at Nuffield Health, has been supporting the programme, drawing on his seven years’ experience in sustainable healthcare. 

“It has been an incredible project to be involved with,” he commented. “People have come with a great deal of enthusiasm and lots of big ideas. With the help of this incredible programme, these ideas have been honed into effective improvement programmes. 

“Not only is their enthusiasm spreading, but action is spreading much further afield. It is increasing education within our own organisation, but also impacting outside of healthcare settings. For example, the manufacturers that produce the surgical packs are starting to change the make-up of those packs and readdress their packaging needs. The projects are having a much wider impact, beyond what was initially anticipated. It has been an incredible journey to watch our nurse leaders go through this programme.” 

Nurse-led improvement projects

A total of 18 nurses have now completed the challenge of implementing nurse-led quality improvement projects to support environmental sustainability at their workplaces. The nurses presented their projects at the celebration event, held on 10 May, at the offices of the Florence Nightingale Foundation. Nurse Practitioner, Sarah Hucker, one of the programme participants, spoke to CSJ about how the initiative has inspired her, and has led to quantifiable reductions in carbon emissions. 

“At the start, we all had big ideas on how we could change the world. But what I learnt was that it is important to focus on a single change that you can realistically achieve. A small change can be much more impactful,” she commented. 

Sarah decided to focus on a project aimed at encouraging staff to prescribe greener inhalers. Few people are aware that the carbon footprint of a single Ventolin Evohaler is equivalent to driving 175 miles in a family car. In comparison dry powder salbutamol inhalers produce the equivalent emissions of driving 4 miles. In fact, inhalers contribute to 13% of the carbon emissions in primary care.

In the first three months of 2022, 22% of salbutamol prescriptions were Ventolin Evohalers. This had a carbon footprint equivalent of driving 6,125 miles (989.1kgCO2 e). By educating staff about the environmental harm of a Ventolin Evohaler, and that there are green alternatives available, the project aimed to change prescribing practice and reduce the carbon emissions within the service – while minimising cost and without affecting patient outcomes. 

A re-audit in 2023 showed that now only 10% of the Salbutamol inhalers prescribed are Ventolin Evohalers. This achieved a saving of 508.68 kgCO2 e – equivalent to 3,150 miles. 

This was a great start to the improvement initiative, but Sarah has been striving to take this even further. She is currently working with the IT teams to add in a pop-up, which will challenge clinicians if they prescribe Ventolin, prompting them to think more sustainably. This will be a system-wide change and has the potential to have a far-reaching impact

“While driving change, you need to work on your leadership skills and start off small, then ‘snowball’ change. Throughout this programme, we have been able to see what a massive impact that small changes can have. But, as we grow as people, and grow in confidence, we will be able to do bigger and better things moving forward,” Sarah observed.

Sarah’s employer, PHL group, learned about what she was doing and asked her to share her experience and innovation across the organisation. The organisation recently acquired another company in Scotland and Sarah’s project has inspired them to implement carbon cutting measures too. A Carbon Reduction Committee has been established and is being tasked with reaching Net Zero within the next 20 years.

“I have been bringing ideas back from the project and it is inspiring change. Jonny and Lucy have lots of ideas on how we can move the project forward in the future. It is not just about the change being delivered as part of the project; it has been changing us as people, showing us that we do have a voice. The leadership skills that I have learnt will help me to inspire others,” commented Sarah.

‘Think before you apron’

At the celebration event, Laura Prang, a Senior Oncology Nurse at Nuffield Health at St Bartholomew’s Hospital, also highlighted her ‘Think before you apron ’ campaign. Single-use, plastic aprons are an environmental problem, and the NHS alone disposes of around 133,000 tonnes of plastic waste each year. She pointed out that one apron equals 65gCO2 e. 

Following a review, Laura ascertained that plastic aprons were being overused. A survey was created of a typical patient journey for her department, involving 10 steps. Each step represented a nursing intervention where an apron may be applied. These interventions were then cross-checked against the Marsden Manual on apron indication. The survey was then administered to the nurses and HCA in the department. 

Based on the results, the staff were found to be using aprons more often than the indicated moments. According to the survey, there were three moments to wear an apron. Laura’s research showed that staff were wearing them at an average of seven moments. The projected environmental impact of the project is annual carbon savings of 3,769kg, and cost savings of £2,000 per year. The project will also save time in donning and doffing of the aprons. 

Laura now plans to survey more departments to collect further data on apron usage throughout the organisation. This will form the basis of a wider education campaign. 

Other highlights included a project by Brittany Bowen, the Clinical Lead for Interventional Cardiology at InHealth Group, aimed at reducing the carbon emissions associated with singleuse procedure packs. Following a conversation with the third-party provider, Kimal (who shared her passion for sustainability), this issue was addressed. The aim of the project was to increase the knowledge and awareness of staff on the impact of hard plastics and seek a low carbon alternative to reduce the environmental impact of single-use packs

Items were swapped with low carbon alternatives. As an example, the swap of one kidney dish for a low carbon alternative, Kimalwide, was estimated to be the equivalent of 17.43 tonnes CO2 e per year. Staff awareness of the impacts of hard plastics and single-use procedure packs also increased with a ripple effect of the team identifying new quality improvement projects

Reducing surgical site infection

Debbie Price, a Senior Nurse ODP, at Nuffield Health York Hospital, highlighted a project that targeted infection prevention to reduce carbon footprint. Following surgical procedures, patients often return to the outpatient department for wound checks. Occasionally, these wounds become infected. Poor nutritional status has a profound impact on the host immune response and makes the patient more susceptible to post-operative infection. 

Patients are unaware of the impact that nutrition has on wound healing. Therefore, improving nutritional status is paramount to good patient outcomes and reducing carbon footprint caused through infection that increases bed days. 

Debbie calculated that the environmental impact of reducing just one infection was a saving equivalent to 667kgCO2 e – equal to the growth of 31 mature trees in one year. Ultimately, reducing post-surgical wounds by promoting good nutrition will help to heal wounds in a timelier manner, reduce carbon emissions associated with inpatient stay, improve patient satisfaction and outcomes, and reduce financial costs associated with infection. 

Winner of the FNF scholarship

From the cohort of 18 nurses, one was singled-out to go forward with a prestigious ‘Florence Nightingale Foundation scholarship’. At the celebration event, Rachael Brown, an Infection Prevention Nurse at Nuffield Health Warwickshire Hospital, was awarded with a scholarship for her sustainable healthcare project that has reduced the use of couch covers at Nuffield Health Warwickshire Hospital. The scholarship will enable Rachael to invest more time into developing her project and implementing it at scale.

“Couch covers (also known as blue-roll covers) are widely available in outpatient, physiotherapy and pre-assessment areas within healthcare sites,” Rachael explained. “From an infection prevention point of view, they serve little purpose. We have now reduced them across our hospital, working with the different hospital teams such as physiotherapy and outpatients. I estimate this could save over seven trees, cut clinical waste of 1,777 kg, and reduce carbon emissions of 4,861 kgC02 e per year at our one hospital. This can be potentially scaled up across Nuffield Health’s other hospitals, fitness and primary care facilities,” she added.

The projected cost savings, from making these changes at the Nuffield Health Warwickshire Hospital, are estimated to be £3,900 per year. However, when scaled up across the Nuffield Health Group, the cost savings are expected to total £87,217 per year. The saving in blue roll/couch covers, is estimated to be the equivalent of 55 miles of paper per year, at the one hospital, or 1,500 across the group.

After joining the programme, Rachael’s project has had a wider impact at her hospital and across Nuffield Health. The estimated savings in clinical waste across the group is an impressive 46,118 kg per year, and a reduction in carbon of 92,374 kgCO2 e per year.

“I shared my project with other infection prevention and control leads at Nuffield Health’s National Infection Prevention Day and I’m now working with our primary care leads about removing couch covers across Nuffield Health’s primary care services,” Rachael commented.

“This has massive potential for the future and there is so much other work we can do. Infection prevention nurses, as a group, have historically driven single use, but we need to work to change that,” she continued. “The beauty of this project was its simplicity. There was some push back, initially, but we explained why we were doing this from a sustainability point of view; no one could find any reasons why using blue roll was useful…We helped people realise that this was about the future of healthcare and our planet, and not just a cost cutting exercise.”

The project helped to prompt wider interest in improving sustainability and, in February, Rachael initiated the first meeting of the Nuffield Health Warwickshire Hospital Sustainability Forum. Around 30 people from different hospital teams attended and they came with different sustainability ideas for their own areas. This has led to the removal of paper cups and the small plastic milk containers from the coffee machines at the hospital. The hospital is now using re-usable crockery and a jug of milk which reduces plastic waste.

Gemma Stacey, Deputy Chief Executive Officer at the Florence Nightingale Foundation, said: “Rachael a deserves the opportunity to become a Florence Nightingale Foundation scholar. All the nurses completing the programme have achieved so much with their projects and there will be a potential ripple effect across the nursing profession. In a short space of time, her project has made a real difference at Nuffield Health Warwickshire Hospital, both in reducing waste but also embedding a sustainable healthcare culture among the wider hospital team. 

“I’m looking forward to seeing Rachael’s progress as she develops as a scholar, following an in-depth personal development plan to enhance her leadership skills. We know that the greatest impact the Florence Nightingale Foundation can have on sustainability is through our alumni and membership community being empowered to lead disruptive change and influence others.” 

Ben Davies, Organisational Development Director at Nuffield Health, added: “Rachael’s project and work throughout the programme shows that nurses have a key part to play in cultivating clinical excellence through sustainable service improvements. 

“We cannot deliver the change we need without our health professionals leading the charge, wholeheartedly committing to collaboration. That’s why we launched the Green Healthcare Leadership Programme. Rachael’s work aligns with Nuffield Health’s ambition to become a sustainable healthcare leader in the UK, reaching carbon Net Zero by 2040 with a shorter-term goal of carbon Net Zero in our own operations by 2030.”

Other projects, presented at the celebration event, focused on reducing road miles, by moving to virtual appointments – so patients no longer need to travel into hospital, unless it is necessary; reducing letters; making greener choices around wound dressing packs; and recycling PVC from oxygen therapy – plus many more. 

The ‘ripple effect’

“We are focused on upscaling these individual projects, not just within the setting they are working within, but across Nuffield Health’s 37 hospitals, and looking further still,” Jonny commented. “We are seeking to share this learning, not just within the Independent sector, but across the whole healthcare system and on a global scale. It starts from the coal face.” 

Commenting on the upscaling of the projects and the impact of the programme, Professor Greta Westwood CBE, the Chief Executive at the Florence Nightingale Foundation, said: “Healthcare organisations will hear what their neighbours are doing and want to get on board. The initiative at Nuffield Health and other independents has widened the network already. With the individuals from the programme working within their organisations, the momentum is gathering speed. 

“Following this example, we expect the NHS will develop their own nurse leadership programme for sustainability. Organisations will want to keep up with their neighbours, so the influence will ultimately multiply. 

“The individuals on this programme will join our network of alumni and will connect with others who have an interest in sustainable health. They can join forces and develop green networks – to learn from each other and disseminate their ideas. This programme will have a massive ripple effect.” 

Speaking at the celebration event, Caroline Smith, Chief Operating Officer – Quality & Operations, at Nuffield Health, emphasised that she was passionate about supporting nurses to “develop their skills, their confidence and their leadership potential”. 

“The nurses on this programme have been challenging their peers to change practice in a variety of ways – including reducing the number of supplies, reusing equipment, reducing waste, and through recycling. But this is only the beginning,” Caroline commented.

“I’m proud that this programme goes further than any other, drawing on the expertise of our nurses to tackle the single most pressing challenge facing us as a sector – climate change. The World Health Organization says this is the biggest healthcare threat facing humanity. It is expected to cause a quarter of a million deaths between 2030 and 2050,” Caroline continued. 

She emphasised that this isn’t “a problem for tomorrow”; the health impacts of air pollution and the outcomes of adverse weather events are being experienced right now.

We need to change the way we deliver healthcare and ensure we reach those Net Zero targets, and – in so doing – give humanity a fighting chance of curbing the worst impacts of climate change,” she concluded.