Thinking big and the WE ACT framework for environmentally sustainable critical care nursing

Let's think big—the entire world—the planet. Beyond the planet, into our atmosphere, which impacts our climate, and deep into the planet, for materials and processes that provide food, shelter, fuel and water for our lives, planetary health is necessary for human health, not only for our physical needs but also to find livelihood, meaning and creativity. However, the planet is being harmed. Humans emit too many greenhouse gases into the atmosphere, leading to a warming planet and resulting heat waves, droughts, floods, storms, wildfires and other disturbances that harm human health and other species.1 We are polluting our air, water and soil with microplastics and other novel entities that disrupt cellular and organismic life. We are damaging parts of the planet through resource depletion and overuse.2 These habits are not sustainable, causing harm to human health today.3 Nursing is concerned with human health. Our profession focuses on maximizing wellness and function, regardless of circumstances, diagnoses or genetics. This means we are professionally interested in a healthy planet, as it is required for health and thriving. Nurses are working around the globe to understand the relationships between the environment and health and to ameliorate damage from pollution and climate change. The International Council of Nurses reminds us that ‘nurses have a shared responsibility to sustain and protect the natural environment from depletion, pollution, degradation and destruction’.4 The nursing Code of Ethics5 in the United States reminds us that ‘nursing must also advocate for policies, programs, and practices within the health care environment that maintain, sustain, and repair the natural world’. Nurses care for patients, families or communities in the context of their families, homes, communities, regions and the greater planet. Nurses understand that preventing harm is often easier than recovering from its impacts. Thus, preventive care, public health and climate health are familiar and intuitive concepts for many nurses. Sadly, health care is a contributor to significant pollution. Globally, health care emits 5.2% of annual global greenhouse gases,6 creates millions of tons of waste per year, depends on single-use, disposable items and uses harmful chemicals in pharmaceuticals, cleaning agents and anaesthesia. In acute care settings, areas of high-intensity care, including surgical services, procedural areas and critical care, tend to use more resources, including greenhouse gas-polluting energy and anaesthetic agents and create more waste. In other words, health care is part of the problem, harming the planet on which health and thriving depend. This cross-purposes with nursing's aim to maximize wellness and function. So, what can critical care nurses do? First, they can acknowledge the issue and commit to improving it. Second, they can learn about the details of decarbonizing health care (reducing and eliminating greenhouse gases) and decreasing harm caused by polluting products, processes and policies while building equitable climate resiliency in the communities we serve. Critical care nurses can use the WE ACT framework7, 8 to discover and address elements of health care-generated pollution. W stands for waste. Arguably, much of the waste generated in critical care settings goes through the hands of nurses. We use many products, supplies, paper, linens, tubing, medications, respiratory equipment and more. Critical care nurses can optimize waste streams by ensuring the right waste goes to the right stream for optimal cost and low greenhouse gas production.3, 9 Some waste must be treated (hazardous, biohazardous) or disposed of. Some can be diverted to recycling, composting or donations. Moreover, much waste can be avoided, or not created in the first place, by questioning whether a product is needed, selecting reusable products, reprocessing items, working with manufacturers and vendors to reduce packaging, reducing redundancy and any disposal of new items. Critical care nurses can learn about the greenhouse gases caused by the treatment of waste streams and strategize how to reduce carbon-intensive treatments (landfill, autoclave and incineration) and maximize low-carbon treatments, including composting, donations, reuse, reprocessing and, in some cases, recycling. E is for Energy & water. Critical care nurses may be less involved with the energy settings in their workplace, but they can enquire about energy efficiency measures in place and advocate for the use of renewable electricity, as well as eliminating fossil-fuel-based heating sources. Nurses on purchasing teams can insist on energy-efficient machines and devices. Nurses' powerful voice as advocates can remind administrators, suppliers and patients that decarbonization is an important health intervention. A is for Agriculture & Food. Critical care nurses help ensure that people recovering from illness are well-nourished. They can advocate for high-quality, sustainable, low-carbon foods to be served to patients and staff in acute care settings. Along with dietary staff, they can help shift menus to plant-forward, lower carbon choices while reducing food waste during food preparation by developing efficient meal planning and food preparation and reducing food waste sent to landfills by developing and supporting post-consumer composting. C is for chemicals. Critical care nurses are exposed to chemicals through pharmaceuticals, cleaning chemicals, products made of plastics and plasticizers, diesel exhaust from ambulance bays and others. It is important for nurses to understand their chemical exposure in the workplace and to advocate for better products and processes. Critical care nurses can also support the reduction in greenhouse gas emissions from health care chemicals, including desflurane, a volatile anaesthetic agent that emits more greenhouse gases than others; nitrous oxide, which often leaks when used in piped central systems, and propellants used to distribute the medication in inhalers. T stands for transportation. Transportation dependent on fossil fuels is a significant contributor to greenhouse gases. Critical care nurses can reduce transportation emissions in their commute to work and by helping build efficient systems for product delivery, care delivery and any necessary business travel. Procurement, or purchasing supplies, goods and services, often constitutes more than half of a hospital or health system's greenhouse gas emissions. Critical care nurses can reduce emissions and waste through source reduction by avoiding overuse and reducing waste by not producing it in the first place. Nurses' voices and input are important for purchasing teams trying to determine the best value of products. It is important to speak up for the planet by encouraging the reduction in waste, toxic chemicals and greenhouse gases from the products we select. Critical care nurses can advocate for reusable, durable products when possible, move away from single-use disposable plastics and work with suppliers to reduce product packaging. Any and all of these suggestions can apply to critical care. Nurses, in collaboration with their multidisciplinary colleagues, must apply a planetary health lens to all care delivery decisions for critically ill patients. We can ask whether policies, products and processes are good for the patient—are we achieving the outcomes we seek? And we now need to ask whether policies, products and processes are good for the planet. Are we inadvertently causing harm? What are the health impacts of that harm? What are the options today for changing how we deliver care, and what questions need to be answered so that we can make better decisions tomorrow? Nurses are the experts in nursing care. Transforming critical care nursing so that it is aligned with planetary health is up to us. Data sharing is not applicable to this article as no new data were created or analyzed in this study.