Education for sustainable healthcare: A transdisciplinary approach to transversal environmental threats

Abstract

Global Environmental Changes are dynamic and complex, crossing disciplines, sectors, regions, and populations and shaping the health of current and future generations. GECs present an unprecedented challenge demanding a response of equal scale and complexity involving unfettered collaboration beyond disciplines with implications for global health. At this critical point, health professions’ education should have moved on from building consensus about the relevance of education for sustainable healthcare (ESH) to active implementation. In this commentary, we discuss why transdisciplinary problem-solving and interprofessional education should be considered in education for sustainable healthcare. We review types of collaborative educational practices, outline opportunities, challenges, and resources to enable implementation.

Keywords:

• Education for sustainable healthcare
• transdisciplinary
• health professions’ education

Introduction

Over a decade ago, climate change was declared the biggest threat to global health (Costello et al. 2009) but was also recognized as one of the greatest opportunities (Watts et al. 2015). Global environmental changes (GECs) are likely to shape the health of current and future generations. Impacts are both direct, e.g. extreme weather events amplified in frequency and intensity - and indirect, mediated through ecological and social systems, e.g., water-borne and vector-borne disease, migration, and conflict (Watts et al. 2017; Haines and Ebi 2019). An unprecedented challenge demands a response of equal scale and complexity, involving unfettered collaboration beyond disciplines and sectors (Watts et al. 2019). Systems thinking, radical collaborative partnerships and resource-sharing are essential to realizing the vision of a health workforce that can deliver environmentally sustainable healthcare (McKimm and McLean 2020) with health professions’ education (HPE) needing to adapt to achieve this.

Practice points

• Climate and global environmental change pose the biggest threat to global health and require an unprecedented response involving unfettered collaboration beyond disciplines and sectors.

• Education for sustainable healthcare (ESH) is part of this response and is considered to be a professional and ethical requirement. Accordingly, health professions educators need to be at the active implementation phase.

• It is too late for each profession to proceed alone on different paths. Transdisciplinary problem-solving is required to bring disciplines together to design curricula to promote the best possible outcomes for patients, communities and the planet.

Education for Sustainable Healthcare (ESH) involves learning about the impacts of GECs such as climate change and ecosystem alterations on health and the effects of healthcare activities on the planet (Thompson et al. 2014; Frumkin and Haines 2019). Governments are increasingly making binding commitments to carbon neutrality, and considering the urgency to act, ESH is now a professional and ethical HPE requirement. At this critical point, educators should have moved beyond agreement regarding the relevance of integrating climate change and environmental sustainability into health professions curricula, to active implementation. This commentary discusses why transdisciplinary problem-solving and interprofessional education should be considered in ESH implementation and outlines the opportunities available and challenges to be addressed.

Collaborative education: Beyond semantics to action

A review of seminal definitions of collaborative educational practices shows that each has something to offer ESH:

• Interprofessional education (IPE) refers to members or students of two or more professions learning about, with and from each other to improve collaboration and the quality of care and services (CAIPE 2019).

• Multidisciplinarity refers to activities of members from academic disciplines (e.g. psychology, sociology, mathematics) who work independently in parallel or sequentially on different aspects of a project within their disciplinary boundaries (Khalili et al. 2019).

• Interdisciplinarity relates to individuals from different disciplines (e.g. anthropology, economics, geography, political science and computer science) working together on a project to analyze, synthesize and harmonize links between them into a coordinated and coherent whole (Khalili et al. 2019) “through strategies such as relating part and whole or the particular and the general” (Stember 1991, p. 4).

• Transdisciplinarity integrates the natural, social, and health sciences in a humanities context (Choi and Pak 2006) across and through different disciplines and beyond individual disciplines (Alvargonzález 2011). According to Stember (1991, p. 4), transdisciplinarity is a “higher level of integrated study…concerned with the unity of intellectual frameworks beyond the disciplinary perspectives.”

Healthcare and HPE is delivered in systems rather than individual professions, and benefits from a systems lens (Suter et al. 2013). Moreover, the challenges of environmentally sustainable healthcare are complex, dynamic, and beyond the scope of a single discipline. We propose that transdisciplinary problem-solving is required to bring disciplines together to design curricula to promote the best possible outcomes for healthcare delivery, where both the health of patients and the planet are prioritized. While there may be no single best ESH approach, transdisciplinary thinking has gained prominence for creating a paradigm shift, which is needed for tackling human-environment relationship problems (Balsiger 2015), and, specifically, the wicked problems of climate change and sustainability. Interconnected knowledge production and translation systems require a culture of reward-sharing, intrinsically valuing collaboration, mutual responsibility, and idealism (Russell et al. 2008). Transdisciplinary thinking is required to determine which professions can optimally work together to solve sustainability challenges. Interprofessional education can in turn be utilized for learners to understand each other’s roles, with a need for incentivizing novel partnerships in this space.

Action on the GECs threatening health and well-being demands the coordination of expertise from a range of disciplines including science, health, the social and behavioral sciences, politics, education, and economics. The recognition that public health, creating inclusive economic growth, preserving the planet and eradicating poverty and inequality are all inextricably linked, and sits at the heart of the Sustainable Development Goals (SDGs) (World Health Organization (WHO) 2016). These goals include addressing environmental health consequences, such as air quality and the associated burden of disease (WHO 2016). Therefore, health professions must be coordinated to work both together, i.e. interprofessionally in teams, and in conjunction with those beyond health in transdisciplinary collaboration to facilitate transformational changes that address environmental threats to health and well-being (Whitmee et al. 2015).

Applications of transdisciplinary thinking in ESH

Planetary health is defined as the health of human civilization and the state of the natural systems on which it depends (Horton and Lo 2015; Rockström et al. 2009). It encompasses several planetary boundaries, one of which is climate change. Planetary health is one of the recognized integrated approaches to health and the environment, along with ‘One Health’ that focuses on the human-animal–ecosystem interface in the evolution and emergence of pathogens (Destoumieux-Garzón et al. 2018), which are relevant to ESH in light of the Covid-19 pandemic.

Requirements for planetary health include systems thinking, a public health approach, preventative focus, and the integration of social and environmental models and perspectives with the biomedical approach to health. ESH considers the triple bottom line of sustainability, including people, planet, and pocket (economic) and ESH concepts transcend many disciplines with none individually able to claim superiority or sole expertise. It also extends beyond individual health professions to incorporate broader knowledge, skills, and values so that all health professionals can work together for safe, inclusive, patient-centered care that advances universal healthcare and health equity while also protecting the population and planetary health. All health professionals have an opportunity to influence the environmental footprint of the health sector and to work with colleagues in other disciplines to be part of the transition to sustainable healthcare delivery.

Health professional teams should take a dual approach: practising patient and community-centered care during epidemics and disasters and attending to the environmental determinants of health and the integrity of the planet’s ecosystems. Given our growing understanding of the interdependence of the health of natural and human systems, society must prioritize the health of the planet and patients equally to ensure environmental sustainability. This endeavor requires the synthesis of many professions, not just health practitioners. The potential of a transdisciplinary approach to ESH is to flatten the hierarchy, lower the walls of disciplinary silos, and expand the circle of professionals with shared responsibility for patients, communities, and the planet.

Opportunities and challenges

Multiple opportunities arise in a transdisciplinary ESH approach. Professional competencies have domains that overlap, e.g. communication, professionalism, leadership, and advocacy (Thistlethwaite and Moran 2010). Essential environmental competencies for healthcare educators and trainees include leadership, research skills, resource stewardship, systems thinking, social, environmental and ecological justice, and global citizenship (Parker et al. 2020). Ethical codes, such as the International Council of Nurse's ethical codes for Nurses, provide a strong argument for a transdisciplinary approach to ESH, with the inclusion of beneficence and justice principles. For example, ‘the nurse practices to sustain and protect the natural environment and is aware of its consequences on health’ (International Council of Nurses (ICN) 2012). Further, the United Nations Education Scientific and Cultural Organization declaration of ethical principles concerning climate change (United Nations Education and Scientific and Cultural Organisation (UNESCO) 2017) refers to ESH by specifically calling for the advancement of education to include sustainable development.

Much has been written about the challenges of IPE (Abu-Rish et al. 2012; Tun 2019). Here we address a few related to ESH and suggest strategies to overcome them. Firstly, there is a lack of environmental sustainability imperatives in professional accreditation standards (Madden et al. 2018). This can be mitigated by using interprofessional groups to lobby accreditation bodies (where they exist) to review standards. Secondly, there is justified resistance to adding more content on ESH into already crowded curricula (Tun 2019). Interprofessional learning, on the other hand, is an accreditation requirement for many professions, e.g. the Australian Medical Council (2019) and the Australian Nursing and Midwifery Accreditation Council (2019). Capacity can be found by tapping into the passion and energy of student organizations and enthusiastic educators to promote ESH elements in IPE curricula. Thirdly, IPE has been limited in some settings due to voluntary participation. Next, unequal hierarchical representation of professions in IPE has been a challenge in historical medical models. ESH offers the opportunity for institutions to consider a transdisciplinary approach to integrating planetary health into curricula, with no single profession having ownership or lead of this area. Finally, the assessment is underdeveloped in IPE (Rogers et al. 2017). ESH offers the potential to work with new partners from environmental disciplines in developing credible and engaging interprofessional and interdisciplinary assessment tasks.

Planetary health teaching resources and ESH learning objectives

Health professions educators can refer to three overarching ESH learning objectives applicable to health professions (SHEN 2015; Teherani et al. 2017):

• Describe how the environment and human health interact at different levels (Clinicians as researchers and scholars).

• Demonstrate the knowledge and skills needed to improve the environmental sustainability of health systems (Clinicians as practitioners).

• Discuss how the duty to protect and promote health is shaped by the dependence of human health on the local and global environment (Clinicians as professionals).

The Planetary Health Alliance has facilitated the first attempt to create a set of 12 cross-cutting principles for planetary health education that intersect scale, levels, and regions of the world (Stone et al. 2018). These provide a foundation for curriculum development as well as a starting point for developing interprofessional curricula (Table 1).

Table 1. Examples of planetary health education principles (Stone et al. 2018).

A planetary health lens	Viewing global challenges with the idea of planetary health in mind. Enabling an understanding of critical links between environmental change and human health.
Communication	Complex challenges across disciplines and sectors need effective and meaningful communication.
Movement building	Students should develop an understanding of the role that organizing in the community and movement building has in the political process both locally and globally.
Bias	Students need to be able to think critically, identify bias, and be aware of the vested interests of different political, social, and economic stakeholders related to environmental change and human health.
Global citizenship and cultural identity	Students can realize their own cultural identities and recognize their membership in both their local and global communities to define values and practices.

In addition to common learning objectives and planetary health principles, Box 1 offers examples of teaching and learning approaches that can be adapted for IPE.

Box 1 Examples of IPE ESH resources.

NurSUS Toolkit: A European collaboration that aims to enhance the availability and relevance of Sustainability Literacy and Competency (SLC) in nurse education by developing innovative teaching and learning approaches and materials. Available in several languages and applicable to all health professions, education, and beyond. (www.nursus.eu)

The Lancet Countdown on Climate Change and Health: The website has a range of resources and materials including briefs for national policymakers, translated report summaries, infographics, podcasts, and videos. (www.thelancet.com/climate-and-health)

Canadian Federation of Medical Students ‘Health and Environment Adaptive Response Taskforce’ (HEART): A set of core competencies on planetary health to incorporate them into Canadian medical school curricula. Evaluation of integration explored the inclusion and quality of teaching on climate change and environmental topics and provided key recommendations. (www.cfms.org)

Conclusions

The GECs challenges are complex and dynamic, spanning many disciplines, sectors, regions, and populations (Stone et al. 2018). These challenges are beyond the scope of a single discipline and would benefit from a systems lens. We propose that transdisciplinary problem-solving is required to bring disciplines together to design curricula to promote the best possible outcomes for healthcare delivery, where both the health of patients and the planet are prioritized. New collaborations across sectors need to bridge societal divisions and address the emerging scientific imperatives relating to environmental degradation and climate change (Prescott and Logan 2018).

At this critical point, where social and planetary tipping points are approaching, with perhaps some already reached, there is a need to recognize ESH not only a requirement for health professions education but more importantly, as an IPE opportunity. HPEs need to join forces with colleagues in other non-health disciplines to ensure that learners are equipped to deal with the health impacts of global environmental change and to be part of the solution using the tools and learning outcomes presented in this paper. We propose that it is too late for each profession to proceed alone on different paths, this imperative requires a collective vision and action that translates into transdisciplinary learning.

Disclosure statement

The authors report no conflicts of interest. The authors alone are responsible for the content and writing of the article.

Correction Statement

This article has been republished with minor changes. These changes do not impact the academic content of the article.

Additional information

Notes on contributors

Patricia Nayna Schwerdtle

Patricia Nayna Schwerdtle, RN, MPH, PGC-Health Professional Education, PGD-Crit.Care, Ba-HP, BN. Ph.D. student at Heidelberg University (Germany) researching climate change, migration, nutrition, and health. Adjunct Academic at Monash University (Australia) leading interprofessional research aiming to integrate sustainable healthcare education across 13 health disciplines.

Graeme Horton

Graeme Horton, MBBS, Ph.D., MEnvStud, is Senior Lecturer in Medical Education and General Practice at the University of Newcastle, Australia where he lectures on climate change and health, convenes the Master of Clinical Medicine (Leadership and Management) Program and is Head of Interprofessional Education and Student Wellbeing for the School of Medicine and Public Health.

Fiona Kent

Fiona Kent, BPT, MHPE, Ph.D., is Associate Professor and Director of Collaborative Care and Work Integrated Learning in the education portfolio, Faculty Medicine, Nursing and Health Sciences, Monash University, Melbourne, Australia.

Lorraine Walker

Lorraine Walker, BN, GDip Nrs Ed, MN(Res), is a Senior Lecturer and Head of Peninsula Campus in the School of Nursing and Midwifery, Faculty of Medicine, Nursing and Health Sciences, Monash University, Melbourne Australia. She is a member of the Faculty Collaborative Care Curriculum Committee, involved in promoting opportunities for interprofessional education in health professional curricula.

Michelle McLean

Michelle McLean, Ph.D., M.Ed, is Profession of Medical Education in the Medical Program at Bond University, Gold Coast, Australia. She is currently involved in integrating planetary health across the five years of the MD Program.