Faculty development and partnership with students to integrate sustainable healthcare into health professions education

Abstract

There is an urgent need for health professionals to address the impacts of accelerating global environmental change. Healthcare faculty therefore have to educate the rising generation of health professionals in subjects unfamiliar to themselves, such as planetary health and sustainable healthcare. This creates a new paradigm where faculty have to learn a new subject area and incorporate and teach it within their own material. It is important to develop faculty knowledge and confidence to integrate education for sustainable healthcare into their educational practice, as faculty can rapidly acquire and build on these skills. Partnership between students and faculty can enhance this faculty development as students bring fresh ideas and possibly greater knowledge of the climate and ecological crisis. Under supervision, they can co-create the necessary new learning. Students can also act as partners in advocating for social and environmental fairness and systemic change toward a sustainable healthcare system. We summarize the impact of various activities of health professions students around the world which advocate for institutional change and enhance faculty development in education for sustainable healthcare. Through diverse case studies from different countries, we illustrate faculty development in education for sustainable healthcare, highlighting student involvement which has enhanced educators’ learning.

Keywords:

• Faculty development
• medical education
• sustainable healthcare
• planetary health
• student partnership

Introduction

Health professionals are increasingly called upon to address the health and wellbeing implications of the climate and ecological crisis which stems from global environmental degradation. Yet the healthcare workforce and educators who train them are not adequately prepared to address these problems and advance potential solutions. The rising generation of health professionals increasingly demands that their education prepare them to create and work in a more sustainable future (Green and Legard 2020). It is therefore important to develop faculty knowledge and confidence to integrate planetary health and sustainable healthcare into health professions education, from undergraduate education to postgraduate training to continuing clinical practice.

Practice points

• Faculty can rapidly acquire and build on necessary skills to integrate planetary health and sustainable healthcare into their teaching.

• Faculty development can take place by applying an environmental sustainability lens to existing learning and teaching.

• Student-faculty partnership in co-creating new learning enhances this faculty development.

• Engagement with personal values on the environment and advocacy for systemic change are integral ethical dimensions of educating for sustainable healthcare.

We build on theory developed by Tun: ‘By embedding sustainability as a theme running through all of medical education, educators and students can teach and learn from each other at the same time as learning about sustainable healthcare, irrespective of specialization’ (Tun 2019, p.1175). To do this, we first describe what we mean by education for sustainable healthcare (ESH), then discuss what faculty development in ESH should address, continue with a focus on student activities that enhance this faculty development and the many ways in which student-faculty partnership can advance progress and, finally, explore current practice in faculty development in this emerging field with illustrative case studies from several countries. Using a model of bidirectional learning, both faculty and student stakeholders can be empowered to take an active role in seeking knowledge and creating enduring educational experiences (O’Brien and Teherani 2011).

Planetary health and education for sustainable healthcare

The concept of planetary health is that human health depends on the health of our planet, with both in peril through unprecedented degradation of earth’s natural systems (United Nations Framework Convention on Climate Change 2020). These natural systems are represented in Raworth’s doughnut model, showing that the tension between delivering the UN Sustainable Development Goals and needing to preserve the life-support capacity of the planet requires a transformative approach (Raworth 2017). Health professionals have to deal with increasingly extreme consequences of human activity. One such consequence is the COVID-19 pandemic, and the co-chairs of the Intergovernmental Science-Policy Platform on Biodiversity and Ecosystem Services (IPBES 2019) warn that deadlier and more frequent future pandemics can be only avoided by protecting nature (Settele et al. 2020).

As the provision of healthcare is a major contributor to environmental degradation, a more sustainable model of healthcare practice is needed to address the ecological impact of healthcare service delivery (Ossebaard and Lachman 2020). Sustainable healthcare ‘focuses on the improvement of health and better delivery of healthcare, rather than late intervention in disease, with resulting benefits to patients and to the environment on which human health depends, thus serving to provide high-quality healthcare now without compromising the ability to meet the health needs of the future’ (Tun 2019, p.1176).

This paper addresses education for sustainable healthcare, which includes education on planetary health as an integral part. The scale and pace of global environmental devastation requires the healthcare workforce to be trained to advocate for policy change to ensure the health of our planet and ourselves. Thus, leadership in health professions education will involve intergenerational fairness as well as other aspects of equity, engagement with values, collaboration, advocacy ‘and, if need be, activism’ (McKimm and McLean 2020).

Faculty development in educating for sustainable healthcare

Core aims of ESH faculty development

To deliver this new learning, faculty themselves need to be prepared, to bring capacity and confidence to this new paradigm.

Educators need knowledge of four ESH core content areas:

1. Fundamental understanding of the climate and ecological crisis i.e. the science relating to climate change and ecosystem degradation

2. How the climate and ecological crisis impacts health, including ethical dimensions

3. Environmental impact of systems of healthcare delivery and steps to make healthcare practice more sustainable

4. Pedagogical and educational content and practice for how to integrate planetary health and sustainable healthcare in the curriculum

These principles require multidisciplinary engagement across the curriculum and are supported by student-inspired ‘bottom-up’ intergenerational faculty development.

Increasingly, accreditation bodies require integration of sustainability into health professions education. Examples include the UK General Medical Council’s (GMC) requirement for new graduates to be able to apply the principles of sustainable healthcare to clinical practice (GMC 2018), the proposed amendments to the Australian Medical Council graduate outcome statements (Madden et al. 2018) and the American Nurses Association’s Scope and Standards of Practice requirement that nurses implement environmental health strategies in nursing practice (Leffers et al. 2015).

Implementation challenges

All health professions need to be involved as healthcare delivery is team-based, and campus-based faculty as well as those in practice need urgent and incremental upskilling. Educators may not feel confident that they have the expertise to teach about sustainable healthcare. Evidence-based guidance such as by Webster and Marshall (2019) on how to raise topics of conversation such as climate change or resource stewardship can increase confidence. Other closely linked issues add to the complexity of the discussion, such as inequality around the globe, and the burden on patients of over-medicalization and defensive practice. Institutional agreement on the importance of this work is therefore needed to gain support and acquire resources. While the content can be integrated into current curricula by adapting existing educational practice, resistance to the intellectual labor involved in change has to be overcome. Thus the vital first step to set in motion the scale of change in perception and practice that is needed is to ‘green the gaze’ (Schroeder et al. 2013).

Institutional context and support

The ultimate aim of faculty development is to improve patient and community care through re-envisioning an institution’s culture of social and moral responsibility and initiating and sustaining change in attitude, knowledge, behavior and practice (McLean et al. 2008). Authors such as Lieff (2009) and Steinert (2014) note the following on faculty development:

• in common with principles fundamental to medical education itself, the development of educators needs to be relevant to the context and practical – interactive, participatory and experientially based;

• faculty development ensures that medical education will continue to be responsive to driving forces of change, and can help change the culture within an institution;

• students place more value on the way that faculty approach their role than on subject matter expertise;

• and faculty should therefore be emboldened to ‘learn on the job,’ try out innovations, and embrace collaborative learning.

Faculty development and student partnership

ESH learning outcomes for students and faculty

In contrast to developing faculty to teach their own specialty, educating for sustainable healthcare requires educators to learn a content area which is unfamiliar and which may change their awareness and attitude, and then incorporate it into their sessions. There is growing interest in this new content area. Core competencies in education for sustainable healthcare were first developed as Priority Learning Outcomes and recognized in 2015 by the GMC (Walpole and Mortimer 2017). Those outcomes have been expanded through a Delphi process (Teherani et al. 2017), and the Global Consortium on Climate and Health Education (GCCHE) has also developed competencies (Columbia University 2018).

A recent scoping review identified three core healthcare competencies as being specific to the environment, namely resource stewardship, systems thinking and social and environmental justice (Parker et al. 2020). The American Association of Colleges of Nursing has taken steps to increase student and faculty awareness of all of the latter three competencies by enhancing curricula at undergraduate and graduate levels (Butterfield et al. 2014), and in public health there is growing expectation that this content on environmental sustainability should be integrated into all university courses (Patrick et al. 2016).

Student initiatives influencing faculty development in ESH

Table 1 sets out activities of many kinds that students have undertaken that help drive ESH faculty development in various parts of the world and in different circumstances. The ideal is to integrate sustainable healthcare into all stages of the core curriculum such that it is requisite learning, substantive, and assessed. Planetary health is seen as part of health professionals’ future role in practice, and includes aspects such as communicating with patients and advocacy. This therefore calls for a more imaginative, discursive approach to assessment (Schwerdtle et al. 2020). Table 1 also highlights resources produced and shared by students, which can be pooled or made available for faculty development.

Table 1. Health student activities which can contribute to faculty development in planetary health and sustainable healthcare.

Impact	Activity	Examples or rationale
Raising awareness	Start a student interest group	Emerging Leaders for Environmental Sustainability in Healthcare University of Toronto students showcased ideas for sustainable healthcare Students have led day-long events/conferences to educate the University of California San Francisco (UCSF) community on planetary health Emphasis can be on peer education, faculty recruitment and organizational change
	Invite expert speakers	Student groups have been powerful in organizing on-campus talks and panels on climate change or sustainability
	Develop a set of core competencies	Canadian Federation of Medical Students has created core curricular competencies to integrate planetary health teaching nationally: Health and Environment Adaptive Response Task force (HEART)
	Generate learning resources	Students at Bond University created videos and posters relating to the Sustainable Development Goals and shared with staff and students, as well as with representatives from other medical schools, for faculty development or student resources Australian Medical Students' Association’s Sustainable Events Planning Guide has been shared with academics and professional staff International Federation of Medical Students Associations (IFMSA) created and circulated a comprehensive Climate and Health Training Manual
Advocacy (institutional)	Initiate student-faculty partnership	Link students with colleagues and experts to co-self-educate, present on environmental issues at medical specialty conferences, and collaborate on publications Involve students in appointment of new staff, including deans and heads of school, to ensure new leaders are environmentally aware Build in a student assistant role in all funding obtained to raise ESH visibility e.g. by having the student introduce or lead presentations Ensure environmental accountability is written into mission statements, and practiced at various levels, from procurement, travel, energy and water usage, catering, curriculum and research e.g. University of Exeter White Paper, fossil fuel divestment University of Oxford
	Submit requests to course directors or deans to integrate planetary health and sustainable healthcare into the curriculum	Faculty advisor can provide talking points e.g. funding and endorsement Workshops training students to advocate for planetary health inclusion in UK - for one school this resulted in students being asked to, and producing, core learning material Students have started their own electives - at UCSF students believed education (three courses to date in medicine, pharmacy, and dentistry) was inadequate Integrate practice sustainability projects into the clinical curriculum, using resources such as the Royal College of General Practitioners/National Union of Students Green Impact for Health and My Green Doctor
	Foster advocacy awareness	Students have hosted advocacy training professionals to educate students how to become involved in policy and advocacy issues around climate change
	Advocate for inclusion of planetary health across institutions	IFMSA’s Climate Health 2020 Vision is an advocacy initiative to include climate change in medical curricula worldwide Planetary Health Report Card grades curricular provision in US and Canada
	Identify lobbying opportunities	Students have been to speak with governmental officials at a US state Capitol
	Join organizations promoting policy change	Such organizations include Medical Society Consortium on Climate and Health, Health Declares Climate and Ecological Emergency, UK Health Alliance on Climate Change and the Global Climate and Health Alliance
	Resolve to change institutional policy or practice	A resolution advocating to discontinue red meat at university events sent to department chairs in the school of medicine - some departments have adopted the resolution A resolution on reducing airline travel among faculty sent to all department chairs in the school of medicine was not adopted but created awareness
Activism	Explore local and global activism or protest activities	Participation in March for Science, global youth Climate Strike actions Student participation in Doctors for Extinction Rebellion Medical Students for a Sustainable Future video
Community building	Build community	Incorporate local sustainability projects, such as composting Build interdisciplinary faculty interest group across professional schools including law/business/medicine aiming to support students and consolidate activities
	Develop NGO partnerships	Sunrise Movement, Health Care Without Harm

Students as partners in ESH faculty development

Health professions students and trainees are important stakeholders in their own education, and Table 1 also showcases the informal involvement of students in ESH faculty development. These include examples of students producing learning materials for both peer learning and faculty development, and leading teaching. Students who become aware of unsustainable practices during their training are ideally placed to identify areas in the curriculum where ESH would have impact whether at the university or in the clinical setting. Student groups have approached deans and faculty to ask that they introduce curricular elements or investigate ways in which sustainability issues can be integrated into existing teaching. In some health professions, learners are already required to be able to teach other learners (GMC 2018, p.10), and their input can minimize the need for additional faculty and teaching time. However they need faculty for implementation and ongoing guidance, and care should be taken that the responsibility for program development and building learning resources is not delegated to the learners, but instead evolves in partnership with faculty.

Student contribution and leadership in curricular change efforts can help build robust student-faculty partnerships, yet faculty may view student roles too narrowly to allow collaboration and co-creation (Burk-Rafel et al. 2020). In order to promote co-learning, students suggest that their feedback should have more impact in implementing changes (Ward et al. 2020).

Case studies

Four case studies present emerging ways in which ESH faculty development directly or indirectly involving students is being addressed on three continents, with examples from institutions in the US, UK and Australia. Table 2 summarizes the relevant core areas of faculty development in ESH addressed, level of student involvement, challenges in implementation and potential solutions. The cases include successful outcomes of educating the educator to incorporate ESH in their topics, and hands-on practice with creating enduring teaching materials. In some cases faculty reconvened several months after being trained, to update their peers about their implementation and what was learned, and to help train others. A key aim of ESH is to embed sustainability into every year of the curriculum, and in the UK medical schools have been able to use research and recommendations by Tun (2019) to inform this process. Success in integrating activities across the curriculum depends on a community of supportive colleagues and students, institutional backing encouraging departments to evolve and expand, and passionate individuals learning by doing to drive ESH forward. Knowledge, practice and student involvement strengthen faculty confidence, which in turn leads to more learning and engagement.

Table 2. Challenges and potential solutions to faculty development (FD) for education for sustainable healthcare (ESH) in four health professions education institutions in Australia, United Kingdom (UK) and United States (US), with core content areas and level of student involvement.

Institution	Core content areas for ESH FD addressed	Level of student contribution or involvement in FD	Potential challenges to implementation	Potential solutions to challenges
University of California, San Francisco School of Medicine, US	Science of climate and ecological crisis Health impacts and ethics Integration into ongoing teaching	Students were involved at all stages of ESH FD	Finding the right channels to recruit students to participate	Anticipate recruitment and publicize through mailing lists, research projects available and sustainability newsletters.
			Recruitment of senior and junior faculty committed to making change	Recruit directly, targeting faculty who reach large numbers of students through core content
Lancaster Medical School, UK	Science of climate and ecological crisis Health impacts and ethics Sustainable healthcare delivery Integration into ongoing teaching	Students were engaged after curricular changes were implemented	Faculty reluctance to deliver unfamiliar content, needing significant support	Share practice and ideas among institutions and in online forums
			Insufficient role-modelling by clinical staff as sustainable healthcare is not practiced in many student clinical placements	Faculty form a sustainability action group to drive through changes, such as developing a green strategy for the faculty (not a direct solution)
Georgetown University School of Medicine, US	Science of climate and ecological crisis Health impacts and ethics	Students asked to be involved after receiving some ESH	Commitment from only one member of faculty	Buy-in from favorable colleagues, focused curricular enhancements, detailed training materials
			Students ask ‘How is this relevant to my training?’	Create faculty-led student interest group/task force - students become ambassadors. Create relevant research and practice opportunities to reduce waste/pollution
Bond University Medical Program, Australia	Science of climate and ecological crisis Health impacts and ethics Sustainable healthcare delivery Integration into ongoing sessions	Students developed resources which were shared with faculty	Infrastructure for introducing student involvement	Provide faculty with access to student resources as assignment markers and as curriculum team members
			Faculty capacity and perceived learning curve	Make use of resources already developed by students

Case study 1: Health professions faculty development in educating for sustainable healthcare, University of California, San Francisco School of Medicine, US

Health professions faculty were recruited based on interest to participate in a day-long faculty development effort. Faculty members across the health professions at the institution (medicine, nursing, dentistry, physical therapy, pharmacy, graduate studies) were trained to incorporate ESH into their ongoing teaching. Post faculty development, trained faculty developed and implemented their educational sessions drawing on centrally created resources, and returned to a second session to share best practices and exchange experiences.

Students have partnered with the faculty and played active roles in these educational efforts, contributing to design, participating in educational material development and running the sessions. When developing the teaching material students have helped with the literature reviews for up to date information and brought their insight into how to make the instruction relevant and dynamic. At the training the students served as presenters describing their own need for knowledge, presenting the material and exemplars of successful ESH sessions, and/or moderating small groups.

Case study 2. Experience of integrating ESH into the medical curriculum, Lancaster Medical School, UK

Lancaster Medical School has integrated Sustainable Healthcare throughout the curriculum, threading themes through established modules – health inequalities, ethics, health promotion, population health and PBL in the early years – and delivering new sustainable healthcare modules in higher years. Senior faculty have taken the lead, being aware of school processes and familiar with the overall curriculum, and this has been crucial. Being a small medical school, Lancaster has been able to adapt and respond swiftly to change. Buy-in from faculty has been excellent and has fitted with the wider university green strategy. GPs (family physicians) delivered new modules in existing primary care education sessions – where there are many cross-over themes – and no new clinical educators were needed.

The inclusion of Sustainable Healthcare in GMC Outcomes for Graduates 2018 (GMC 2018) provided leverage for senior faculty. Published literature such as Fulfilling a New Obligation (Tun 2019) was useful to the process of embedding ESH. Sharing practice and ideas between institutions, at an education day held by the Centre for Sustainable Healthcare and in online forums, was instrumental.

Students have engaged well, have presented at a national sustainability conference and expressed aspirations to become future leaders in the field. Further details can be found as Supplemental Material, Appendix 1.

Case study 3: Faculty development in sustainability, Georgetown University School of Medicine, US

Beginning with just one faculty member focused on climate change education, and supported by her department, the first step was the development of required course content. The faculty member created and taught a one-time lecture/workshop on climate change and health integrated into an existing course, bringing in outside experts to co-teach the workshop. This introduced course faculty and administration to core concepts. The faculty member also created a training manual that rotating faculty would use to teach an air pollution module (Supplemental Material, Appendices 2 and 3). The ultimate principle utilized was of top-down faculty development involving acquisition of discrete skills to teach specific content, ‘just in-time’ teaching.

Each year, several students expressed interest in the course content and wanted to know what they could do. In year 3 of the aforementioned lecture and on-going module, students were sufficient in number to convene a Climate Health and Medical Sustainability Group. This now allowed students to set an agenda, focusing on expanding curricular content to preclinical courses by approaching course directors, doing community outreach, and developing extracurricular programing. The principle here was multidisciplinary and bottom-up faculty development, in line with integrated curricula and intergenerational health education.

Case study 4: Using student resources to upskill faculty, Bond University, Australia

Bond University is in the process of integrating planetary health and environmental sustainability across all years of the curriculum. A team collaboration platform serves as a repository for relevant curriculum documents and is used to communicate curriculum, national and international updates, including resources.

Students are indirectly involved in faculty development around sustainability. A major Planetary Health assignment in Year 2 involves self-selected teams producing relevant ‘products,’ such as videos and posters, showcasing the UN Sustainable Development Goals (SDG13 – Climate Action, and at least one other), some of which are shared with faculty. Faculty are also invited to the end-of-semester conference in which the best products are showcased and students vote for the ‘People’s Choice’. Examples of distributed resources include a poster on sustainable diets and a video on the environmental footprint of anesthetic gases. With permission, these resources have also been shared across Australian and New Zealand medical schools either for faculty development or as student resources. Other student resources shared include the Australian Medical Students’ Association (AMSA) online short course on climate change, AMSA’s Sustainable Events Guide and AMSA’s Climate Policy.

Benefits for educators’ own clinical and educational practice

Educational interventions can help healthcare professionals become more sustainable in their practice. The case studies indicate significant untapped interest among educators in learning about ESH and then teaching it. At the same time recruiting faculty or engaging clinicians to teach sustainability can be challenging. Having training in this area available provides opportunities and forums for educators to network and build community, which in turn can help move ESH work forward. Institutions can demonstrate their support by linking ESH to continuing professional development or awards and career recognition.

Most importantly for meeting the pressing need for change, faculty development in ESH may be a two-way process whereby learning in order to meet student demands may change clinicians’ own practice. Practicing more sustainably may then increase satisfaction in clinical work and enhance engagement in further teaching.

Conclusion

A new paradigm of faculty development is needed so that educators can prepare the rising generation of health professionals for the world of global environmental change they are entering. In partnership with learners, faculty can develop knowledge and confidence to integrate learning on emerging themes such as planetary health and sustainable healthcare. Students can bring enthusiasm and fresh ideas to this enterprise, as well as awareness and deep concern about sustainability. While shared resources and support are available, the challenge is to shift attitudes sufficiently rapidly to implement sustainability in clinical practice and advocate for policy change. Faculty development to enable education for sustainable healthcare can therefore benefit the health of our planet, our health systems and our patients.

Acknowledgments

The authors would like to thank Dr Felicity Connolly, Deputy Director of Primary Care Academic Teaching, Lancaster University Medical School, UK for providing Case 2 and the Appendix 1 in supplementary material and Professor Michelle McLean, Bond University, Australia for providing Case 4.

Disclosure statement

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

Additional information

Notes on contributors

SanYuMay Tun

SanYuMay Tun, MB BS, MSc, DIC, FHEA, is a medical educator and former General Practitioner in London, UK and teaches Planetary Health and Sustainable Healthcare.

Caroline Wellbery

Caroline Wellbery, MD, PhD, is a Professor in the Department of Family Medicine, Georgetown University School of Medicine, Washington, DC and Associate Deputy Editor of American Family Physician.

Arianne Teherani

Arianne Teherani, PhD, is a Professor of Medicine, Education Scientist, Centre for Faculty Directors, and Director of Program Evaluation, University of California San Francisco, School of Medicine.