This Education for Sustainability case study is from Melanie Maddison. After a 20 year career in the NHS with particular interest in cardiology nursing leadership and sustainable healthcare, Melanie joined King’s as Lecturer in Adult Nursing in the School of Nursing, Midwifery and Palliative Care. She was instrumental in making the School the first in the country to be awarded Beacon Status by the Centre for Sustainable Healthcare. Here Melanie discusses sustainability teaching across undergraduate Nursing modules including clinical skills, quality improvement and working with and motivating others.

“We teach students about movements like Black Lives Matter and Me Too, so they start to realise that they don’t need to take everything on their own shoulders, and if enough people agree that something could change then they don’t need to wait for somebody with leadership in their job role.”

What is the purpose of the module and why is sustainability important to it?

We want nursing students to come out of university being able to make their patients’ lives better, the planet better – all these things. The NHS is busy and overloaded and part of that is because our processes sometimes don’t talk to each other and because we’ve always done it in a certain way. You can put a sustainability spin on that, because whatever you’re wasting – PPE, anaesthetic gas, a patient’s time, turning up to six different appointments, fuel, money, your own time fetching something stored in an inconvenient place. Less waste is better.

The environment has a huge role to play in human health, but the Nursing & Midwifery Council Code and Nursing Standards were written in 2018 and don’t have much to say about this yet. That is in contrast to the General Medical Council Outcomes for Graduates which states that newly qualified doctors need to bring the principles of sustainable healthcare into their practice and make a link between planetary health and human health.

That said, our undergraduate nursing students learn about sustainability in their leadership, and their quality improvement modules. The leadership module is called  ‘Working With and Motivating Others’ and supports third year nursing students to become agents of change in certain situations and develop the self-confidence to know that they have some power and some purchase when they qualify. We say to students that yes, it is really, really busy in the NHS, but if you don’t try to change stuff – particularly when you first start work – then you’ll get sucked into the daily treadmill and never believe you can innovate. We teach students about movements like Black Lives Matter and Me Too, so they start to realise that they don’t need to take everything on their own shoulders, and if enough people agree that something could change then they don’t need to wait for somebody with leadership in their job role. Teaching them about eco-activism fits well with this and avoids eco-anxiety which can lead to inertia and acceptance.

How do you bring together sustainability and disciplinary learning?

Since 2021 eleven members of our faculty have worked with the Centre for Sustainable Healthcare (CSH) to incorporate the principles of sustainability into our curriculum. This includes the ‘triple bottom line’ which looks at the financial savings, reduction in environmental damage and improving the social determinants of health. This is a nice way of thinking holistically about patient outcomes. The CSH have open-licensed resources and case studies for adult nursing so I can show students, say, how an A&E decided they were using too many cannulas, took a look at why that was and managed to reduce the number of cannulas. This is better for the patient, less cost and less plastic waste. Boom! That’s how you frame it, and students respond well to that type of case study.

Our job as educators is to bring in pedagogical design to how we use these CSH materials. For example students can do my Cardiology course and learn how to use more environmental sustainable products in a clinical setting. I start the session with Sustainability Bingo that acts as an ice-breaker and allows students to explore their personal values about the climate crisis and apply it to their professional persona.

We’ve also been working on a project to audit the contents of the bins in the clinical skills lab to see what people throw away during the session. The aim is to reduce the waste produced in these sessions. ‘Bin Diving’ was not something I thought I would be doing as an educator but this just shows how glamorous my life is as a lecturer at times, but seriously it has been very revealing. We found that we’re incinerating used aprons and gloves that haven’t been contaminated by clinical exposure to bodily fluids, or certain items such as syringes that could have been reused for those six different practice attempts with the same plastic mannequin. That’s a huge carbon footprint and has a financial implication which we could solve in a heartbeat, and in a way which keeps the clinical verisimilitude and doesn’t interfere with the habits and muscle memory of, say, always putting on gloves before going to a real patient. If students are practising with one mannequin throughout the session then they can use the same pair of gloves for all their attempts without harm to anyone. If we’re using mock substances and the gear isn’t contaminated, then it can be part of a re-use or recycle scheme rather than being thrown away. This does need to be considered in line with the student’s level of competency and we do not want to encourage poor practice but overall, we can make changes to excessive use in the sessions as well as how it is ultimately disposed of.

How do you assess sustainability learning?

The nursing curriculum is often competency-based and driven by prescribed learning outcomes so teaching and assessing values and a sense of agency is challenging. There is no mandate from the Nursing and Midwifery Council yet. Currently nursing students have only three years and a tight schedule with many competing demands before they qualify. Assessing sustainability learning in clinical placements is also tricky because nursing students are only there for approximately six weeks and it’s often outside their scope to make quality improvement interventions.

But what’s been clear is that most of our nursing students have an appetite for this, so we’re asking the Nursing and Midwifery Council to consider including competencies and an Episode of Care reflection related to environmental sustainability. When we have that mandate to make a link between planetary health and human health, we’ll be able to include that in our learning outcomes and assess it fully.

Thinking longer term, for the ‘Working With and Motivating Others’ module, what I want to know is how much students already know and how much they are taking to heart. The students do an academic reflection where they make a toolbox for themselves about maintaining their own resilience and well-being in their careers – you know, “I have a bladder and it’s been 12 hours on shift, so I have to go to the toilet now” – and about gaining the strength to become an agent of change. So, if they see a different way to do something that helps the patient, the environment and themselves, by saying it out loud, suddenly they are a quality improver.

What support do students need?

“Post-pandemic, many students may have been left with mental health and anxiety issues, and they’re also in a profession that brings heavy mental trauma, insult and injury, all of which can lead to occupational burnout. So, what you don’t want them to do is get so anxious about the state of the planet that they can’t do anything at all.”

The triple bottom line is quite simple to teach because you just give students some problems to solve, and they work it out using the equation. But teaching values is less simple. Post-pandemic many students may have mental health and anxiety issues, and they’re also in a profession that brings heavy mental trauma, insult and injury, all of which leads to burnout. So what you don’t want them to do is get so anxious about the state of the planet that they can’t do anything at all. In environmental movements they talk about turning your eco-anxiety into eco-activity. This course is about empowerment and agency, so without being doom-laden we try to engage with them on a personal level – because on a personal level so many of them are already invested in it.

What benefits have you seen?

This year we will be evaluating students’ responses to the sustainability sessions and encouraging them to get involved with such initiatives as the Planetary Health Report Card, a student-led evaluation of the eco sustainability of their campus and learning environment. For ‘Working With and Motivating Others’ specifically, it would be lovely to meet with them at the end and find out whether they think it will be helpful. As part of our curriculum co-design, I am trying to get them back after they’ve qualified and talk about the parts of the course which made them a motivator or an agent of change – or which didn’t, since this course is dynamic and has to evolve yearly. I have recorded a short podcast with an outgoing student and shown it to the new cohort so that they can see how that student has responded to the issues raised in the course.

Do you have any suggestions?

There’s very little literature about teaching sustainability values specific to nursing. It mostly focuses on, say, the carbon footprint of a clinical skills session, or digital learning, but far less about developing values. So if anyone is teaching this kind of thing, they should publish about it! A lot of tutors don’t feel comfortable talking about sustainability because they don’t feel they know enough. And I find that quite funny because sustainability is not an elitist thing – anyone can do it. But maybe people need to make that connection between sustainability and global health for example through the UN Sustainable Development Goals and the World Health Organisation.

Another thing is one-to-ones I’ve had with overwhelmed educators worrying about having no space in their curriculum. We’ve been able to talk about bringing the Triple Bottom Line into problem-based learning scenarios without adding anything extra. We view the content through the lens of sustainability rather than adding more. It’s a case of reframing the curriculum and I don’t think there is any conflict or competition there. And if there’s too much going on, I think about it in terms of inequality – because it’s the most disadvantaged people who have the worst living conditions and tend to face the most discrimination. Climate change and the impact on health hits hardest amongst disadvantaged communities. It should be a priority.

It’s been great getting involved in the sustainability events at King’s led by Frans Berkhout. Through meeting sustainability colleagues in Estates I found out about lab recycling and reuse schemes in medical education which we can bring into our labs. I would never have had any kind of interface with that role otherwise, so that’s proper collaborative working.

This Education for Sustainability case study is from Claire Lucas, Professor of Engineering Teaching and Learning at King’s. As well as time in industry, Claire has taken a national role in Engineering education, including as a QAA subject specialist and deputy chair of the 2022 subject benchmark statement review for Engineering. Here she discusses Energy & Sustainability 4CCE1SUS, a core module all new Electronic Engineering and General Engineering students take in the first semester of their first year.

“Students learn that Engineering is about compromise rather than making the most efficient thing possible, and that historically the compromise has been one way.”

What is the purpose of your module and why is sustainability important to it?

Often at the start of their degree, Engineering students have a classical Engineering science module. With our module we want to make it really obvious from the start that Engineering science and sustainability are intrinsically linked. For example, when you learn about thermodynamics (the interaction of temperature and air movement) in the lab you learn how the internal combustion engine or ram pump relate to thermodynamics and ultimately to global warming – which itself is a thermodynamic process.

How do you bring together sustainability and disciplinary learning?

We have a competency framework with some overlap with the ESD competencies – systems thinking, for example, which we take to be understanding emerging and interactive behaviour. In the first year of Engineering, the functional competency is to apply methods to solve broadly-defined problems, and the non-functional competencies are self-awareness, ability to reflect, cultural competency and creative thinking. Different parts of the degree address different competencies.

The first half of the module is the science and lab part where students learn about mechanical, electrical, thermal and fluid energy. We’re showing that, say, fluid flowing round pipes follows the same principles as electricity flowing round a circuit or heat flowing round your house. We have five labs where they analyse these principles in action. One of those labs is an internal combustion engine where they learn about chemical heat process, thermodynamics and fluid dynamics. The reason we have that – and it might seem really old-fashioned – is that at this early stage, students don’t have the material science knowledge to understand the complex electrical machines that power a wind turbine, but taking an internal combustion engine apart and putting it back together is a really good way to learn about the interactions between mechanical, electrical, chemical and thermal energy – and in the process how much energy is wasted as heat and pollution.

The labs are interesting because as well as the standard activities like learning to write a lab report, we also want them to start thinking experimentally as early as possible, so that they can validate their decisions and their models. So when they learn how to operate a piece of equipment, we are also scaffolding their thinking about what that equipment could validate. All of this prepares them for the science of sustainability in their Materials module – that’s where they’ll start using formal tools to analyse supply chains and lifecycles.

Then the second half of the module is Problem-Based Learning (PBL) to demonstrate why the science and labs are relevant. The groups need put their maths so far into practice to take a sustainability perspective on modelling realistic cases like buildings or vehicles. Students learn that Engineering is about compromise rather than making the most efficient thing possible, and that historically the compromise has been one way.

How do you assess the learning?

One element is PBL group coursework. That exists to show students that sustainability is something you can quantify and evaluate, and that you can use Engineering science to do that. They take an energy model of a building or a vehicle and carry out a lifecycle analysis. They use their maths so far to design an energy system to meet the demands of normal use – we give some datasets on this – and protect the environment by maximising efficiency, minimising pollution, or being responsive to changing energy demands. We’ve decided to give a group mark for this module rather than an individually differentiated mark.

For these first years we pitch the problem carefully so they’re working on something new rather than retrofitting an existing site – that way we can manage the systems thinking complexity based on what they know at this early stage. One option they have is a tender for a greenfield house building scheme and the other is a tender for new buses. There’s always a business-as-usual baseline which they use their creativity to improve on. They explain their criteria, they use their maths to do the modelling. We also ask them to write an individual reflective statement where they respond to prompts about what they learned and the kinds of problems they faced. That helps develop self-awareness.

The other assessments are individual coursework on the labs (30%) and an exam on the scientific knowledge (40%), which is fairly typical for this kind of course.

What support do students need?

We spend a lot of time scaffolding the skills students will need for group work. We explicitly give students approaches to teamwork, negotiation, and decision making with formal decision-making comparison tools like pugh matrices and multi-criteria analysis graphs. It’s about evidence for the decision rather than the person who is the strongest leader winning – we doing all we can to help students keep an open mind about group work and avoid settling into fixed roles early on. We timetable the PBL group work and observe attendance, and in the following semester we give each student a specific role within their groups.

We see this group work scaffolding as just as important as learning how to use a piece of equipment to take measurements in a lab. Students often arrive with habits of keeping their ideas secret. We say that we’re not looking for the Dragon’s Den person who ‘wins’ and actually, winning is sometimes about losing your idea or bringing it into the open so it can be iterated and improved. The way we put it is that to be truly excellent you have to help others to be excellent.

I mentioned already that we manage complexity for students based on their level of learning. We don’t do complex systems without systems boundaries until Level 6 or 7. This is why we give first years the problem of designing a new system from a blank slate – it means they’re thinking about conflicting requirements, which is a kind of systems thinking, but with a lot less complexity than retrofitting a system that already exists, like the existing London transport network, or existing buildings. This is because retrospectively adapting existing systems in the real world is often a matter of iterating based on a restricted number of leverage points which as a systems thinking problem is often really challenging.

But ultimately students do need to be able to claim that systems thinking competency, so this first year problem is the start of a thread that students follow throughout the degree. When they revisit it in their third year Energy Generation and Storage module, this time the constraints are removed, they gather their own data, the models are more complex because the systems already exists, and the techno-economical and lifecycle aspects are present.

One thing I often wonder about is how much to explain to students about why something is important without making them sick of the framing. We spend a lot of time justifying why we teach what we teach in the way we teach it, and it sometimes comes out in students’ reflections that they would rather just get on with the project. I sometimes wonder if women spend more time defending their decisions, and whether if we didn’t it would make a difference. But on the other hand, there are good pedagogical reasons to do it and it gives students a chance to criticise the approach.

What benefits have you seen?

The labs mean that students are generally well-prepared for the second semester. They have a good understanding of engineering as multidisciplinary and can start to take different perspectives and recognise commonalities between problems in other disciplines. Typically this group project is not successful, and that’s why it exists – it’s there to shake things out a bit and give us a chance to observe the cohort ready for the next semester when the group project is higher stakes.

Students learn that sustainability needs both Engineering science and qualitative judgement. They learn that sustainability does have a cost, and Engineering science can be used to bring  quantitative sustainability equations to negotiating balanced outcomes between competing priorities. They get an introduction to some approaches and tools for that analysis, and they start learning how to reflect on their own contributions, roles and strengths.

Do you have any suggestions?

We’re talking here about a single module, but we don’t think it is possible to fully develop the sustainability competencies in just one module and it would be a mistake to try to put everything students need to know about sustainability into a single module. So we are separating the sustainability science from the sustainability competencies, and mapping the competencies out across the degree so we can reinforce them all the way through.

I really recommend to anyone to make a table for their discipline where they set out the knowledge students will learn but also the corresponding skills which help them learn really well and become great mathematicians, historian or lawyers. And then to think about whether some sustainability competencies are more advanced and cognitively challenging than others, and how to develop them.