Gerontological nursing, plastics and the planet: A call for research in sustainable care for older people

Abstract

Every year, April and May bring two important days of commemoration. Earth Day we typically recognize in our communities and at home. We celebrate International Nurses Day in our workplaces and professional societies. But this year these international fetes fit together in a distinct and valuable way. The themes for Earth Day and International Nurses Day are as intertwined as Florence Nightingale—our first nurse data scientist—expressed the profound interconnections among nursing, environment and health over 160 years ago.

This year, Earth Day on April 22 recognized the need to address the frail health of our planet with a critical focus. The theme of this year's Earth Day was Planet vs. Plastics (https://www.earthday.org). International Nurses Day addressed a similarly essential focus. Nurses around the world, remembering Florence Nightingale's birthday on May 12, celebrated the day with the theme of Our Nurses. Our Future. The economic power of care. (https://www.icn.ch/news/international-nurses-day-2024-theme-announced-our-nurses-our-future-economic-power-care). Each theme's relevance for us as nurses and for the communities and populations in our care is undeniable. Together, these themes send a clear message to us as gerontological nurses and all nurses around the world. Restoring a healthy planet and the critical need for sustainable healthcare mandate that we must address plastics and plastic pollution in our research, education, practice and policy.

Plastic pollution is endangering the clean air, clean water and nutritious food supplies that Florence Nightingale and many other nurses who followed her advanced as fundamental to health. While legions of nurses have echoed Nightingale's emphasis on health and the environment, our profession has been slow to contend with the specific threat that plastics pose to our planet and to human health. Healthcare is a significant plastics polluter just as it is with greenhouse gases. Worldwide, the healthcare industry contributes about five per cent of gases that cause global warming (Eckelman et al., 2020; Lenzen et al., 2020). Plastic pollution, like greenhouse gases, places our world, human health and healthful aging in peril through a variety of mechanisms (Tang et al., 2024). Moreover, both plastics and greenhouse gases are tied to fossil fuel use, so plastics are also contributing directly to global warming.

Curbing plastic pollution and greenhouse gases requires limiting use of plastics to only that which is essential, searching for alternative materials that do not rely on fossil fuels for composition and production, and redesigning waste management for essential plastics. While the proportion of plastic waste attributable to healthcare is presently unmeasured, the magnitude of plastic use in healthcare is easy for us as nurses to see. Plastics, both in single-use and reusable products, abound in every healthcare setting. As we look around us, we quickly realize that plastic products like gloves, syringes, bedpans and countless other items are a large part of daily waste created wherever we care for older people. Nonetheless, we may not fully understand the full scope of pollution that waste generates. Plastic pollution affects our entire biosphere in a myriad of ways. Macleod and colleagues outline the massive scope of plastic pollution, underscoring the need for radical reduction of plastics and coordinated global waste management (MacLeod et al., 2021). Reduction and management efforts of the scale necessary require global policy married to national, local and institutional procedures.

In 2022, the United Nations put forward the United Nations Environmental Assembly Resolution 5/14 entitled ‘End plastic pollution: Towards an international legally binding instrument’, sometimes called the global plastics treaty (United Nations, 2024). This resolution is currently being negotiated by an intergovernmental negotiating committee (INC). Among other challenges, the INC is contending with a bid to exempt the healthcare industry from this treaty (Healthcare Without Harm, 2024). Both healthcare institutions and healthcare professionals including many nurses are presently fighting against this bid to help ensure the healthcare industry does not receive such an exemption so that we may better achieve the goal of ending plastic pollution to support planetary health.

Our actions as nurses, citizens and scientists in planetary health and sustainable healthcare policies are instrumental to making those policies successful. Supporting planetary health policy like the United Nations Environmental Assembly Resolution 5/14 speaks to our global citizenship and to our professionalism. Nevertheless, the scope of policy necessary for a healthy planet includes much more than global policies like this one. As nurses, we are surrounded by policies from the team and ward levels up to and including those at institutional, municipality, state, provincial and national levels. Many of those policies—especially those that shape our team's, ward's and institution's activity—currently entail the use of plastics.

As nurses, we frequently oversee or collaborate in the oversight and implementation of policies involving plastics. In these roles, we typically consider plastic products from the evidence-base for use through procurement and clinical application. We may also contend with some aspects of local waste management including levels of contamination and appropriate waste streams. Thus, the opportunities to examine the life cycle of these plastics, overuse, misuse and co-benefits are as limitless as the plastic products we use every day. Co-benefits are health benefits achieved when taking climate action (Haines, 2017). An example of a co-benefit many gerontological nurses can achieve comes in evidence-based approaches to improving urinary and bowel continence among older people. Taking the sustainable action of replacing disposable absorbent garments and bed pads with washable garments and pads can uncover an opportunity to improve continence rather than manage incontinence. Improving continence through exercise, behaviour change and even clothing choices to reduce functional incontinence thus becomes a co-benefit of sustainable continence care. Replacing disposable continence products that contain plastics with washable products from renewable sources is inarguably valuable for our planet. But we nurses see the often-missed value of helping people feel more dignified, comfortable and capable when they regain continence.

Our roles, as nurses, in policies, practices and procedures that involve use of products made partly or wholly of plastics provides us a gateway to sustainable healthcare research. Research we undertake in phenomena involving those policies, practices and procedures offers immediate opportunities to shape sustainable healthcare for older people. As with the example of urinary and bowel continence, commonplace reliance on plastic products typically goes unnoticed and unexamined. We simply accept the ageist myth that older people become incontinent and then believe we need to use disposable plastic undergarments and bed pads when caring for them. Older people themselves often believe those same myths. While not everyone can become continent again, many can do so with our skilled intervention and support. But when we accede to the faulty expectation of incontinence, we do more than contribute to plastics pollution. Imagine the chagrin of the older person who relies on those products and then comes to stereotype themselves as frail and incapable. Striving to understand the older person's perspective can help us break through ageist complacency to launch person-centred sustainable gerontological nursing research.

Person-centred sustainable gerontological nursing research benefits from using the triple bottom line, a concept from quality improvement (Mortimer et al., 2018). The triple bottom line posits that the value of outcomes for individuals and populations are balanced against social, environmental and economic impacts. Excitingly, when deployed in research as well as in quality improvement projects, the triple bottom line helps mitigate the common misconception that sustainable healthcare is always significantly more expensive than unsustainable care. Cost savings realized through sustainable care often surprise those who expected financial losses. The triple bottom line helps us focus on the people who are in our care and places our care for them in context, calling out social, environmental and economic factors. These factors align perfectly with our emphasis on social, environmental and commercial determinants of health. The triple bottom line helps us outline key elements to consider in any clinical research project while suggesting potential co-benefits on which we might capitalize.

The triple bottom line is as well matched to age friendly healthcare as it is to the social, environmental and commercial determinants of health. All the domains in any model of age friendly healthcare—what matters, mobility, mentation, medication and complexity or multicomplexity—are amenable to a triple bottom line analysis. For example, within the domain of medication, a study of nurse-led deprescribing offers manifold potential benefits to older individuals and populations given globally widespread polypharmacy and unchallenged use of potentially inappropriate medications. Deprescribing offers environmental benefits by reducing plastic medication packaging, economic benefits through limiting medication-related expenditures and social benefits by reducing burden of home medication management, among others. Capturing such benefits should be an integral part of any deprescribing research project. The benefits revealed by application of the triple bottom line to this example enable us to envision how we can bring this year's International Nurses Day theme Our Nurses. Our Future. The economic power of care. to all our research and reach farther by adding social and environmental impact to the financial outcomes.

Thinking back to Florence Nightingale with her reliance on data and careful consideration of salutogenic forces, I imagine she would have fully endorsed this year's themes for Earth Day and for her birthday celebration of International Nurses Day. Miss Nightingale could never have imagined all the plastic we use in healthcare today. I can, however, imagine that she would be pleased by the usefulness of some products and appalled by others. Plastic medicine cups? Why do we use them, when renewable paper or sterilizable metal versions are sustainable and just as easy to use? Disposable gloves are terrific in care that specifically mandates their use but risk infections and threaten psychological harm when overused or used inappropriately. The juxtaposition of Earth Day, International Nurses Day and Florence Nightingale's legacy uncovers remarkable possibilities for us as gerontological nurses and for all nurses. The connections between and among human health, aging, planetary health and plastics allow us to look with fresh eyes on our irreplaceable work caring for older people around the world.

Bringing the themes of Planet vs. Plastics and Our Nurses. Our Future. The economic power of care. to our research is an unmissable opportunity. We nurses can drive development of sustainable healthcare around the world. From simple policy and procurement changes to complex clinical trials, we possess the perspectives and partnerships to achieve necessary change. With just a little bit of effort, we can learn what else we need to know, find partners in relevant disciplines like engineering and environmental sciences and design groundbreaking studies. Going forward, we at the International Journal of Older People Nursing (IJOPN) invite you to submit reports of your person-centred sustainable gerontological nursing research.

Submit your manuscripts on person-centred sustainable gerontological nursing research to IJOPN here: https://wiley.atyponrex.com/journal/OPN. We want to read about how you integrate the triple bottom line and about the person-centred experiences, outcomes and co-benefits you and those taking part in your research achieve. In addition to your manuscripts reporting research in sustainable care for older people, we welcome commentaries on research into phenomena where plastic must be reduced or redesigned and on approaches to and methodologies for research in sustainable care for older people. And, while we do not publish reports of quality improvement, we hope you will share your challenges and successes in developing sustainable care with and for older people and people of all ages in your institutions and communities with us on social media. Please tag @IntJnlOPN in your posts on X (formerly Twitter) and on Facebook at https://www.facebook.com/IJOPN/ and use our signature hashtag #GeroNurses when you post what you have accomplished in person-centred sustainable healthcare!

The author has no conflicts of interest to disclose.