Exploring Nursing Students’ Metaphorical Perceptions and Cognitive Structures Related to the Global Climate Crisis's Impact on Nursing

ABSTRACT

Objective

This study aimed to explore the metaphorical perceptions and cognitive structures of Turkish nursing students related to the impact of the global climate crisis on their profession.

Methods

Researchers adopted a qualitative approach centered on metaphor analysis and involved 40 Turkish nursing students enrolled in programs in Türkiye during October 2023. Using metaphor analysis and techniques involving writing and drawing, the study uncovered how these students perceive and cognitively structure the influence of the global climate crisis on their nursing careers. The interview form featured the metaphor expression “The reflection of the global climate crisis on nursing is like … because …,” while the drawing component prompted students to determine their perspectives on the climate crisis's impact on nursing through concept drawings. The research adhered to the COREQ checklist.

Results

The study revealed that nursing students generated 22 metaphors each through written and drawing techniques. Written metaphors were grouped into five categories: psychosocial challenges faced by nurses, patient populations, diseases and coping, burdens on the health system, and the growing importance of various fields within nursing. Drawing technique metaphors were grouped into four categories: nurses and the difficulties they face, the impact of the global climate crisis on the world, the impact of the global climate crisis on the healthcare sector, and the roles and responsibilities of nurses.

Conclusions

While nursing students expressed diverse opinions, their concerns about the reflection of the global climate crisis on nursing yielded similar emotional responses. Metaphors are mostly focused on psychosocial challenges faced by nurses, the patient population, diseases, and coping mechanisms. The findings underscored nursing students’ concerns about the global climate crisis's impact on both their profession and the broader community.

1. Background

Climate change is a worldwide challenge impacting our planet, giving rise to issues in health and potentially leading to societal, economic, political, and health outcomes for both present and future generations (Kalogirou, Olson, and Davidson ²⁰²⁰). Factors like rising temperatures, increased precipitation, floods, rising sea and ozone levels, and compromised air quality, coupled with growing droughts causing water scarcity, diminishing agricultural productivity, and a surge in infectious diseases, highlight the multifaceted effects of climate change. This pervasive influence on all aspects of life has ushered in diseases and altered disease patterns (Sayre et al. 2010). The WHO estimated that climate change is expected to cause approximately 250,000 additional deaths per year between 2030 and 2050: 38,000 due to heat exposure in elderly people; 48,000 due to diarrheal disease; 60,000 due to malaria; and 95,000 due to childhood undernutrition. Additional negative outcomes include unintentional injuries related to coastal and inland flooding, droughts, and fires, with the greatest areas impacted in resource‐limited countries^. (World Health Organization ^{2014a, 2014b}; Nicholas and Breakey ²⁰¹⁷). The more recent report of the U.S. Global Change Research Program (USGCRP), The Impacts of Climate Change on Human Health in the United States: A Scientific Assessment, highlights the health impacts related to air, food, water, extreme weather, vectors, and temperature‐related deaths. The report also focuses attention on the social determinants of health, with special attention to issues affecting vulnerable populations and the adverse effects on mental health and wellbeing (U.S. Global Change Research Program ²⁰¹⁶). Thus, it becomes imperative for healthcare professionals to raise their awareness and take measures to reduce existing and potential health impacts (Sayre et al. 2010).

The nursing profession's metaparadigm encompasses the individual, health and illness, environment, and nursing. The environmental dimension underscores nurses’ responsibilities toward the environment (Kalogirou, Olson, and Davidson ²⁰²⁰; Ünsal ²⁰¹⁷). Consequently, nurses bear moral obligations, professional responsibilities, and roles to champion meaningful actions and policies of decision‐makers, which involve reducing carbon footprints, protecting planetary health, educating society about climate change and fostering awareness, advocating for climate justice, and contributing to the creation of a more sustainable environment (Martin and Vold 2019; Dzurec ²⁰²⁰; Law, Kalogirou, and Dahlke ²⁰²¹; McDermott‐Levy ²⁰²¹; LeClair and Potter ²⁰²²). Nurses should strive to facilitate the transition to a more just, healthy, and sustainable global order (Kalogirou, Olson, and Davidson ²⁰²⁰; Rosa and Upvall ²⁰¹⁹; Kurth and Potter ²⁰²²).

Planetary health emerges as a social movement necessitating an interdisciplinary approach that delves into solutions by analyzing the impacts of human‐induced degradation on Earth's natural systems and human health (LeClair and Potter ²⁰²²; Kurth and Potter ²⁰²²; İlaslan and Çakar ²⁰²¹). Planetary health asserts that the scale of the human enterprise has outstripped the resources available to it from the only habitable planet we know. Human activities are driving fundamental biophysical change at rates that are much steeper than have existed in the history of our species (Law, Kalogirou, and Dahlke ²⁰²¹). These biophysical changes are taking place across six dimensions: (a) disruption of the global climate system; (b) widespread pollution of air, water, and soils; (c) rapid biodiversity loss; (d) reconfiguration of biogeochemical cycles, including that of carbon, nitrogen, and phosphorus; (e) pervasive changes in land use and land cover; and (f) resource scarcity, including that of fresh water and arable land. Each of these dimensions interacts with the others in complex ways, altering the quality of the air we breathe, the water we have access to, and the food we can produce (Myers 2017). In contrast, planetary nursing is defined as a nursing approach rooted in Florence Nightingale's foundational principles of improvement, leadership, and global action, centering on a comprehensive understanding of global nursing, considering social determinants of health, and advocating for the promotion of sustainable, equitable, and accessible health for all (Rosa and Upvall 2019; İlaslan and Çakar ²⁰²¹; Kurth ²⁰¹⁷). When it comes to the conceptualization of the environment, almost all the main grand theorists understood that a person's environment had an impact on their health. Furthermore, those same theorists acknowledged that the environment comprised a blend of both internal and external factors. Fawcett's (1984) metaparadigm was the version most commonly accepted when it was published. It attempted to reflect the profession's core values as outlined by the mandate, and its purpose was to direct nursing's research agenda and practice goals. It comprised four main concepts—person, health, nurse, and environment—that drove nursing research as they were considered to represent the unique domain of nursing's knowledge, and, as required at the time, also defined nursing practice by providing areas of care that distinguished nursing (Kalogirou, Olson, and Davidson ²⁰²⁰; Fawcett ¹⁹⁸⁴; Risjord ²⁰¹⁰).

Nurses represent a pivotal group capable of influencing and fostering awareness in climate change studies, owing to their substantial presence in the health sector, adept therapeutic communication with patients, and their recognized reliability as healthcare professionals within society and among patients (Law, Kalogirou, and Dahlke ²⁰²¹; Kurth and Potter ²⁰²²; Kurth ²⁰¹⁷). This underscores the imperative for nurses, given their potential to shape outcomes in alignment with ongoing processes, to embrace the role of planetary nurses. Consequently, there is a distinct responsibility for nurses to contribute to the enhancement of planetary health.

Being a planetary nurse should be seen as a situation that should be instilled in students during their undergraduate years of nursing. In our country, the criterion of being a bachelor's degree graduate to obtain the title of nurse was introduced in 2014. Undergraduate education is given in 4‐year nursing departments or nursing faculties of universities. In addition, nurses who wish can do a 2‐year master's degree followed by a 4‐year doctorate after 4 years of undergraduate education (Butterfield, Leffers, and Vásquez ²⁰²¹; Morin et al. ²⁰²²).

The scarcity of studies investigating the perception of the global climate crisis among nurses and nursing students in our country shows the significance of this research in contributing to the existing literature. In this context, the study aimed to investigate the concerns of nursing students in Turkey regarding how the global climate crisis is reflected in the nursing profession. To achieve a comprehensive understanding, the study employed metaphors and a drawing‐writing technique to explore the impact of the global climate crisis on nursing. Specifically, the study sought to address the following sub‐objectives:

1. What are the metaphorical perceptions of nursing students regarding the impact of the global climate crisis on nursing?

2. Into which categories can the metaphors created by nursing students about the impact of the global climate crisis on nursing be grouped based on similarity?

3. What are the cognitive structures of nursing students concerning the impact of the global climate crisis on nursing?

2. Methods

Throughout the course of this study, the authors adhered to the Consolidated Criteria for Reporting Qualitative Research (COREQ) guidelines (Table 1), ensuring a comprehensive reporting of their research process (Tong, Sainsbury, and Craig ²⁰⁰⁷).

TABLE 1.

Consolidated Criteria for Reporting Qualitative Research (COREQ) (Tong, Sainsbury, and Craig ²⁰⁰⁷).

Alan 1: Research team and reflexivity
Personal characteristics
Number	Characteristics	Guiding questions	Explanations
1	Interviewer/facilitator	Which author(s) conducted the interview or focus group?	The first author conducted the interview.
2	Credentials	What were the credentials of the researchers? e.g., Ph.D., MD.	First author: Ph.D. Second author: Ph.D.
3	Occupation	What was their occupation during the study?	First author: Dr. Faculty Member, Psychiatric Nursing Second author: Dr. Lecturer, Psychiatric Nursing
4	Gender	What was the sex of the researcher?	Two researchers Female
5	Experience and education	What are the experiences and education levels of the researchers?	The first author has taken qualitative courses. The second author has taken qualitative courses, has experience in qualitative research, and has published qualitative studies in international journals.
Relationship with participants
6	Relationship status	Was there a relationship between the researcher and the participants before the training?	Participants were students of the researcher.
7	Interviewee's information about the interviewer	What did the participants know about the researcher, e.g., personal goals and reasons for doing the research?	Participants knew that the researcher had a doctorate in the field of mental health and diseases.
8	Interviewee characteristics	What characteristics of the interviewer/facilitator were reported? e.g., bias, assumptions, reasons, and interests in research.	At the beginning of each interview, participants were informed about the purpose and objectives of the study.
Domain 2: Study design
Theoretical framework
9	Methodological orientation and theory	What methodological orientation was identified to support the study, e.g., discourse analysis, ethnography, phenomenology, and content analysis?	This was a qualitative study.
Sampling
10	Sampling	How were the participants selected? e.g., purposeful, convenience, consecutive, snowball.	The criterion sampling method, one of the purposive sampling methods, was used.
11	Approach method	How were the participants reached? e.g., face‐to‐face, telephone, mail.	The time of the interviews was scheduled by the students who voluntarily agreed to participate in the study.
12	Sample size	How many participants were there in the study?	A total of 40 individuals were included in the study.
13	Exclusion	How many people refused to participate or dropped out? Reasons?	No adolescents refused to participate in the study.
Setting
14	The setting of data collection	Where were the data collected? e.g., home, clinic, or workplace.	Detailed information is given in the data collection section of the study.
15	Presence of non‐participants	Was there anyone else other than the participants and the researchers?	No, there was not.
16	Description of the sample	What are the important characteristics of the sample? e.g., demographic data, date.	Individuals who agreed to participate in the study were included in the study.
Data collection
17	Interview guide	Were questions, prompts, and guidelines provided by the authors? Were they tested in a pilot study?	Detailed information is given in the methods section.
18	Repeat interviews	Were repeated interviews conducted? If yes, how many?	No, they were not.
19	Audio/visual recording	Was audio recording or visual recording used to collect data in the research?	The forms used in the interviews were kept in a protected place.
20	Field notes	Were field notes taken during and/or after the interview or focus group?	The responses of all individuals and the researcher's observations were recorded.
21	Duration	How long were the interviews or focus groups?	Each interview lasted between 15 min.
22	Data saturation	Was data saturation discussed?	Yes, it was.
23	Transcripts returned	Were transcripts returned to participants for comment and/or correction?	No, they were not.
Domain 3: Analysis and results
24	Number of data coders	How many data coders coded the data?	Two researchers and a third individual coded the data.
25	Description of the coding tree	Did the authors describe the coding tree?	The titles and subtitles in the results section represent the final coding tree.
26	Derivation of themes	Were the themes predetermined or derived from the data?	Themes were derived from the data.
27	Software	If any, what software was used to manage the data?	The data were analyzed manually.
28	Participant control	Did participants provide feedback on the findings?	No, they did not.
Reporting
29	Quotations provided	Are participant quotes cited to illustrate themes/findings? Is each quote identified, e.g., by participant number?	Yes, they are. Participant quotes are provided to illustrate themes/findings, e.g., participant number.
30	Data and findings consistent	Was there consistency between the data presented and the findings?	Yes, there was.
31	Clarity of the main themes	Are the main themes presented in the findings?	Yes, they are.
32	Clarity of subthemes	Is there a description of the different cases or a discussion of minor issues?	Yes, there is.

2.1. Study Design

This research was conducted using a case study design within the framework of the qualitative research model. Morrow (2015) defines a case study as an in‐depth description and analysis of a limited system. It involves a detailed and longitudinal examination of data obtained through participant observations, in‐depth interviews, and document collection (Creswell and Poth 2016; Glesne ²⁰¹⁵). The qualitative research model and case study design were chosen for this study to thoroughly explore the metaphorical perceptions and cognitive structures of nursing students in Turkey regarding how the global climate crisis is reflected in the nursing profession, requiring the collection of detailed data for this purpose.

2.2. Research Team and Reflexivity

The research team consisted of two active faculty members, both holding doctorates in psychiatric nursing. Both researchers possessed clinical nursing experience in hospital settings and received training in qualitative research methods. No relationship between the researcher and the participants was established before starting the study. The authors have no conflicts of interest to declare.

2.3. Study Group

The criterion sampling method, a purposeful sampling technique, was employed to select participants for the study. This method involves sampling individuals, events, objects, or situations with predetermined qualities relevant to the research problem (Altunay, Oral, and Yalçınkaya ²⁰¹⁴; Başkaya and Demir ²⁰²³). The study engaged 40 second‐year nursing students from a university in eastern Türkiye and was conducted through face‐to‐face interactions. Participants were chosen from those attending the environmental health course on the data collection day, and the sampling continued until saturation was achieved. Data were collected in the classroom. Participation in the environmental health course was voluntary. This group was selected because it was thought that taking the environmental health course might create selective perception in students. At the time of the interview, students were actively taking the course.

Inclusion criteria were: (a) being a nursing student; (b) being willing to engage in communication; and (c) agreeing to participate in the study (d) being taking environmental health course. Exclusion criteria were: (a) having language, speech, or hearing impairments hindering communication.

2.4. Data Collection Tools

In this study, the metaphorical perceptions and cognitive structures of Turkish nursing students regarding the impact of the global climate crisis on their profession were explored using the metaphor technique and the drawing‐writing technique.

2.4.1. Metaphor Technique

In the first part of the data collection process, data were gathered through a semi‐structured metaphor form developed by the researchers. Each student was asked to complete the prompt: “The reflection of the global climate crisis on nursing is like… because….” Semi‐structured questions are commonly used in research that employs metaphor techniques (Döş 2010) because metaphors alone may not fully capture their visual and descriptive power. To clarify the meaning behind each metaphor, it is crucial to ask follow‐up questions like “why,” as different individuals may interpret the same metaphor differently (Döş 2010).

2.4.2. Drawing‐Writing Technique

In the second part of the data collection, the drawing‐writing technique was used. This technique is particularly effective for activating and capturing the visual structures related to thoughts, meanings, attitudes, images, and cognitive structures, which might otherwise remain passive and unused in learners’ minds, and it allows these concepts to be obtained as personalized, high‐value scientific data (Ekici 2019). In this study, nursing students were asked to respond to the prompt: “How is the reflection of the global climate crisis on nursing? Explain by drawing (picture‐figure).” Additionally, they were encouraged to express their thoughts on the subject freely and in detail, without any limitations. The students were informed that the data collected would be used in a scientific study and that no personal information would be disclosed.

2.5. Data Collection

The data collection process utilized a “semi‐structured interview form” and the “Form for Drawing the Global Climate Crisis.” The semi‐structured interview form was designed to generate questions about predetermined subjects and areas, covering all dimensions relevant to the research problem (Patton 2022; Yıldırım and Şimşek ²⁰¹³). This form is particularly favored in metaphor analysis methods and has been used in studies based on metaphor analysis (Apaydin Cirik, Aksoy, and Bulut ²⁰²³; Ekici and Akdeniz ²⁰¹⁸). The researchers created the semi‐structured interview form based on existing literature concerning nursing students’ perceptions of the global climate crisis (Bulut and Kasap 2023). The form included a metaphor question, prompting participants to associate the concept of “reflection of the global climate crisis on nursing” with a metaphor, explaining their choice. The participants were asked to complete the following sentence: “The reflection of the global climate crisis on nursing is like …. because ….” Additionally, participants were asked to depict the reflection of the global climate crisis on nursing through drawings. The “Semi‐structured Interview Form” and drawings underwent analysis by two researchers specializing in the field of mental health and disease nursing. The analysis assessed applicability, content, scope, appropriateness, and clarity. In metaphor studies, data collection typically involves observation, interviews, and document analysis (Apaydin Cirik, Aksoy, and Bulut ²⁰²³). In this study, all participants completed the forms in approximately 15 min, and no exclusions were made since each student provided their own metaphor.

2.6. Data Analysis

Document analysis and content analysis were employed to evaluate the metaphors created by nursing students regarding the reflection of the global climate crisis on nursing. Document analysis, recognized as an innovative data collection method, facilitates data transfer and expedites analysis (Başkaya and Demir 2023; Cirik, Aksoy, and Bulut ²⁰²³). Document analysis involves the process of skimming, thorough reading, examining content, and interpretation of documents. Depending on the research question, one may use a rating scale, checklist, as well as a matrix analysis for examining content. Fereday and Muir‐Cochrane posit that document analysis involves a focused reading of the document, whereupon the researcher engages in the identification of patterns in the data, and formation of codes and themes on which the analysis is based (Fereday and Muir‐Cochrane ²⁰⁰⁶). Bowen argues that document review and document analysis both involve the following aspects: (a) selection and classification of relevant documents, (b) extraction and analysis of data to draw insights and conclusions about a concept, (c) answering research questions (Bowen 2009). The data collected from documents therefore need to be treated as “scientific.” This means the application of specific and rigorous processes that are systematically followed to ensure the accuracy, representativeness, and reliability of the data and the results of its study. These systematic processes also include identifying irregularities and patterns when collecting data and paying attention to which data to include and exclude through data condensation to condense large volumes of information. This ensures that each piece of data is reduced without losing its meaning, as this will affect the way the data is subsequently displayed (Hughes, Taylor, and Tight ¹⁹⁹⁶; Semansky et al. ²⁰¹³). Content analysis involves grouping relevant information into predetermined themes and concepts, interpreted in an understandable manner (Bowen 2009). The content analysis process comprised five stages: naming, classifying, categorizing, ensuring validity and reliability, and quantifying the data.

In the naming stage, metaphors that are used by nursing students to express concerns about the reflection of the global climate crisis on nursing are listed. Forms without metaphors were excluded. In the classification stage, metaphors are categorized by discussing their similarities. Researchers independently analyzed each metaphor, considering the subject, source, and the relationship between the two, creating a metaphor list. Six different categories based on the metaphor list and grouping were formed in the categorization stage. The Cohen Kappa coefficient and reliability formula were used in the validity and reliability steps.

2.7. Validity and Reliability

In the context of metaphor studies, ensuring validity is based on a detailed analysis and appropriate categorization of each metaphor (Başkaya and Demir 2023; Miles and Huberman ¹⁹⁹⁹; Steele, Baird, and Davies ²⁰²²). In this study, a rigorous data analysis process was employed to examine 22 metaphors presented through both written (n = 22) and drawing (n = 22) techniques. To enhance the research's reliability, a multistage process was employed. Initially, a compilation of metaphors and categories was formed and presented to two experts. One of the two experts is a professor specialized in the field of educational sciences and the other is a faculty member who conducts metaphor studies in the field of nursing.

Subsequently, each category was assigned a code, and experts were tasked with aligning the corresponding category numbers with the metaphors. The ensuing stage involved comparing these expert‐assigned categories with those determined by the researchers. Following expert and researcher evaluations in the fourth stage, consensus and disagreement metaphors were identified. Disagreement metaphors underwent further discussion, leading to the finalization of the categories to which they belonged. In the fifth stage of the study, research reliability was assessed using the formula proposed by Miles and Huberman (1999): reliability = (consensus/agreement + disagreement) × 100. An agreement of 88% or higher between expert and researcher evaluations was considered indicative of research reliability. If reliability calculations exceeded 70%, the research was considered reliable. The study's reliability was determined to be 88% (22/[22 + 3] × 100), demonstrating satisfactory reliability (Miles and Huberman 1999). To ensure the representativeness of metaphors within different categories, the perspectives of two instructors were sought. The Cohen Kappa coefficient, assessing coder agreement, yielded a rate of 0.92, signifying a high level of agreement in this study. Furthermore, the validity and reliability of the forms were analyzed by two experts specializing in the global climate crisis and nursing. Consequently, four experts evaluated the study's validity and reliability.

2.8. Ethical Considerations

Regarding ethical considerations, the research received approval from the Hakkari University Scientific Research and Publication Ethics Committee (dated June 14, 2023, numbered 2023/64‐01). Participants provided informed consent before participating in interviews, aligning with the principles of the Declaration of Helsinki and the ethical standards of the National Research Committee.

3. Results

Nursing students expressed their worries regarding the impact of the global climate crisis on nursing through the identification of 22 metaphors using a writing technique. These metaphors were classified into five categories: psychosocial challenges faced by nurses, patient population, implications for diseases and coping mechanisms, burden on the health system, and the growing importance of various fields within nursing (Table 2).

TABLE 2.

Metaphor categories created by nursing students with the writing technique regarding their concerns about the reflection of the global climate crisis on nursing.

Categories	Metaphors	Frequency
A. Psychosocial challenges faced by nurses	A1. Anxiety	11
	A2. Depression	10
	A3. Fatigue	11
	A4. Panic	9
	A5. Fear	8
	A6. Burnout	6
	A7. Hopelessness	5
	A8. Aggressive behavior	5
	A9. Mood disorders	3
	A10. Reduced motivation	5
	A11. Anger due to a lack of precautions	1
B. Patient populations	B1. Increased number of patients	16
	B2. More complicated patients	13
C. Diseases and coping	C1. Patients requiring challenging treatment	12
	C2. Difficulty in coping with illnesses	11
	C3. The emergence of different diseases	10
D. Burdens on the health system	D1. Growing burden on the health system	12
	D2. Inadequate health system	10
	D3. Insufficient number of nurses	5
E. The growing importance of various fields within nursing	E1. Growing importance of disaster nursing	11
	E2. Growing importance of community mental health nursing	10
	E3. Being a planetary nurse	8
Total	22 metaphors	182

Note: The study involved 40 participants, and they expressed their worries using a writing technique (metaphors: 22, frequency: 182 times).

3.1. Psychosocial Challenges Faced by Nurses

Nursing students employed metaphors of anxiety (n = 11), depression (n = 10), and fatigue (n = 11) to articulate the psychosocial challenges faced by nurses in the context of the global climate crisis. Those who associated the crisis with anxiety expressed sentiments such as, “The global climate crisis means life is gradually coming to an end, causing anxiety” (P2) and “The uncertainty of what will happen in the future causes distress.” (P4)

For students characterizing the impact as depression, their explanations included reflections like, “It gives a feeling that there is no power to fight against it” (P17) and “It diminishes the joy of life over time…” (P29). Students attributing the crisis to fatigue explained their reasons, stating, “It eventually makes a person unable to enjoy life.” (P19)

3.2. Patient Population

In the patient population category, nursing students utilized metaphors of an increased number of patients (n = 16) and patients becoming more complex (n = 13). Those associating the crisis with an increase in patients explained, “I believe the global climate crisis means pandemic, and a pandemic means an increase in patient numbers…” (P19). Students perceiving the crisis as making patients more complex stated, “Diseases are becoming more complex, and antibiotics are no longer effective…” (P40).

3.3. Diseases and Coping

In the diseases and coping category, metaphors of patients requiring more challenging treatment (n = 12), difficulty in coping with diseases (n = 11), and the emergence of different diseases (n = 10) were utilized. Students linking the crisis to the complexity of disease treatment mentioned, “Diseases, especially viruses, are mutating, and antibiotics no longer work” (P17).

Students interpreting the impact of the global climate crisis on nursing as a challenge in coping with diseases reported their concerns, stating, “People will eventually feel helpless, and medicine won't be able to solve this” (P16). Those perceiving the crisis as the emergence of different diseases provided explanations like, “Because the climate crisis, in my opinion, brings diseases and prepares the end of people” (P37) and “Because it causes various diseases such as COVID‐19.” (P8)

3.4. Burdens on the Health System

In the burdens on the health system category, nursing students employed metaphors of the increasing burden on the health system (n = 12), the inadequate health system (n = 10), and an insufficient number of nurses (n = 5). Those associating the crisis with the burden on the health system explained, “As diseases increase, it will place a greater burden on the health system in parallel.” (P15)

Students attributing the crisis to the inadequacy of the health system stated, “Because I believe that as the end of the world approaches, viruses will increase even more, leading to major pandemics, and the health system will be inadequate, with patients lying in hospital corridors.” (P3)

Students characterizing the crisis as resulting in a shortage of nurses remarked, “Because, as the climate crisis affects the health sector, hospitals, and health professionals, especially nurses, will unfortunately be insufficient in number, and qualified care will decrease.” (P29)

3.5. The Growing Importance of Various Fields Within Nursing

Nursing students used the metaphors of the increasing importance of disaster nursing (n = 11), the increasing importance of community mental health nursing (n = 10), and being a planetary nurse (n = 8) the growing importance of various fields within nursing. The students who evaluated the reflection of the global climate crisis on nursing as disaster nursing gaining importance said, “Because it is obvious that disasters will haunt the world. As man harms nature, nature will take its revenge” (P17).

Students emphasizing the growing importance of community mental health nursing conveyed, “I believe that the mental health of people in our country and globally is declining each day. Consequently, there will be a substantial demand for community mental health nurses…” (P23).

Those advocating for a planetary nursing approach expressed, “The climate crisis isn't just our concern; it's a global issue that necessitates adopting a planetary nursing perspective.” (P27)

Utilizing a drawing technique to determine nursing students’ concerns about the impact of the global climate crisis on their profession, 22 metaphors were identified. These metaphors were categorized into four groups: nurses and the difficulties they face, the impact of the global climate crisis on the world, the impact of the global climate crisis on the healthcare sector, and the roles and responsibilities of nurses (Table 3).

TABLE 3.

Metaphor categories created by nursing students using the drawing technique regarding their concerns about the reflection of the global climate crisis on nursing mental health.

Categories	Metaphors	Frequency
A. Nurses and the difficulties they face	A1. Emotional crisis	11
	A2. Anxiety	10
	A3. Fatigue	8
	A4. Panic	9
	A5. Fear	5
	A6. Burnout	5
	A7. Hopelessness	7
	A8. Depression	2
B. The impact of the global climate crisis on the world	B1. Increasing air pollution and respiratory diseases	7
	B2. Polluted water and increasing general diseases	8
	B3. Crisis due to diseases	6
	B4. Disrupted world order due to disasters	6
	B5. Increasing epidemics	5
	B6. Human desperation	3
C. The impact of the global climate crisis on the healthcare sector	C1. Inadequate health sector	5
	C2. Burnout among health professionals	4
D. The roles and responsibilities of nurses	D1. Participating in activities to raise public awareness	9
	D2. Reducing carbon footprint	6
	D3. Creating impact and awareness in society	4
	D4. Organizing training for environmental awareness and giving certificates	3
	D5. Supporting research on climate change and the climate crisis	2
	D6. Waste management advocacy	1
Total	22 metaphors	125

Note: The drawing technique involved 40 nursing students expressing their concerns about the impact of the global climate crisis on nursing. The total number of metaphors generated was 22, with a total frequency of 125.

3.6. Nurses and the Difficulties They Face

In the category of nurses and the problems they face, nursing students predominantly employed metaphors related to emotional crisis (n = 11) and anxiety (n = 10).

For instance, P2, one of the nursing students perceiving the reflection of the global climate crisis on nursing as an emotional crisis, depicted his thoughts through the following drawing:

P5, one of the nursing students who thought that the impact of the global climate crisis on nursing was anxiety, reflected her thoughts in the drawing as follows:

3.7. The Impact of the Global Climate Crisis on the World

In the category of impact of the global climate crisis on the world, nursing students mainly used metaphors such as air pollution and an increase in respiratory system diseases (n = 7), pollution of water, and an increase in general diseases (n = 8):

The drawing of P23, one of the nursing students who thought that the reflection of the global climate crisis on nursing was the pollution of water and the increase in general diseases, is as follows:

3.8. The Impact of the Global Climate Crisis on the Healthcare Sector

Nursing students used the metaphors of inadequacy in the health sector (n = 5) and burnout in health professionals (n = 4) in the category of the impact of the global climate crisis on the health sector.

The drawing of P36, one of the nursing students who thought the impact of the global climate crisis on nursing was the inadequacy of the health sector, is as follows:

P12, one of the nursing students who considered the reflection of the global climate crisis on nursing as burnout among health professionals, reflected her thoughts in her drawing as follows:

3.9. The Roles and Responsibilities of Nurses

In the category focusing on the duties and responsibilities of nurses, nursing students mostly employed metaphors related to participating in community awareness‐raising activities (n = 9), reducing carbon footprints (n = 6), and creating impact and awareness in society (n = 4).

For example, P11, a nursing student who perceived the reflection of the global climate crisis on nursing as involving participation in community awareness‐raising activities, emphasized the potential impacts of the global climate crisis through the following drawing:

The drawing of P18, one of the nursing students who considered the reflection of the global climate crisis on nursing as reducing the carbon footprint, is as follows:

P18, one of the nursing students who considered the reflection of the global climate crisis on nursing as creating impact and awareness in society, drew as follows:

4. Discussion

The use of metaphors provides a unique perspective on intricate concepts by associating familiar ideas with other well‐known concepts (Patton 2022). Climate change, recognized as a global issue, has profound effects on our planet, posing challenges within the context of health and potentially causing social, economic, political, and health repercussions for present and future generations (Kalogirou, Olson, and Davidson ²⁰²⁰). Consequently, this study aims to explore the concerns of nursing students in Türkiye regarding the implications of the global climate crisis on nursing through the interpretation of metaphors. The metaphors used by nursing students, employing both writing and drawing techniques, will be analyzed under two distinct categories.

4.1. Metaphors Emerging From the Writing Technique

It was found that nursing students mostly produced metaphors related to the problems experienced by nurses in the reflection of the global climate crisis on nursing, patient population, diseases, and coping. In addition, it was concluded in the study that although nursing students expressed different opinions about the reflection of the global climate crisis on nursing, they experienced similar feelings.

Climate change manifests significant health impacts, including heat stroke, stress, increased allergens and asthma, increased vector‐borne diseases, elevated rates of heart and respiratory diseases, mental health issues, and a surge in infectious diseases (Martin and Vold 2019; Semansky et al. ²⁰¹³). Nurses possess the potential to implement corrective and preventive measures addressing both health concerns and the wellbeing of patients, institutions, and the environment. Positioned as trusted leaders and providers of health services within the community, nursing is a profession that advocates for change and contributes to the development of sustainable policies, fostering a sustainable society and environment (Kurth 2017). Kurth underscores the pivotal role of nurses in achieving sustainable development goals, emphasizing the intersection of environmental sustainability and human welfare in planetary health (2017). Three crucial aspects of planetary nursing are the education, compliance, and climate/carbon footprint reduction behaviors of nurses and health professionals (Sayre et al. 2010). Education, both for nursing staff and students, stands as a critical focal point, urging the integration of planetary health and nursing education into undergraduate curricula or the creation of certificate training programs (Fawcett 1984; Nicholas and Breakey ²⁰¹⁷). It should not be forgotten that nurses are the leading voice in sustainability and will be at the forefront of the global climate crisis.

Climate change's global effect, including social, economic, political, and health impacts on current and future generations, underscores the imperative for health professionals to raise their awareness and take proactive measures to reduce present and future health consequences. The nursing profession's environmental dimension, embedded in its metaparadigm, defines nurses’ responsibilities toward the environment. Thus, nurses bear professional moral obligations to advocate for policies, reduce carbon footprints, protect planetary health, raise public awareness regarding climate change, and contribute to the creation of a more sustainable environment (Kurth and Potter 2022; Tekin and Korkmaz ²⁰²²). The awareness and sense of responsibility among nursing students regarding the global climate crisis become evident in this context. In this case, it is considered a pleasing situation for our nursing students who are the health professionals of the future.

4.2. Metaphors Emerging From the Drawing Technique

The nursing students’ concern about the global climate crisis and its reflection on nursing is evident in their drawings for themselves and the societies of the world. In addition, the drawings of nursing students were interpreted as the increase in diseases and the related patient population and that the world will change and get worse as a result of the global climate crisis.

Efforts toward adaptation include forming alliances with decision‐makers, providing guidance to patients and their families, preparing health facilities, and promoting climate justice. Initiatives aimed at diminishing the carbon footprint present an opportunity for catalyzing changes in the context of climate change and planetary health—both on an individual and institutional scale, setting an example for society. At the personal level, individuals, particularly nurses, can advance planetary health by curbing their carbon footprint and exhibiting environmentally conscious behaviors. This includes opting for public transport, bicycles, or electric vehicles; using water and energy judiciously; practicing waste segregation and recycling; minimizing plastic usage; and enhancing education and awareness on these matters. Institutionally, the use of public transport, energy‐efficient measures in health institutions, adoption of green technologies, exploration of alternative energy sources, implementation of sustainable building designs, and adherence to green energy practices all contribute to planetary health (Martin and Vold 2019; Butterfield, Leffers, and Vásquez ²⁰²¹; Günal, Yücel Işıldar, and Atik ²⁰¹⁸; LeClair, Evans‐Agnew, and Cook ²⁰²²). Nursing students highlighted their pivotal roles and responsibilities, emphasizing participation in community awareness initiatives, reduction of carbon footprint, fostering societal impact and awareness, organizing environmental awareness training and certification programs, supporting research on climate change and crises, and advocating for waste management. These results are consistent with the literature and highlight the importance of these endeavors. This situation is evaluated as a pleasing situation for our country.

The climate crisis poses various detrimental consequences, like health issues, water scarcity, inefficiencies in food resources, planetary resource depletion, inequities in access to information and resources among vulnerable populations, and pollution of air and water (Ediz and Yanik 2023). As a reliable profession in society, nursing carries both professional duties and moral responsibilities to protect and enhance environmental health. Grounded in its paradigm, professional ethics, and societal closeness, nursing must draw attention to the climate crisis and prevent potential health impacts resulting from environmental damage (Tekin and Korkmaz 2022).

To fulfill these responsibilities effectively, nurses and students must acquire eco‐literacy, recognizing their pivotal role in achieving sustainable development goals, particularly within frameworks such as planetary health. Addressing the planetary health problem of climate change necessitates adopting a perspective that integrates the ecosystem. Collective efforts, goals, and values should align with this perspective, emphasizing the imperative for change and transformation. Failure to acknowledge and act upon these principles may lead to severe and destructive consequences arising from the future impacts of climate change.

5. Implications for Nursing Policy

For future nurses to be prepared to lead transformative planetary health initiatives, changes are needed in nursing education. The current nursing education is not at a sufficient level to address the health impacts of climate change in terms of climate change knowledge, appropriate education, and training. The educational curricula of nursing departments need to be reorganized to include climate change and health issues, for a higher level of involvement of societies in changing conditions, developing science, and planetary health issues. Nurses can lead sustainability efforts in the healthcare industry by identifying and promoting sustainable practices in their own practice areas and hospitals. In this sense, nurse leadership and the establishment of nurse‐led “green teams” have been suggested to reduce the significant ecological footprint of health centers. Because global climate health involves education, research, leadership, advocacy, and practice, nurses can provide a more inclusive view of planetary health by gaining a global climate health perspective. For this reason, nurses should be good ecological‐literate. Thus, nurses will be enabled to fulfill their critical roles and responsibilities, such as being able to evaluate hazards, lead the reduction of damage to the environment, cooperate to reduce risks, advocate policies for sustainability, and research.

6. Conclusion

Climate change stands as a paramount item on the agendas of countries worldwide, constituting a global health challenge. The anticipated outcomes of climate change span direct and indirect impacts on ecosystems, as well as social and economic sectors. These effects include phenomena such as glacier melting, rising sea levels, and extreme weather events. The current study examined the perspectives of nursing students concerning the intersection of the global climate crisis with their profession. Despite varying opinions, these students expressed shared concerns, often articulating their apprehensions through metaphors. The focus of these concerns revolved around challenges faced by nurses, impacts on patient populations, diseases, and coping mechanisms. The findings underscored the nursing students’ unease about the global climate crisis and its implications for both their profession and the broader global community. Notably, the study revealed concerns about potential social crises arising from increased disease prevalence and its impact on patient populations. The study advocates for proactive measures, suggesting that nursing students, as the future healthcare workforce, need to comprehend the multifaceted effects of climate change on societal wellbeing. It proposes the integration of courses on planetary health, environmental health, and climate crisis into nursing curricula, ensuring that students are equipped to assess and address these effects in patient care.

7. Limitations

The selection of participants from students enrolled in the course and the small sample size are considered limitations of the research.

Author Contributions

Çiçek Ediz: study conception, planning of analyses, data analysis, data interpretation, manuscript writing, supervision, manuscript revision, final approval for publication. Sevda Uzun: study conception, planning of analyses, data analysis, data interpretation, manuscript writing, supervision, manuscript revision, final approval for publication.

Ethics Statement

The study was approved by the Hakkari University Scientific Research and Publication Ethics Committee (dated June 14, 2023, numbered 2023/64‐01). Participants provided informed consent before participating in interviews, aligning with the principles of the Declaration of Helsinki and the ethical standards of the National Research Committee.

Conflicts of Interest

The authors declare no conflicts of interest.

Data Availability Statement

The data that support the findings of this study are available on request from the corresponding author. The data are not publicly available due to privacy or ethical restrictions.