Implementing nurse-led decarbonization practices: a transferable framework from a Spanish public hospital

Abstract

Background

Healthcare systems contribute nearly 4.4% of global greenhouse gas (GHG) emissions, making environmental sustainability a critical professional and ethical priority. Nurses, as the largest and most operationally involved workforce in healthcare, are uniquely positioned to lead behavioural and organisational change. However, the mechanisms through which nurse-led actions achieve measurable carbon reductions at hospital level remain poorly documented.

Methods

A mixed-method implementation case study was conducted at the Hospital Universitario Lucus Augusti (HULA, Spain), a 900-bed tertiary public hospital integrated within the Galician Health Service. Aggregated data from the hospital’s verified Carbon Management Plan (ISO 14001:2015) were analysed for key emission categories associated with nursing-related domains—anaesthetic gases, plastics, gloves, and paper. Implementation processes were mapped across four iterative phases (Planning, Action, Monitoring, Integration) to identify transferable steps, indicators, and nursing roles.

Results

Between 2021 and 2023, total hospital emissions decreased by 35%, including a 95% reduction in anaesthetic gases, 41% in paper, 17% in plastics, and 7% in gloves. Nursing-led initiatives such as rational glove use, digital documentation, and reusable equipment substitution accounted for most improvements. The resulting Nurse-Led Decarbonization Framework identifies five transferable components: leadership alignment, nurse engagement, feedback systems, continuous education, and performance monitoring.

Conclusions

This implementation case study describes institutional emission reductions observed during the introduction of structured organisational and clinical practice adjustments within a nurse-informed implementation framework. The proposed framework outlines phases, roles and measurable emission domains that may support transferability to comparable hospital settings. Integrating sustainability into nursing governance may strengthen organisational alignment with environmental objectives and support professional engagement in climate mitigation efforts. However, the framework should be interpreted as a suggested, conceptually derived guide rather than a validated model, and further multicentre evaluation is required.

Implications for nursing management/practice

Empowering nurses with carbon literacy, feedback mechanisms, and decision-making authority enables them to act as catalysts for hospital sustainability. The Nurse-Informed Decarbonization Framework provides a transferability-oriented framework that nursing managers may adopt to embed sustainability into clinical governance, improve resource efficiency, and align professional practice with planetary health goals.

Introduction

Healthcare faces an ethical and operational paradox: while its mission is to protect health, it substantially contributes to greenhouse gas (GHG) emissions. Recent estimates place healthcare at ~ 4.4% of global emissions—comparable to the footprint of a large country—underscoring the urgency of embedding environmental sustainability in the core of care delivery. Within this agenda, nursing—by far the largest professional workforce and the group most involved in day-to-day clinical operations—occupies a pivotal position for change [1–2].

The nursing tradition has long recognised the environment as a determinant of health, a lineage traceable to Nightingale’s foundational view of hygiene and surroundings. In the twenty-first century, this perspective extends to planetary health, circular resource management and sustainable clinical practice. International bodies, including the International Council of Nurses (ICN) and the World Health Organization (WHO), now explicitly frame environmental stewardship as a professional responsibility for nurses; however, translation of these principles into measurable, hospital-level outcomes remains uneven [3–5].

Empirical evidence identifies energy use, procurement, waste streams, consumables (e.g., gloves, single-use plastics, paper), and transportation—including supply chains and staff mobility—as major drivers of the healthcare carbon footprint [1, 2, 6, 7, 13]. These domains are closely interwoven with routine clinical and nursing practice, particularly in relation to consumable management, documentation processes and infection-control procedures. Studies in clinical nursing further link waste reduction and responsible resource use to ethical accountability, professional agency, and leadership-driven ecological awareness in education and practice [3, 8, 9].

Yet, despite growing advocacy and the emergence of sustainability initiatives, there remains a scarcity of peer-reviewed studies that explicitly connect quantitative decarbonization data with clearly operationalised nursing-related implementation processes within hospitals. Although sustainability initiatives are increasingly visible across healthcare systems, including nurse-driven programmes in several European countries, peer-reviewed evidence explicitly linking quantitative decarbonization outcomes with clearly operationalised nursing-related implementation processes at hospital level remains limited. Published accounts frequently emphasise engineering, procurement, or managerial dimensions, with comparatively less detail on measurable nursing roles and behavioural indicators within institutional carbon strategies [6–10].

The experience of a Spanish public tertiary hospital (Hospital Universitario Lucus Augusti, HULA) offers an opportunity to examine how institutional decarbonization processes can be operationalised at hospital level. Between 2021 and 2023, HULA reported a 35% reduction in total institutional GHG emissions across Scopes 1, 2 and selected Scope 3 categories, according to its verified ISO 14001:2015 Carbon Management Plan (Hospital Universitario Lucus Augusti, internal institutional environmental report, 2023; data available upon reasonable request). Scope 1 reductions were primarily associated with optimisation of anaesthetic gases (− 95%), while reductions in selected Scope 3 categories were observed in waste-related and consumable domains, including plastics (− 17%).

National healthcare decarbonization strategies in the United Kingdom, France and Australia have reported progressive reductions in healthcare-related emissions following structured policy and system-level interventions [11–13]. Direct comparison across jurisdictions is methodologically inappropriate due to differences in reporting standards, system boundaries and emission scopes; however, these international trajectories provide contextual background for institutional-level mitigation efforts.

Accordingly, this article advances from descriptive reporting to an implementation-oriented perspective by (a) articulating a transferable, nurse-informed decarbonization framework mapped onto routine clinical processes; (b) specifying implementation phases (planning, action, monitoring and integration) with indicators directly linked to nursing-related emission domains (gloves, plastics, paper and anaesthetic-related practices); and (c) situating these elements within the broader international sustainability context. The approach follows established guidance for observational and implementation reporting, including the STROBE statement and the Standards for Reporting Implementation Studies (StaRI) [14, 15], and uses aggregated institutional data verified within an ISO 14001:2015 certified environmental management system [16].

By reframing hospital decarbonization through the lens of nursing implementation, we address three persistent gaps identified in the literature. First, operationalisation—how nurses can enact sustainability responsibly without compromising patient safety—has been highlighted as a key challenge in translating environmental principles into routine clinical practice [3, 8, 9]. Second, measurement—which indicators matter at ward and hospital level, and how they can support feedback-driven behaviour change—remains underdeveloped despite growing evidence on healthcare carbon footprints and waste streams [1, 6, 7]. Third, transferability—the organisational conditions required to sustain environmentally responsible practice, including leadership alignment, carbon literacy and feedback systems—has been recognised as essential for embedding sustainability within nursing governance and culture [4, 5, 9, 13].

Our central claim, consistent with emerging scholarship on sustainable nursing practice and planetary health ethics [3, 4, 19], is that every nursing action carries an environmental consequence, and that structuring those actions within a pragmatic, implementation-oriented framework may enable hospitals to pursue measurable, scalable and ethically grounded climate mitigation.

Study aim. To develop and describe a nurse-informed implementation framework for hospital decarbonization based on the HULA case, specifying phases, roles and indicators that may support transferability to similar settings, and to outline priorities for multicentre validation.

Methods

Design

This study adopted an implementation case study design grounded in principles of observational and implementation science. Quantitative and qualitative data were integrated to identify transferable steps and indicators of nurse-informed decarbonization in hospital settings. Reporting followed the STROBE statement for observational studies and the Standards for Reporting Implementation Studies (StaRI) to ensure transparency in context, process and outcomes [14, 15]. Aggregated institutional data were verified within an ISO 14001:2015 certified environmental management system [16].

The design was selected to translate a local decarbonization initiative into a framework reproducible across institutions, focusing on how nursing actions and leadership structures contribute to measurable reductions in greenhouse gas (GHG) emissions.

The hospital’s ISO 14,001 Environmental Management Plan included progressive emission reduction targets aligned with regional sustainability objectives, with annual monitoring and internal audit cycles. Specific numeric reduction targets are institutionally defined and monitored internally.

Setting

The study was conducted at the Hospital Universitario Lucus Augusti (HULA), a 900-bed tertiary public hospital in northwest Spain serving approximately 330 000 inhabitants. The institution employs over 3 000 professionals, including 1 500 nurses, and operates under the Galician Health Service (SERGAS).

Between 2021 and 2023, HULA implemented a comprehensive Decarbonization Strategy integrated into its ISO 14001:2015 Environmental Management System. The strategy was aligned with the European project Low-Carbon Healthcare in the Mediterranean Region [17].

Data sources

Institutional data were derived from the hospital’s verified Carbon Management Plan (CMP), encompassing:

• Anaesthetic gases (desflurane, sevoflurane, N₂O).

• Plastic waste (clinical and non-clinical).

• Glove consumption.

• Paper usage (administrative and clinical).

• Total GHG emissions (tCO₂e).

All figures were aggregated, anonymised, and expressed as relative reductions over the 2021–2023 period.

International healthcare decarbonization strategies were reviewed descriptively to provide contextual background on system-level mitigation efforts. No quantitative cross-jurisdiction comparison was undertaken due to differences in reporting standards, emission boundaries and scope definitions.

Emission calculation and data derivation

Total greenhouse gas (GHG) emissions were derived from the hospital’s annual Carbon Management Plan developed under its ISO 14001:2015 certified Environmental Management System. Emissions were calculated in tonnes of carbon dioxide equivalent (tCO₂e) following standard greenhouse gas accounting practices aligned with the GHG Protocol framework.

Scope 1 emissions included direct on-site sources such as anaesthetic gases and fuel combustion. Scope 2 emissions reflected purchased electricity. Selected Scope 3 categories included waste management and selected consumables (e.g., plastics and gloves), as defined within the institutional environmental audit boundaries.

Activity data (e.g., volume of anaesthetic gases used, waste weight, consumable procurement records, paper consumption) were extracted from institutional administrative and environmental monitoring systems. Emission factors applied in the Carbon Management Plan were based on nationally recognised conversion factors used within the Spanish public health system.

All values reported represent aggregated institutional-level data. No patient-level or individual-level data were included. Annual emissions were compared between 2021 and 2023 to estimate relative percentage change.

Emission reductions in consumable categories were calculated using activity-based data (e.g., units purchased or waste weight) multiplied by standard emission factors applied within the institutional Carbon Management Plan.

Implementation and process measures

To operationalise “nurse-led behavioural and organisational change”, we extracted implementation indicators from institutional documentation and routine quality records: (i) number of nursing training sessions on sustainable practice and estimated attendance; (ii) number of nursing units receiving monthly sustainability dashboards and feedback reports; (iii) frequency of infection-control audits related to glove use and waste segregation; (iv) adoption milestones of digital nursing documentation (e.g., rollout dates and proportion of units using paperless records); and (v) number and role profile of designated nurse champions participating in the multidisciplinary Green Team. These indicators were used to describe implementation intensity and fidelity at unit level, not to measure individual behaviour change.

Implementation framework

To enable replication, the implementation process was mapped into four iterative phases reflecting the Plan–Do–Study–Act cycle commonly used in nursing quality improvement [7]:

1. Planning: Baseline emission audit; establishment of a cross-disciplinary “Green Team”; alignment of hospital leadership with sustainability goals.

2. Action: Introduction of low-flow anaesthesia, rational glove use, paperless documentation, and substitution of single-use plastics.

3. Monitoring: Regular feedback to nursing units through sustainability dashboards and monthly reports.

4. Integration: Inclusion of sustainability indicators in departmental objectives, continuous training, and recognition of nurse champions.

Each phase was analysed in terms of nursing roles, indicators, and replicability potential.

Table 1 summarises the resulting Transferable Implementation Framework for Nurse-Led Decarbonization, providing a structured guide for institutions seeking to reproduce the process.

Table 1.

Transferable implementation framework for nurse-led D ecarbonization

Phase	Core actions	Nursing roles	Indicators / metrics	Replicability guidance
1. Planning	Baseline audit; establish sustainability goals; create Green Team	Nurse managers, infection-control nurses	Existence of baseline GHG inventory; leadership endorsement	Ensure administrative alignment; identify nurse champions early
2. Action	Implement low-flow anaesthesia; reduce single-use plastics; digital documentation; rational glove use	Perioperative nurses, ward nurses, digital champions	Reduction (%) in anaesthetic gases, plastics, gloves, paper	Start with feasible clinical practice adjustments within existing organisational structures; integrate infection-control oversight.
3. Monitoring	Track and communicate progress; display unit dashboards	Quality and safety nurses, data officers	Frequency of feedback reports; staff engagement rate (%)	Visual feedback reinforces behavioural change; maintain monthly updates
4. Integration	Embed sustainability in training, audits, and annual goals	Nurse educators, department heads	Sustainability training hours; sustainability indicators in evaluation forms	Incorporate metrics into existing quality frameworks to ensure continuity

Note. Framework structured according to the Plan–Do–Study–Act (PDSA) cycle, linking each phase with corresponding nursing roles, measurable indicators, and guidance for replication across hospitals

Data synthesis

Quantitative data were summarised as absolute values and percentage changes between 2021 and 2023. No formal statistical testing was undertaken, as the study reports aggregated institutional-level trends.

Qualitative synthesis integrated institutional documentation, training records, audit reports and organisational communications to describe implementation activities occurring during the study period. Patterns of nursing participation were identified through triangulation of these documentary sources. Individual-level behavioural change was not directly measured.

Methodological oversight

The study design, operationalisation of implementation indicators and reporting strategy were reviewed by an independent methodologist with expertise in implementation/observational research to strengthen transparency, internal coherence and reporting quality.

Ethical considerations

No human or patient data were collected. All information was derived from aggregated, publicly reportable institutional metrics within the hospital’s certified environmental management system. In accordance with JAN’s ethical guidance for secondary-data studies, formal ethics committee approval was not required [8].

Results

Implementation indicators

During the implementation period, nursing participation was documented through routine organisational metrics, including training delivery, dashboard dissemination, audit feedback cycles and the appointment of nurse champions. These indicators describe implementation activity occurring alongside emission trends and provide contextual information on organisational engagement. Individual-level behavioural change was not directly measured. During the study period, sustainability training sessions were delivered across clinical units, monthly dashboards were disseminated to all departments, and nurse champions were formally designated within the Green Team structure.

Overall emission reductions

Between 2021 and 2023, total institutional greenhouse gas (GHG) emissions decreased from 7,262.9 tCO₂e to 4,687.1 tCO₂e (− 35%). Total emissions comprised Scope 1 (direct on-site emissions including anaesthetic gases and fuel use), Scope 2 (purchased electricity), and selected Scope 3 categories (waste management and defined consumables) as specified in the institutional ISO 14,001 Carbon Management Plan. Scope 1 emissions decreased by 52% over the study period. Anaesthetic gases represented the largest direct emission source within Scope 1 at baseline; therefore, the 95% reduction in anaesthetic-related emissions translated into a substantial overall reduction in total Scope 1 emissions. Other direct emission sources (e.g., fuel combustion) remained comparatively stable according to institutional records.

Emission categories associated with nursing practice

Reductions in categories directly related to nursing activities are presented in Table 2.

Table 2.

Emission reductions by category (2021–2023)

Category	Baseline (2021)	2023	% Change	Associated nursing-related processes
Anaesthetic gases	1 842 kg CO₂e	92 kg CO₂e	−95%	Implementation of low-flow protocols supported by perioperative nursing teams
Plastic waste	63.4 t	52.6 t	−17%	Introduction of reusable alternatives and segregation training involving nursing staff
Glove use	9.3 million units	8.6 million units	−7%	Infection-control audits and educational sessions on appropriate glove use
Paper consumption	12.4 t	7.3 t	−41%	Implementation of digital records and paperless nursing documentation
Total GHG emissions	7 262.9 tCO₂e	4 687.1 tCO₂e	−35%	Institutional sustainability initiatives implemented during the study period, including nursing managerial participation

Note. Data derived from the hospital’s verified Carbon Management Plan (ISO 14001:2015). Percentages represent relative reduction over the two-year period. Nursing-related processes are presented as implementation components occurring during the study period; no causal attribution between specific nursing actions and emission reductions was quantitatively tested

The most significant improvement was observed in anaesthetic gases (− 95%), followed by paper consumption (− 41%), plastic waste (− 17%), and glove use (− 7%).

Although glove reduction was numerically smaller, it occurred alongside infection-control audits and educational initiatives promoting rational use.

To illustrate how emission reductions aligned with nursing-related activities, Table 2 summarises the quantitative outcomes across key categories of the hospital’s carbon management plan. The table highlights the magnitude of change and the nursing-related implementation processes occurring during the study period in these domains.

Glove use

Baseline glove consumption was derived from central procurement records (9.3 million units in 2021). Reduction strategies included reinforcement of appropriate glove indications in line with infection-prevention guidelines, audit-and-feedback cycles conducted by infection-control teams, and educational sessions addressing overuse in non-indicated clinical situations. Glove consumption was monitored through institutional procurement data and expressed as total annual units purchased. No changes were made to manufacturer recommendations regarding single-use indications.

Plastic waste

Plastic reduction focused primarily on non-critical single-use items (e.g., packaging materials, selected disposable accessories) identified through waste audits. Where feasible, reusable alternatives were introduced following procurement review and infection-prevention approval. No deviation from manufacturer recommendations for single-use medical devices was implemented. Product selection was conducted collaboratively between procurement, infection-control and sustainability teams to ensure regulatory compliance.

Paper consumption

Baseline paper use (12.4 t in 2021) reflected administrative and clinical documentation processes. Reduction strategies included progressive implementation of electronic nursing documentation systems, digital reporting tools and internal communication platforms. Paper consumption was measured through central purchasing records.

Safety considerations

Institutional infection-prevention surveillance data did not indicate an increase in reported infection-related incidents during the study period. However, the study was not designed to formally evaluate clinical safety outcomes, and no statistical analysis of infection rates was conducted.

Qualitative findings: nursing engagement and behavioural change

Analysis of implementation documents and staff reports indicated sustained nursing involvement throughout all four implementation phases, consistent with previous research highlighting the central role of nurses in operational sustainability initiatives [8, 9].

• Planning: Nurse managers led the baseline audit and defined sustainability indicators, reflecting evidence that leadership engagement is a key determinant of environmentally responsible practice in clinical settings [9, 18].

• Action: Ward nurses applied glove-use rationalisation, promoted reusable materials, and supported digital workflows, aligning with studies identifying consumable management and documentation practices as major leverage points for reducing healthcare carbon footprints [1, 6, 7].

• Monitoring: Monthly feedback dashboards increased visibility and engagement, consistent with implementation research demonstrating that audit-and-feedback mechanisms enhance adherence to sustainable behaviours [7, 9].

• Integration: Sustainability was incorporated into training sessions, departmental goals, and quality-assurance meetings, echoing calls to embed environmental stewardship within institutional governance and professional education [3, 10, 19].

Across departments, nurses reported stronger awareness of the environmental consequences of routine care and increased motivation when progress data were publicly shared, a finding aligned with literature linking carbon literacy and ethical awareness to pro-environmental decision-making among nurses [8, 17, 20].

Although technological adjustments (e.g., gas-capture systems) contributed to emission reductions, behavioural and organisational implementation components were introduced concurrently during the study period. Prior analyses of healthcare decarbonization strategies highlight the potential relevance of such mechanisms in supporting sustainable emission reductions [6, 13].

Conceptual synthesis

The Nurse-Led Decarbonization Logic Model was developed by the authors through thematic synthesis of implementation phases and emission trends observed in this case study. The model is conceptual in nature, derived from the HULA experience, and has not undergone external validation.

The model integrates three interdependent levels of action—individual, organisational, and system—drawing on multilevel approaches described in sustainability and green leadership literature [9, 13, 18, 21].

At the individual level, nurses may translate sustainability principles into daily care through practices such as rational glove use, digital documentation, waste segregation, and collaboration in low-flow anaesthesia—domains identified as high-impact areas within healthcare carbon footprint analyses [1, 6, 7].

At the organisational level, these practices can be supported through leadership commitment, interprofessional Green Teams, and sustainability dashboards that embed ecological accountability within quality and safety systems, consistent with green leadership and organisational culture frameworks in nursing management [9, 18].

At the system level, structured sustainability initiatives may align institutional practice with broader planetary health objectives, as advocated by international bodies including WHO and the ICN [4, 5].

By linking awareness, professional practice, and governance structures, the model conceptualises nurse-informed decarbonization as a continuous quality-improvement process grounded in ethical responsibility, education, and institutional leadership [3, 4, 19].

Figure 1 presents a conceptual logic model developed to synthesise the multilevel dynamics observed in this case study. Derived from the HULA implementation experience, the model illustrates how individual clinical behaviours, organisational leadership mechanisms and system-level alignment interact within a continuous quality-improvement cycle to support measurable decarbonization. Although grounded in observed institutional processes, the figure represents a theory-informed implementation framework rather than a validated predictive model.

Fig. 1.

Nurse-led decarbonization logic model. Note. This figure is a conceptual logic model illustrating hypothesised pathways linking nursing practices, organisational enablers and measurable environmental outcomes. It complements (but is distinct from) the phase-based implementation framework in Table 1

Discussion

Main findings and interpretation

This study describes institutional emission reductions observed during a period in which structured organisational and clinical practice adjustments were introduced within a nurse-informed implementation framework. The 35% overall reduction in greenhouse gas (GHG) emissions recorded at the Hospital Universitario Lucus Augusti (HULA) occurred alongside sustainability initiatives targeting anaesthetic gases, consumables and documentation processes, domains previously identified as relevant contributors to healthcare carbon footprints [1, 6, 7].

While technological interventions such as anaesthetic gas optimisation contributed to Scope 1 reductions, multiple implementation components—including clinical practice adjustments and organisational engagement mechanisms—were introduced during the same period. Prior analyses of healthcare decarbonization strategies suggest that multicomponent interventions combining technical and organisational elements are commonly associated with emission mitigation efforts [6, 13]. However, the relative contribution of individual behavioural change to emission reductions was not directly quantified in this study.

These observations are consistent with literature describing nurses as occupying a critical interface between clinical decision-making and operational systems within hospitals [3, 9]. Given that nurses are closely involved in direct care delivery and resource-intensive processes, sustainability initiatives frequently engage nursing roles in implementation activities and organisational change processes [8, 9, 18].

The proposed Nurse-Informed Decarbonization Framework offers a structured conceptual representation of implementation components observed in this case study. Conceptual models linking clinical practice, organisational governance and sustainability outcomes have been advocated in green leadership and planetary health scholarship [9, 18, 19]. Rather than claiming validated replicability, the framework should therefore be interpreted as a transferability-oriented guide that may inform future multicentre implementation and evaluation research [13, 19].

Comparison with previous literature

The findings of this study are consistent with international analyses highlighting the substantial contribution of healthcare systems to global greenhouse gas emissions and the need for structured decarbonization strategies [1, 2]. National-level initiatives such as the NHS Net Zero plan in the United Kingdom [11], the French decarbonization analyses led by The Shift Project [12], and global roadmaps developed by Health Care Without Harm [13] illustrate increasing policy commitment to healthcare climate mitigation.

At the professional level, previous research emphasises the role of nursing leadership and organisational culture in advancing sustainable healthcare practices [8, 9, 20]. Studies have shown that when nurses are engaged in sustainability governance structures and supported by leadership frameworks, environmentally responsible practices may be strengthened within clinical settings [8, 9, 20]. These findings align with the implementation activities documented in the present case study.

Furthermore, systematic reviews of healthcare carbon footprints have underscored the relevance of waste management, consumable use and clinical processes as key emission domains [6, 7]. By explicitly linking institutional emission data with nursing-related implementation processes, the present study contributes to bridging the gap between environmental accounting and clinical governance.

Hospitals operating within structured environmental management systems, such as ISO 14,001-certified frameworks, may provide organisational conditions that facilitate sustained engagement with sustainability initiatives [16, 18]. In this context, the proposed Nurse-Informed Decarbonization Framework offers a conceptual implementation structure derived from a single-site experience, intended to inform—but not replace—future multicentre validation efforts.

While several countries have established structured healthcare sustainability strategies [11–13], detailed hospital-level implementation reporting within Spain remains less extensively documented in the peer-reviewed literature. The present case therefore contributes institutional-level implementation detail within a broader international policy landscape.

Ethical and educational implications

The integration of sustainability into nursing practice is not merely technical but also ethical. Environmental stewardship extends the nursing duty of care beyond individual patients to encompass planetary health and intergenerational justice [8, 9, 22]. Recent evidence links ethical awareness with sustainable decision-making among nurses, reinforcing the moral dimension of environmental stewardship [17]. Incorporating sustainability principles into clinical governance and ethics codes—such as the International Council of Nurses (ICN) Code of Ethics—reinforces the moral foundation for environmentally responsible practice [18].

Education plays a pivotal role in enabling this transformation. The findings suggest that when nurses are trained in carbon literacy and provided with feedback on environmental outcomes, their motivation and professional pride increase significantly. Embedding these competencies into undergraduate curricula and continuing education programmes could ensure that sustainability becomes an intrinsic dimension of clinical competence [19–20, 22].

Organisational and policy relevance

At the organisational level, the results highlight the importance of visible leadership and institutional alignment [9, 20]. When sustainability goals are integrated into audits, procurement processes and quality indicators, they can become embedded within organisational governance structures rather than remaining isolated projects [16, 18]. Nurse managers and educators are particularly well positioned to act as change agents, bridging clinical practice with environmental strategy [9].

At the policy level, the nursing profession may advocate for the inclusion of sustainability metrics in accreditation systems, performance evaluation and national nursing standards. Aligning professional regulation with planetary health goals is consistent with international policy frameworks articulated by the World Health Organization and professional nursing bodies [4, 5].

Limitations and future directions

This study is based on institutional data and does not include patient-level or individual staff variables. Therefore, causal inference regarding behavioural determinants cannot be fully established. Cross-country comparisons were constrained by differences in data reporting standards and scope of emissions.

Future research should adopt mixed-method and multicentre designs to quantify behavioural drivers of sustainability and to validate the Nurse-Led Decarbonization Framework across diverse healthcare systems. Additionally, linking environmental indicators with patient-safety and quality metrics would provide a more comprehensive understanding of how ecological and clinical outcomes intersect.

The framework is derived from a single-site implementation case study and therefore should be interpreted as a proposed, transferability-oriented guide rather than a validated replicable model. Multicentre testing is required to assess generalisability, feasibility and effectiveness across hospitals with different organisational and regulatory contexts.

Conclusions

This implementation case study describes the development of a nurse-informed decarbonization framework derived from institutional experience within a Spanish public hospital. The proposed framework outlines implementation phases, organisational roles and measurable emission domains that may support transferability to comparable settings.

The study documents institutional emission trends observed during a period in which structured sustainability initiatives—including clinical practice adjustments and organisational engagement mechanisms—were introduced. However, individual-level behavioural change was not directly measured, and the relative contribution of specific implementation components to emission reductions cannot be quantitatively isolated.

The framework should therefore be interpreted as a suggested, conceptually derived implementation guide rather than a validated or externally generalisable model. Future multicentre research is required to test feasibility, effectiveness and contextual adaptability across healthcare systems.

Relevance to clinical practice

This study reinforces that sustainability is increasingly recognised as an inherent dimension of safe and ethical nursing care [3, 4, 19]. By visualising how daily clinical decisions affect a hospital’s carbon footprint, the proposed Nurse-Informed Decarbonization Framework supports the translation of environmental responsibility into structured clinical practice, consistent with evidence linking resource management and consumable use to measurable healthcare emissions [1, 6, 7].

Applying this model in clinical settings may encourage reflective practice, strengthen carbon literacy, and support leadership structures that embed sustainability within governance and quality systems [8, 9, 18]. Empowering nurses to act as environmental stewards aligns with international calls from professional and global health bodies to integrate planetary health into nursing roles and competencies [4, 5], and may contribute to improved organisational efficiency and environmentally responsible care delivery within structured sustainability frameworks [9, 13].

Author contributions

Juan Francisco Insua Esmorís-Recamán: Conceptualization, Data curation, Formal analysis, Writing – original draft.María José Ferreira-Díaz: Supervision, Methodology, Writing – review & editing, Visualization, Project administration.

Funding

No external funding was received for this study.

Data availability

All aggregated data supporting the findings of this study are derived from the Hospital Universitario Lucus Augusti’s verified Carbon Management Plan (ISO 14001:2015). These institutional datasets are not publicly available due to confidentiality agreements but may be provided by the corresponding author upon reasonable request.

Declarations

Ethics approval and consent to participate

This study was conducted in accordance with the ethical principles of the Declaration of Helsinki (2013 revision). As it was implemented within an academic framework and involved no clinical intervention or collection of sensitive personal data, formal approval from an external ethics committee was not required under institutional regulations. Written authorization was obtained from the hospital administration prior to data collection.

Consent for publication

Not applicable. This manuscript does not contain any identifiable personal data from individuals.

Competing interests

The authors declare no competing interests.