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Evidence-Based Practice and Nursing Research

Evidence-based practice is now widely recognized as the key to improving healthcare quality and patient outcomes. Although the purposes of nursing research (conducting research to generate new knowledge) and evidence-based nursing practice (utilizing best evidence as basis of nursing practice) seem quite different, an increasing number of research studies have been conducted with the goal of translating evidence effectively into practice. Clearly, evidence from research (effective innovation) must be accompanied by effective implementation, and an enabling context to achieve significant outcomes.

As mentioned by Professor Rita Pickler, “nursing science needs to encompass all manner of research, from discovery to translation, from bench to bedside, from mechanistic to holistic” ( Pickler, 2018 ). I feel that The Journal of Nursing Research must provide an open forum for all kind of research in order to help bridge the gap between research-generated evidence and clinical nursing practice and education.

In this issue, an article by professor Ying-Ju Chang and colleagues at National Cheng Kung University presents an evidence-based practice curriculum for undergraduate nursing students developed using an action research-based model. This “evidence-based practice curriculum” spans all four academic years, integrates coursework and practicums, and sets different learning objectives for students at different grade levels. Also in this issue, Yang et al. apply a revised standard care procedure to increase the ability of critical care nurses to verify the placement of nasogastric tubes. After appraising the evidence, the authors conclude that the aspirate pH test is the most reliable and economical method for verifying nasogastric tube placement at the bedside. They subsequently develop a revised standard care procedure and a checklist for auditing the procedure, conduct education for nurses, and examine the effectiveness of the revised procedure.

I hope that these two studies help us all better appreciate that, in addition to innovation and new breakthrough discoveries, curriculum development and evidence-based quality improvement projects, though may not seem so novel, are also important areas of nursing research. Translating evidence into practice is sound science and merits more research.

Cite this article as: Chien, L. Y. (2019). Evidence-based practice and nursing research. The Journal of Nursing Research, 27 (4), e29. https://doi.org/10.1097/jnr.0000000000000346

• Pickler R. H. (2018). Honoring the past, pursuing the future . Nursing Research , 67 ( 1 ), 1–2. 10.1097/NNR.0000000000000255 [ PubMed ] [ CrossRef ] [ Google Scholar ]

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Nursing, research, and the evidence

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• Anne Mulhall , MSc, PhD
• Independent Training and Research Consultant West Cottage, Hook Hill Lane Woking, Surrey GU22 0PT, UK

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Why has research-based practice become so important and why is everyone talking about evidence-based health care? But most importantly, how is nursing best placed to maximise the benefits which evidence-based care can bring?

Part of the difficulty is that although nurses perceive research positively, 2 they either cannot access the information, or cannot judge the value of the studies which they find. 3 This journal has evolved as a direct response to the dilemma of practitioners who want to use research, but are thwarted by overwhelming clinical demands, an ever burgeoning research literature, and for many, a lack of skills in critical appraisal. Evidence-Based Nursing should therefore be exceptionally useful, and its target audience of practitioners is a refreshing move in the right direction. The worlds of researchers and practitioners have been separated by seemingly impenetrable barriers for too long. 4

Tiptoeing in the wake of the movement for evidence-based medicine, however, we must ensure that evidence-based nursing attends to what is important for nursing. Part of the difficulty that practitioners face relates to the ambiguity which research, and particularly “scientific” research, has within nursing. Ambiguous, because we need to be clear as to what nursing is, and what nurses do before we can identify the types of evidence needed to improve the effectiveness of patient care. Then we can explore the type of questions which practitioners need answers to and what sort of research might best provide those answers.

What is nursing about?

Increasingly, medicine and nursing are beginning to overlap. There is much talk of interprofessional training and multidisciplinary working, and nurses have been encouraged to adopt as their own some tasks traditionally undertaken by doctors. However, in their operation, practice, and culture, nursing and medicine remain quite different. The oft quoted suggestion is that doctors “cure” or “treat” and that nurses “care”, but this is not upheld by research. In a study of professional boundaries, the management of complex wounds was perceived by nurses as firmly within their domain. 5 Nurses justified their claim to “control” wound treatment by reference to scientific knowledge and practical experience, just as medicine justifies its claim in other areas of treatment. One of the most obvious distinctions between the professions in this study was the contrast between the continual presence of the nurse as opposed to the periodic appearance of the doctor. Lawler raises the same point, and suggests that nurses and patients are “captives” together. 6 Questioning the relevance of scientific knowledge, she argues that nurses and patients are “focused on more immediate concerns and on ways in which experiences can be endured and transcended”. This highlights the particular contribution of nursing, for it is not merely concerned with the body, but is also in an “intimate” and ongoing relationship with the person within the body. Thus nursing becomes concerned with “untidy” things such as emotions and feelings, which traditional natural and social sciences have difficulty accommodating. “It is about the interface between the biological and the social, as people reconcile the lived body with the object body in the experience of illness.” 7

What sort of evidence does nursing need?

These arguments suggest that nursing, through its particular relationship with patients and their sick or well bodies, will rely on many different ways of knowing and many different kinds of knowledge. Lawler's work on how the body is managed by nurses illustrates this. 6 She explains how an understanding of the physiological body is essential, but that this must be complemented by evidence from the social sciences because “we also practice with living, breathing, speaking humans.” Moreover, this must be grounded in experiential knowledge gained from being a nurse, and doing nursing. Knowledge, or evidence, for practice thus comes to us from a variety of disciplines, from particular paradigms or ways of “looking at” the world, and from our own professional and non-professional life experiences.

Picking the research design to fit the question

Scientists believe that the social world, just like the physical world, is orderly and rational, and thus it is possible to determine universal laws which can predict outcome. They propose the idea of an objective reality independent of the researcher, which can be measured quantitatively, and they are concerned with minimising bias. The other major paradigm is interpretism/naturalism which takes another approach, suggesting that a measurable and objective reality separate from the researcher does not exist; the researcher cannot therefore be separated from the “researched”. Thus who we are, what we are, and where we are will affect the sorts of questions we pose, and the way we collect and interpret data. Furthermore, in this paradigm, social life is not thought to be orderly and rational, knowledge of the world is relative and will change with time and place. Interpretism/naturalism is concerned with understanding situations and with studying things as they are. Research approaches in this paradigm try to capture the whole picture, rather than a small part of it.

This way of approaching research is very useful, especially to a discipline concerned with trying to understand the predicaments of patients and their relatives, who find themselves ill, recovering, or facing a lifetime of chronic illness or death. Questions which arise in these areas are less concerned with causation, treatment effectiveness, and economics and more with the meaning which situations have—why has this happened to me? What is my life going to be like from now on? The focus of these questions is on the process, not the outcome. Data about such issues are best obtained by interviews or participant observation. These are aspects of nursing which are less easily measured and quantified. Moreover, some aspects of nursing cannot even be formalised within the written word because they are perceived, or experienced, in an embodied way. For example, how do you record aspects of care such as trust, empathy, or “being there”? Can such aspects be captured within the confines of research as we know it?

Questions of causation, prognosis, and effectiveness are best answered using scientific methods. For example, rates of infection and thrombophlebitis are issues which concern nurses looking after intravenous cannulas. Therefore, nurses might want access to a randomised controlled trial of various ways in which cannula sites are cleansed and dressed to determine if this affects infection rates. Similarly, some very clear economic and organisational questions might be posed by nurses working in day surgery units. Is day surgery cost effective? What are the rates of early readmission to hospital? Other questions could include: what was it like for patients who had day surgery? Did nurses find this was a satisfying way to work? These would be better answered using interpretist approaches which focus on the meaning that different situations have for people. Nurses working with patients with senile dementia might also use this approach for questions such as how to keep these patients safe and yet ensure their right to freedom, or what it is like to live with a relative with senile dementia. Thus different questions require different research designs. No single design has precedence over another, rather the design chosen must fit the particular research question.

Research designs useful to nursing

Nursing presents a vast range of questions which straddle both the major paradigms, and it has therefore embraced an eclectic range of research designs and begun to explore the value of critical approaches and feminist methods in its research. 8 The current nursing literature contains a wide spectrum of research designs exemplified in this issue, ranging from randomised controlled trials, 9 and cohort studies, 10 at the scientific end of the spectrum, through to grounded theory, 11 ethnography, 12 and phenomenology at the interpretist/naturalistic end. 13 Future issues of this journal will explore these designs in depth.

Maximising the potential of evidence-based nursing

Evidence-based care concerns the incorporation of evidence from research, clinical expertise, and patient preferences into decisions about the health care of individual patients. 14 Most professionals seek to ensure that their care is effective, compassionate, and meets the needs of their patients. Therefore sound research evidence which tells us what does and does not work, and with whom and where it works best, is good news. Maximum use must be made of scientific and economic evidence, and the products of initiatives such as the Cochrane Collaboration. However, nurses and consumers of health care clearly need other evidence, arising from questions which cannot be framed in scientific or economic terms. Nursing could spark some insightful debate concerning the nature and contribution of other types of knowledge, such as clinical intuition, which are so important to practitioners. 15

In summary, in embracing evidence-based nursing we must heed these considerations:

Nursing must discard its suspicion of scientific, quantitative evidence, gather the skills to critique it, and design imaginative trials which will assist in improving many aspects of nursing

We must promulgate naturalistic/interpretist studies by indicating their usefulness and confirming/explaining their rigour in investigating the social world of health care

More research is needed into the reality and consequences of adopting evidence-based practice. Can practitioners act on the evidence, or are they being made responsible for activities beyond their control?

It must be emphasised that those concerns which are easily measured or articulated are not the only ones of importance in health care. Space is needed to recognise and explore the knowledge which comes from doing nursing and reflecting on it, to find new channels for speaking of concepts which are not easily accommodated within the discourse of social or natural science—hope, despair, misery, love.

• ↵ Bostrum J, Suter WN. Research utilisation: making the link with practice. J Nurs Staff Dev 1993 ; 9 : 28 –34. OpenUrl PubMed
• ↵ Lacey A. Facilitating research based practice by educational intervention. Nurs Educ Today 1996 ; 16 : 296 –301.
• ↵ Pearcey PA. Achieving research based nursing practice. J Adv Nurs 1995 ; 22 : 33 –9. OpenUrl CrossRef PubMed Web of Science
• ↵ Mulhall A. Nursing research: our world not theirs? J Adv Nurs 1997 ; 25 : 969 –76. OpenUrl CrossRef PubMed Web of Science
• ↵ Walby S, Greenwell J, Mackay L, et al. Medicine and nursing: professions in a changing health service . London: Sage, 1994.
• ↵ Lawler J. The body in nursing . Edinburgh: Churchill Livingstone, 1997.
• ↵ Lawler J. Behind the screens nursing . Edinburgh: Churchill Livingstone, 1991.
• ↵ Street AF. Inside nursing: a critical ethnography of clinical nursing practice . New York: State University Press of New York, 1992.
• ↵ Madge P, McColl J, Paton J. Impact of a nurse-led home management training programme in children admitted to hospital with acute asthma: a randomised controlled study. Thorax 1997 ; 52 : 223 –8. OpenUrl Abstract
• ↵ Kushi LH, Fee RM, Folsom AR, et al . Physical activity and mortality in postmenopausal women. JAMA 1997 ; 277 : 1287 –92. OpenUrl CrossRef PubMed Web of Science
• ↵ Rogan F, Shmied V, Barclay L, et al . Becoming a mother: developing a new theory of early motherhood. J Adv Nurs 1997 ; 25 : 877 –85. OpenUrl CrossRef PubMed Web of Science
• ↵ Barroso J. Reconstructing my life: becoming a long-term survivor of AIDS. Qual Health Res 1997 ; 7 : 57 –74. OpenUrl CrossRef Web of Science
• ↵ Thibodeau J, MacRae J. Breast cancer survival: a phenomenological inquiry. Adv Nurs Sci 1997 ; 19 : 65 –74. OpenUrl PubMed
• ↵ Sackett D, Haynes RB. On the need for evidence-based medicine . Evidence-Based Medicine 1995 ; 1 : 5 –6. OpenUrl Abstract / FREE Full Text
• ↵ Gordon DR Tenacious assumptions in Western biomedicine. In: Lock M, Gordon DR , eds . Biomedicine Examined. London: Kluwer Academic Press, 1988;19–56.

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THE IMPACT OF NURSE–LED EDUCATION, ON QUALITY OF LIFE IN PATIENTS WITH HEART FAILURE DURING CARDIAC REHABILITATION: A REVIEW OF THE LITERATURE

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M Li Vigni, B Meucci, F Gambone, V Giordano, THE IMPACT OF NURSE–LED EDUCATION, ON QUALITY OF LIFE IN PATIENTS WITH HEART FAILURE DURING CARDIAC REHABILITATION: A REVIEW OF THE LITERATURE, European Heart Journal Supplements , Volume 26, Issue Supplement_2, April 2024, Page ii138, https://doi.org/10.1093/eurheartjsupp/suae036.348

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The complex mosaic of cardiac rehabilitation (CR) in heart failure (HF) is composed of several "pieces": adherence to the rehabilitation program (Mazza & Paneroni, 2019), therapeutic education, improvement of perceived QoL and self–care (Deek et al., 2017). To improve the patient‘s QoL, however, it is imperative to position them at the focal point of the care process. Several studies, have documented the favorable impact of CR on QoL in HF patients (Conway et al., 2015). Although variations in therapeutic and rehabilitative treatment plans vary according to each stage of the disease, adopting lifestyle changes is a recommended strategy regardless of the stage of HF from which the person is affected (ACC/AHA 2005; Yancy et al., 2005). However, despite the evidence–based benefits of post–discharge interventions combined with patient education in HF patients, the specific impact and benefits of nurse–led patient education alone, independent of the broader health care system, remain still unclear.

This review aims to investigate the influence of the nurse‘s educational role on the quality of life of patients with HF in the setting of cardiac rehabilitation.

A comprehensive literature review was conducted using databases such as PubMed, Scopus, CIHNAL Complete and EMBASE. The review followed the PICO methodology, with the formulation of a research question. MeSH terms and keywords were combined using Boolean operators and inclusion criteria. The primary outcome of interest was improved QoL. Relevant articles were subjected to preliminary analysis on the Rayyan platform. They were first evaluated by title and abstract, then selected for full–text reading, and finally subjected to "quality appraisal".

Individuals with HF experience a decline in QoL and are at increased risk of poor prognosis, characterized by exacerbation episodes leading to frequent re–hospitalizations and increased mortality rates (Heo et al., 2009; Rechenberg et al., 2020; Freedland et al., 2021). Therefore, improving QoL in patients with HF is a priority from both care and organizational perspectives (Ades et al., 2013; Darkins et al., 2015). Notably, a tailored CR educational program helps to improve self–care management and, consequently, improve QoL. That highlights the importance of nurse–led CR for HF patients in improving health behaviors and adherence to therapeutic practices.

• cardiac rehabilitation
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• knowledge acquisition
• health behavior
• quality of life
• rehabilitation
• lifestyle changes
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Cultural Relativity and Acceptance of Embryonic Stem Cell Research

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There is a debate about the ethical implications of using human embryos in stem cell research, which can be influenced by cultural, moral, and social values. This paper argues for an adaptable framework to accommodate diverse cultural and religious perspectives. By using an adaptive ethics model, research protections can reflect various populations and foster growth in stem cell research possibilities.

INTRODUCTION

Stem cell research combines biology, medicine, and technology, promising to alter health care and the understanding of human development. Yet, ethical contention exists because of individuals’ perceptions of using human embryos based on their various cultural, moral, and social values. While these disagreements concerning policy, use, and general acceptance have prompted the development of an international ethics policy, such a uniform approach can overlook the nuanced ethical landscapes between cultures. With diverse viewpoints in public health, a single global policy, especially one reflecting Western ethics or the ethics prevalent in high-income countries, is impractical. This paper argues for a culturally sensitive, adaptable framework for the use of embryonic stem cells. Stem cell policy should accommodate varying ethical viewpoints and promote an effective global dialogue. With an extension of an ethics model that can adapt to various cultures, we recommend localized guidelines that reflect the moral views of the people those guidelines serve.

Stem cells, characterized by their unique ability to differentiate into various cell types, enable the repair or replacement of damaged tissues. Two primary types of stem cells are somatic stem cells (adult stem cells) and embryonic stem cells. Adult stem cells exist in developed tissues and maintain the body’s repair processes. [1] Embryonic stem cells (ESC) are remarkably pluripotent or versatile, making them valuable in research. [2] However, the use of ESCs has sparked ethics debates. Considering the potential of embryonic stem cells, research guidelines are essential. The International Society for Stem Cell Research (ISSCR) provides international stem cell research guidelines. They call for “public conversations touching on the scientific significance as well as the societal and ethical issues raised by ESC research.” [3] The ISSCR also publishes updates about culturing human embryos 14 days post fertilization, suggesting local policies and regulations should continue to evolve as ESC research develops. [4]  Like the ISSCR, which calls for local law and policy to adapt to developing stem cell research given cultural acceptance, this paper highlights the importance of local social factors such as religion and culture.

I.     Global Cultural Perspective of Embryonic Stem Cells

Views on ESCs vary throughout the world. Some countries readily embrace stem cell research and therapies, while others have stricter regulations due to ethical concerns surrounding embryonic stem cells and when an embryo becomes entitled to moral consideration. The philosophical issue of when the “someone” begins to be a human after fertilization, in the morally relevant sense, [5] impacts when an embryo becomes not just worthy of protection but morally entitled to it. The process of creating embryonic stem cell lines involves the destruction of the embryos for research. [6] Consequently, global engagement in ESC research depends on social-cultural acceptability.

a.     US and Rights-Based Cultures

In the United States, attitudes toward stem cell therapies are diverse. The ethics and social approaches, which value individualism, [7] trigger debates regarding the destruction of human embryos, creating a complex regulatory environment. For example, the 1996 Dickey-Wicker Amendment prohibited federal funding for the creation of embryos for research and the destruction of embryos for “more than allowed for research on fetuses in utero.” [8] Following suit, in 2001, the Bush Administration heavily restricted stem cell lines for research. However, the Stem Cell Research Enhancement Act of 2005 was proposed to help develop ESC research but was ultimately vetoed. [9] Under the Obama administration, in 2009, an executive order lifted restrictions allowing for more development in this field. [10] The flux of research capacity and funding parallels the different cultural perceptions of human dignity of the embryo and how it is socially presented within the country’s research culture. [11]

b.     Ubuntu and Collective Cultures

African bioethics differs from Western individualism because of the different traditions and values. African traditions, as described by individuals from South Africa and supported by some studies in other African countries, including Ghana and Kenya, follow the African moral philosophies of Ubuntu or Botho and Ukama , which “advocates for a form of wholeness that comes through one’s relationship and connectedness with other people in the society,” [12] making autonomy a socially collective concept. In this context, for the community to act autonomously, individuals would come together to decide what is best for the collective. Thus, stem cell research would require examining the value of the research to society as a whole and the use of the embryos as a collective societal resource. If society views the source as part of the collective whole, and opposes using stem cells, compromising the cultural values to pursue research may cause social detachment and stunt research growth. [13] Based on local culture and moral philosophy, the permissibility of stem cell research depends on how embryo, stem cell, and cell line therapies relate to the community as a whole . Ubuntu is the expression of humanness, with the person’s identity drawn from the “’I am because we are’” value. [14] The decision in a collectivistic culture becomes one born of cultural context, and individual decisions give deference to others in the society.

Consent differs in cultures where thought and moral philosophy are based on a collective paradigm. So, applying Western bioethical concepts is unrealistic. For one, Africa is a diverse continent with many countries with different belief systems, access to health care, and reliance on traditional or Western medicines. Where traditional medicine is the primary treatment, the “’restrictive focus on biomedically-related bioethics’” [is] problematic in African contexts because it neglects bioethical issues raised by traditional systems.” [15] No single approach applies in all areas or contexts. Rather than evaluating the permissibility of ESC research according to Western concepts such as the four principles approach, different ethics approaches should prevail.

Another consideration is the socio-economic standing of countries. In parts of South Africa, researchers have not focused heavily on contributing to the stem cell discourse, either because it is not considered health care or a health science priority or because resources are unavailable. [16] Each country’s priorities differ given different social, political, and economic factors. In South Africa, for instance, areas such as maternal mortality, non-communicable diseases, telemedicine, and the strength of health systems need improvement and require more focus. [17] Stem cell research could benefit the population, but it also could divert resources from basic medical care. Researchers in South Africa adhere to the National Health Act and Medicines Control Act in South Africa and international guidelines; however, the Act is not strictly enforced, and there is no clear legislation for research conduct or ethical guidelines. [18]

Some parts of Africa condemn stem cell research. For example, 98.2 percent of the Tunisian population is Muslim. [19] Tunisia does not permit stem cell research because of moral conflict with a Fatwa. Religion heavily saturates the regulation and direction of research. [20] Stem cell use became permissible for reproductive purposes only recently, with tight restrictions preventing cells from being used in any research other than procedures concerning ART/IVF.  Their use is conditioned on consent, and available only to married couples. [21] The community's receptiveness to stem cell research depends on including communitarian African ethics.

c.     Asia

Some Asian countries also have a collective model of ethics and decision making. [22] In China, the ethics model promotes a sincere respect for life or human dignity, [23] based on protective medicine. This model, influenced by Traditional Chinese Medicine (TCM), [24] recognizes Qi as the vital energy delivered via the meridians of the body; it connects illness to body systems, the body’s entire constitution, and the universe for a holistic bond of nature, health, and quality of life. [25] Following a protective ethics model, and traditional customs of wholeness, investment in stem cell research is heavily desired for its applications in regenerative therapies, disease modeling, and protective medicines. In a survey of medical students and healthcare practitioners, 30.8 percent considered stem cell research morally unacceptable while 63.5 percent accepted medical research using human embryonic stem cells. Of these individuals, 89.9 percent supported increased funding for stem cell research. [26] The scientific community might not reflect the overall population. From 1997 to 2019, China spent a total of $576 million (USD) on stem cell research at 8,050 stem cell programs, increased published presence from 0.6 percent to 14.01 percent of total global stem cell publications as of 2014, and made significant strides in cell-based therapies for various medical conditions. [27] However, while China has made substantial investments in stem cell research and achieved notable progress in clinical applications, concerns linger regarding ethical oversight and transparency. [28] For example, the China Biosecurity Law, promoted by the National Health Commission and China Hospital Association, attempted to mitigate risks by introducing an institutional review board (IRB) in the regulatory bodies. 5800 IRBs registered with the Chinese Clinical Trial Registry since 2021. [29] However, issues still need to be addressed in implementing effective IRB review and approval procedures.

The substantial government funding and focus on scientific advancement have sometimes overshadowed considerations of regional cultures, ethnic minorities, and individual perspectives, particularly evident during the one-child policy era. As government policy adapts to promote public stability, such as the change from the one-child to the two-child policy, [30] research ethics should also adapt to ensure respect for the values of its represented peoples.

Japan is also relatively supportive of stem cell research and therapies. Japan has a more transparent regulatory framework, allowing for faster approval of regenerative medicine products, which has led to several advanced clinical trials and therapies. [31] South Korea is also actively engaged in stem cell research and has a history of breakthroughs in cloning and embryonic stem cells. [32] However, the field is controversial, and there are issues of scientific integrity. For example, the Korean FDA fast-tracked products for approval, [33] and in another instance, the oocyte source was unclear and possibly violated ethical standards. [34] Trust is important in research, as it builds collaborative foundations between colleagues, trial participant comfort, open-mindedness for complicated and sensitive discussions, and supports regulatory procedures for stakeholders. There is a need to respect the culture’s interest, engagement, and for research and clinical trials to be transparent and have ethical oversight to promote global research discourse and trust.

d.     Middle East

Countries in the Middle East have varying degrees of acceptance of or restrictions to policies related to using embryonic stem cells due to cultural and religious influences. Saudi Arabia has made significant contributions to stem cell research, and conducts research based on international guidelines for ethical conduct and under strict adherence to guidelines in accordance with Islamic principles. Specifically, the Saudi government and people require ESC research to adhere to Sharia law. In addition to umbilical and placental stem cells, [35] Saudi Arabia permits the use of embryonic stem cells as long as they come from miscarriages, therapeutic abortions permissible by Sharia law, or are left over from in vitro fertilization and donated to research. [36] Laws and ethical guidelines for stem cell research allow the development of research institutions such as the King Abdullah International Medical Research Center, which has a cord blood bank and a stem cell registry with nearly 10,000 donors. [37] Such volume and acceptance are due to the ethical ‘permissibility’ of the donor sources, which do not conflict with religious pillars. However, some researchers err on the side of caution, choosing not to use embryos or fetal tissue as they feel it is unethical to do so. [38]

Jordan has a positive research ethics culture. [39] However, there is a significant issue of lack of trust in researchers, with 45.23 percent (38.66 percent agreeing and 6.57 percent strongly agreeing) of Jordanians holding a low level of trust in researchers, compared to 81.34 percent of Jordanians agreeing that they feel safe to participate in a research trial. [40] Safety testifies to the feeling of confidence that adequate measures are in place to protect participants from harm, whereas trust in researchers could represent the confidence in researchers to act in the participants’ best interests, adhere to ethical guidelines, provide accurate information, and respect participants’ rights and dignity. One method to improve trust would be to address communication issues relevant to ESC. Legislation surrounding stem cell research has adopted specific language, especially concerning clarification “between ‘stem cells’ and ‘embryonic stem cells’” in translation. [41] Furthermore, legislation “mandates the creation of a national committee… laying out specific regulations for stem-cell banking in accordance with international standards.” [42] This broad regulation opens the door for future global engagement and maintains transparency. However, these regulations may also constrain the influence of research direction, pace, and accessibility of research outcomes.

e.     Europe

In the European Union (EU), ethics is also principle-based, but the principles of autonomy, dignity, integrity, and vulnerability are interconnected. [43] As such, the opportunity for cohesion and concessions between individuals’ thoughts and ideals allows for a more adaptable ethics model due to the flexible principles that relate to the human experience The EU has put forth a framework in its Convention for the Protection of Human Rights and Dignity of the Human Being allowing member states to take different approaches. Each European state applies these principles to its specific conventions, leading to or reflecting different acceptance levels of stem cell research. [44]

For example, in Germany, Lebenzusammenhang , or the coherence of life, references integrity in the unity of human culture. Namely, the personal sphere “should not be subject to external intervention.” [45]  Stem cell interventions could affect this concept of bodily completeness, leading to heavy restrictions. Under the Grundgesetz, human dignity and the right to life with physical integrity are paramount. [46] The Embryo Protection Act of 1991 made producing cell lines illegal. Cell lines can be imported if approved by the Central Ethics Commission for Stem Cell Research only if they were derived before May 2007. [47] Stem cell research respects the integrity of life for the embryo with heavy specifications and intense oversight. This is vastly different in Finland, where the regulatory bodies find research more permissible in IVF excess, but only up to 14 days after fertilization. [48] Spain’s approach differs still, with a comprehensive regulatory framework. [49] Thus, research regulation can be culture-specific due to variations in applied principles. Diverse cultures call for various approaches to ethical permissibility. [50] Only an adaptive-deliberative model can address the cultural constructions of self and achieve positive, culturally sensitive stem cell research practices. [51]

II.     Religious Perspectives on ESC

Embryonic stem cell sources are the main consideration within religious contexts. While individuals may not regard their own religious texts as authoritative or factual, religion can shape their foundations or perspectives.

The Qur'an states:

“And indeed We created man from a quintessence of clay. Then We placed within him a small quantity of nutfa (sperm to fertilize) in a safe place. Then We have fashioned the nutfa into an ‘alaqa (clinging clot or cell cluster), then We developed the ‘alaqa into mudgha (a lump of flesh), and We made mudgha into bones, and clothed the bones with flesh, then We brought it into being as a new creation. So Blessed is Allah, the Best of Creators.” [52]

Many scholars of Islam estimate the time of soul installment, marked by the angel breathing in the soul to bring the individual into creation, as 120 days from conception. [53] Personhood begins at this point, and the value of life would prohibit research or experimentation that could harm the individual. If the fetus is more than 120 days old, the time ensoulment is interpreted to occur according to Islamic law, abortion is no longer permissible. [54] There are a few opposing opinions about early embryos in Islamic traditions. According to some Islamic theologians, there is no ensoulment of the early embryo, which is the source of stem cells for ESC research. [55]

In Buddhism, the stance on stem cell research is not settled. The main tenets, the prohibition against harming or destroying others (ahimsa) and the pursuit of knowledge (prajña) and compassion (karuna), leave Buddhist scholars and communities divided. [56] Some scholars argue stem cell research is in accordance with the Buddhist tenet of seeking knowledge and ending human suffering. Others feel it violates the principle of not harming others. Finding the balance between these two points relies on the karmic burden of Buddhist morality. In trying to prevent ahimsa towards the embryo, Buddhist scholars suggest that to comply with Buddhist tenets, research cannot be done as the embryo has personhood at the moment of conception and would reincarnate immediately, harming the individual's ability to build their karmic burden. [57] On the other hand, the Bodhisattvas, those considered to be on the path to enlightenment or Nirvana, have given organs and flesh to others to help alleviate grieving and to benefit all. [58] Acceptance varies on applied beliefs and interpretations.

Catholicism does not support embryonic stem cell research, as it entails creation or destruction of human embryos. This destruction conflicts with the belief in the sanctity of life. For example, in the Old Testament, Genesis describes humanity as being created in God’s image and multiplying on the Earth, referencing the sacred rights to human conception and the purpose of development and life. In the Ten Commandments, the tenet that one should not kill has numerous interpretations where killing could mean murder or shedding of the sanctity of life, demonstrating the high value of human personhood. In other books, the theological conception of when life begins is interpreted as in utero, [59] highlighting the inviolability of life and its formation in vivo to make a religious point for accepting such research as relatively limited, if at all. [60] The Vatican has released ethical directives to help apply a theological basis to modern-day conflicts. The Magisterium of the Church states that “unless there is a moral certainty of not causing harm,” experimentation on fetuses, fertilized cells, stem cells, or embryos constitutes a crime. [61] Such procedures would not respect the human person who exists at these stages, according to Catholicism. Damages to the embryo are considered gravely immoral and illicit. [62] Although the Catholic Church officially opposes abortion, surveys demonstrate that many Catholic people hold pro-choice views, whether due to the context of conception, stage of pregnancy, threat to the mother’s life, or for other reasons, demonstrating that practicing members can also accept some but not all tenets. [63]

Some major Jewish denominations, such as the Reform, Conservative, and Reconstructionist movements, are open to supporting ESC use or research as long as it is for saving a life. [64] Within Judaism, the Talmud, or study, gives personhood to the child at birth and emphasizes that life does not begin at conception: [65]

“If she is found pregnant, until the fortieth day it is mere fluid,” [66]

Whereas most religions prioritize the status of human embryos, the Halakah (Jewish religious law) states that to save one life, most other religious laws can be ignored because it is in pursuit of preservation. [67] Stem cell research is accepted due to application of these religious laws.

We recognize that all religions contain subsets and sects. The variety of environmental and cultural differences within religious groups requires further analysis to respect the flexibility of religious thoughts and practices. We make no presumptions that all cultures require notions of autonomy or morality as under the common morality theory , which asserts a set of universal moral norms that all individuals share provides moral reasoning and guides ethical decisions. [68] We only wish to show that the interaction with morality varies between cultures and countries.

III.     A Flexible Ethical Approach

The plurality of different moral approaches described above demonstrates that there can be no universally acceptable uniform law for ESC on a global scale. Instead of developing one standard, flexible ethical applications must be continued. We recommend local guidelines that incorporate important cultural and ethical priorities.

While the Declaration of Helsinki is more relevant to people in clinical trials receiving ESC products, in keeping with the tradition of protections for research subjects, consent of the donor is an ethical requirement for ESC donation in many jurisdictions including the US, Canada, and Europe. [69] The Declaration of Helsinki provides a reference point for regulatory standards and could potentially be used as a universal baseline for obtaining consent prior to gamete or embryo donation.

For instance, in Columbia University’s egg donor program for stem cell research, donors followed standard screening protocols and “underwent counseling sessions that included information as to the purpose of oocyte donation for research, what the oocytes would be used for, the risks and benefits of donation, and process of oocyte stimulation” to ensure transparency for consent. [70] The program helped advance stem cell research and provided clear and safe research methods with paid participants. Though paid participation or covering costs of incidental expenses may not be socially acceptable in every culture or context, [71] and creating embryos for ESC research is illegal in many jurisdictions, Columbia’s program was effective because of the clear and honest communications with donors, IRBs, and related stakeholders.  This example demonstrates that cultural acceptance of scientific research and of the idea that an egg or embryo does not have personhood is likely behind societal acceptance of donating eggs for ESC research. As noted, many countries do not permit the creation of embryos for research.

Proper communication and education regarding the process and purpose of stem cell research may bolster comprehension and garner more acceptance. “Given the sensitive subject material, a complete consent process can support voluntary participation through trust, understanding, and ethical norms from the cultures and morals participants value. This can be hard for researchers entering countries of different socioeconomic stability, with different languages and different societal values. [72]

An adequate moral foundation in medical ethics is derived from the cultural and religious basis that informs knowledge and actions. [73] Understanding local cultural and religious values and their impact on research could help researchers develop humility and promote inclusion.

IV.     Concerns

Some may argue that if researchers all adhere to one ethics standard, protection will be satisfied across all borders, and the global public will trust researchers. However, defining what needs to be protected and how to define such research standards is very specific to the people to which standards are applied. We suggest that applying one uniform guide cannot accurately protect each individual because we all possess our own perceptions and interpretations of social values. [74] Therefore, the issue of not adjusting to the moral pluralism between peoples in applying one standard of ethics can be resolved by building out ethics models that can be adapted to different cultures and religions.

Other concerns include medical tourism, which may promote health inequities. [75] Some countries may develop and approve products derived from ESC research before others, compromising research ethics or drug approval processes. There are also concerns about the sale of unauthorized stem cell treatments, for example, those without FDA approval in the United States. Countries with robust research infrastructures may be tempted to attract medical tourists, and some customers will have false hopes based on aggressive publicity of unproven treatments. [76]

For example, in China, stem cell clinics can market to foreign clients who are not protected under the regulatory regimes. Companies employ a marketing strategy of “ethically friendly” therapies. Specifically, in the case of Beike, China’s leading stem cell tourism company and sprouting network, ethical oversight of administrators or health bureaus at one site has “the unintended consequence of shifting questionable activities to another node in Beike's diffuse network.” [77] In contrast, Jordan is aware of stem cell research’s potential abuse and its own status as a “health-care hub.” Jordan’s expanded regulations include preserving the interests of individuals in clinical trials and banning private companies from ESC research to preserve transparency and the integrity of research practices. [78]

The social priorities of the community are also a concern. The ISSCR explicitly states that guidelines “should be periodically revised to accommodate scientific advances, new challenges, and evolving social priorities.” [79] The adaptable ethics model extends this consideration further by addressing whether research is warranted given the varying degrees of socioeconomic conditions, political stability, and healthcare accessibilities and limitations. An ethical approach would require discussion about resource allocation and appropriate distribution of funds. [80]

While some religions emphasize the sanctity of life from conception, which may lead to public opposition to ESC research, others encourage ESC research due to its potential for healing and alleviating human pain. Many countries have special regulations that balance local views on embryonic personhood, the benefits of research as individual or societal goods, and the protection of human research subjects. To foster understanding and constructive dialogue, global policy frameworks should prioritize the protection of universal human rights, transparency, and informed consent. In addition to these foundational global policies, we recommend tailoring local guidelines to reflect the diverse cultural and religious perspectives of the populations they govern. Ethics models should be adapted to local populations to effectively establish research protections, growth, and possibilities of stem cell research.

For example, in countries with strong beliefs in the moral sanctity of embryos or heavy religious restrictions, an adaptive model can allow for discussion instead of immediate rejection. In countries with limited individual rights and voice in science policy, an adaptive model ensures cultural, moral, and religious views are taken into consideration, thereby building social inclusion. While this ethical consideration by the government may not give a complete voice to every individual, it will help balance policies and maintain the diverse perspectives of those it affects. Embracing an adaptive ethics model of ESC research promotes open-minded dialogue and respect for the importance of human belief and tradition. By actively engaging with cultural and religious values, researchers can better handle disagreements and promote ethical research practices that benefit each society.

This brief exploration of the religious and cultural differences that impact ESC research reveals the nuances of relative ethics and highlights a need for local policymakers to apply a more intense adaptive model.

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[5] Concerning the moral philosophies of stem cell research, our paper does not posit a personal moral stance nor delve into the “when” of human life begins. To read further about the philosophical debate, consider the following sources:

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[7] Socially, at its core, the Western approach to ethics is widely principle-based, autonomy being one of the key factors to ensure a fundamental respect for persons within research. For information regarding autonomy in research, see: Department of Health, Education, and Welfare, & National Commission for the Protection of Human Subjects of Biomedical and Behavioral Research (1978). The Belmont Report. Ethical principles and guidelines for the protection of human subjects of research.; For a more in-depth review of autonomy within the US, see: Beauchamp, T. L., & Childress, J. F. (1994). Principles of Biomedical Ethics . Oxford University Press.

[8] Sherley v. Sebelius , 644 F.3d 388 (D.C. Cir. 2011), citing 45 C.F.R. 46.204(b) and [42 U.S.C. § 289g(b)]. https://www.cadc.uscourts.gov/internet/opinions.nsf/6c690438a9b43dd685257a64004ebf99/$file/11-5241-1391178.pdf

[9] Stem Cell Research Enhancement Act of 2005, H. R. 810, 109 th Cong. (2001). https://www.govtrack.us/congress/bills/109/hr810/text ; Bush, G. W. (2006, July 19). Message to the House of Representatives . National Archives and Records Administration. https://georgewbush-whitehouse.archives.gov/news/releases/2006/07/20060719-5.html

[10] National Archives and Records Administration. (2009, March 9). Executive order 13505 -- removing barriers to responsible scientific research involving human stem cells . National Archives and Records Administration. https://obamawhitehouse.archives.gov/the-press-office/removing-barriers-responsible-scientific-research-involving-human-stem-cells

[11] Hurlbut, W. B. (2006). Science, Religion, and the Politics of Stem Cells.  Social Research ,  73 (3), 819–834. http://www.jstor.org/stable/40971854

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[13] Source for further reading: Tangwa G. B. (2007). Moral status of embryonic stem cells: perspective of an African villager. Bioethics , 21(8), 449–457. https://doi.org/10.1111/j.1467-8519.2007.00582.x , see also Mnisi, F. M. (2020). An African analysis based on ethics of Ubuntu - are human embryonic stem cell patents morally justifiable? African Insight , 49 (4).

[14] Jecker, N. S., & Atuire, C. (2021). Bioethics in Africa: A contextually enlightened analysis of three cases. Developing World Bioethics , 22 (2), 112–122. https://doi.org/10.1111/dewb.12324

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[18] Oosthuizen, H. (2013). Legal and Ethical Issues in Stem Cell Research in South Africa. In: Beran, R. (eds) Legal and Forensic Medicine. Springer, Berlin, Heidelberg. https://doi.org/10.1007/978-3-642-32338-6_80 , see also: Gaobotse G (2018) Stem Cell Research in Africa: Legislation and Challenges. J Regen Med 7:1. doi: 10.4172/2325-9620.1000142

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[21] Kooli, C. Review of assisted reproduction techniques, laws, and regulations in Muslim countries.  Middle East Fertil Soc J   24 , 8 (2020). https://doi.org/10.1186/s43043-019-0011-0 ; Gaobotse, G. (2018) Stem Cell Research in Africa: Legislation and Challenges. J Regen Med 7:1. doi: 10.4172/2325-9620.1000142

[22] Pang M. C. (1999). Protective truthfulness: the Chinese way of safeguarding patients in informed treatment decisions. Journal of medical ethics , 25(3), 247–253. https://doi.org/10.1136/jme.25.3.247

[23] Wang, L., Wang, F., & Zhang, W. (2021). Bioethics in China’s biosecurity law: Forms, effects, and unsettled issues. Journal of law and the biosciences , 8(1).  https://doi.org/10.1093/jlb/lsab019 https://academic.oup.com/jlb/article/8/1/lsab019/6299199

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[30] Chen, H., Wei, T., Wang, H.  et al.  Association of China’s two-child policy with changes in number of births and birth defects rate, 2008–2017.  BMC Public Health   22 , 434 (2022). https://doi.org/10.1186/s12889-022-12839-0

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[35] Alahmad, G., Aljohani, S., & Najjar, M. F. (2020). Ethical challenges regarding the use of stem cells: interviews with researchers from Saudi Arabia. BMC medical ethics, 21(1), 35. https://doi.org/10.1186/s12910-020-00482-6

[36] Association for the Advancement of Blood and Biotherapies.  https://www.aabb.org/regulatory-and-advocacy/regulatory-affairs/regulatory-for-cellular-therapies/international-competent-authorities/saudi-arabia

[37] Alahmad, G., Aljohani, S., & Najjar, M. F. (2020). Ethical challenges regarding the use of stem cells: Interviews with researchers from Saudi Arabia.  BMC medical ethics ,  21 (1), 35. https://doi.org/10.1186/s12910-020-00482-6

[38] Alahmad, G., Aljohani, S., & Najjar, M. F. (2020). Ethical challenges regarding the use of stem cells: Interviews with researchers from Saudi Arabia. BMC medical ethics , 21(1), 35. https://doi.org/10.1186/s12910-020-00482-6

Culturally, autonomy practices follow a relational autonomy approach based on a paternalistic deontological health care model. The adherence to strict international research policies and religious pillars within the regulatory environment is a great foundation for research ethics. However, there is a need to develop locally targeted ethics approaches for research (as called for in Alahmad, G., Aljohani, S., & Najjar, M. F. (2020). Ethical challenges regarding the use of stem cells: interviews with researchers from Saudi Arabia. BMC medical ethics, 21(1), 35. https://doi.org/10.1186/s12910-020-00482-6), this decision-making approach may help advise a research decision model. For more on the clinical cultural autonomy approaches, see: Alabdullah, Y. Y., Alzaid, E., Alsaad, S., Alamri, T., Alolayan, S. W., Bah, S., & Aljoudi, A. S. (2022). Autonomy and paternalism in Shared decision‐making in a Saudi Arabian tertiary hospital: A cross‐sectional study. Developing World Bioethics , 23 (3), 260–268. https://doi.org/10.1111/dewb.12355 ; Bukhari, A. A. (2017). Universal Principles of Bioethics and Patient Rights in Saudi Arabia (Doctoral dissertation, Duquesne University). https://dsc.duq.edu/etd/124; Ladha, S., Nakshawani, S. A., Alzaidy, A., & Tarab, B. (2023, October 26). Islam and Bioethics: What We All Need to Know . Columbia University School of Professional Studies. https://sps.columbia.edu/events/islam-and-bioethics-what-we-all-need-know

[39] Ababneh, M. A., Al-Azzam, S. I., Alzoubi, K., Rababa’h, A., & Al Demour, S. (2021). Understanding and attitudes of the Jordanian public about clinical research ethics.  Research Ethics ,  17 (2), 228-241.  https://doi.org/10.1177/1747016120966779

[40] Ababneh, M. A., Al-Azzam, S. I., Alzoubi, K., Rababa’h, A., & Al Demour, S. (2021). Understanding and attitudes of the Jordanian public about clinical research ethics.  Research Ethics ,  17 (2), 228-241.  https://doi.org/10.1177/1747016120966779

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[43] The EU’s definition of autonomy relates to the capacity for creating ideas, moral insight, decisions, and actions without constraint, personal responsibility, and informed consent. However, the EU views autonomy as not completely able to protect individuals and depends on other principles, such as dignity, which “expresses the intrinsic worth and fundamental equality of all human beings.” Rendtorff, J.D., Kemp, P. (2019). Four Ethical Principles in European Bioethics and Biolaw: Autonomy, Dignity, Integrity and Vulnerability. In: Valdés, E., Lecaros, J. (eds) Biolaw and Policy in the Twenty-First Century. International Library of Ethics, Law, and the New Medicine, vol 78. Springer, Cham. https://doi.org/10.1007/978-3-030-05903-3_3

[44] Council of Europe. Convention for the protection of Human Rights and Dignity of the Human Being with regard to the Application of Biology and Medicine: Convention on Human Rights and Biomedicine (ETS No. 164) https://www.coe.int/en/web/conventions/full-list?module=treaty-detail&treatynum=164 (forbidding the creation of embryos for research purposes only, and suggests embryos in vitro have protections.); Also see Drabiak-Syed B. K. (2013). New President, New Human Embryonic Stem Cell Research Policy: Comparative International Perspectives and Embryonic Stem Cell Research Laws in France.  Biotechnology Law Report ,  32 (6), 349–356. https://doi.org/10.1089/blr.2013.9865

[45] Rendtorff, J.D., Kemp, P. (2019). Four Ethical Principles in European Bioethics and Biolaw: Autonomy, Dignity, Integrity and Vulnerability. In: Valdés, E., Lecaros, J. (eds) Biolaw and Policy in the Twenty-First Century. International Library of Ethics, Law, and the New Medicine, vol 78. Springer, Cham. https://doi.org/10.1007/978-3-030-05903-3_3

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[47] Regulation of Stem Cell Research in Germany . Eurostemcell. (2017, April 26). https://www.eurostemcell.org/regulation-stem-cell-research-germany

[48] Regulation of Stem Cell Research in Finland . Eurostemcell. (2017, April 26). https://www.eurostemcell.org/regulation-stem-cell-research-finland

[49] Regulation of Stem Cell Research in Spain . Eurostemcell. (2017, April 26). https://www.eurostemcell.org/regulation-stem-cell-research-spain

[50] Some sources to consider regarding ethics models or regulatory oversights of other cultures not covered:

Kara MA. Applicability of the principle of respect for autonomy: the perspective of Turkey. J Med Ethics. 2007 Nov;33(11):627-30. doi: 10.1136/jme.2006.017400. PMID: 17971462; PMCID: PMC2598110.

Ugarte, O. N., & Acioly, M. A. (2014). The principle of autonomy in Brazil: one needs to discuss it ...  Revista do Colegio Brasileiro de Cirurgioes ,  41 (5), 374–377. https://doi.org/10.1590/0100-69912014005013

Bharadwaj, A., & Glasner, P. E. (2012). Local cells, global science: The rise of embryonic stem cell research in India . Routledge.

For further research on specific European countries regarding ethical and regulatory framework, we recommend this database: Regulation of Stem Cell Research in Europe . Eurostemcell. (2017, April 26). https://www.eurostemcell.org/regulation-stem-cell-research-europe   

[51] Klitzman, R. (2006). Complications of culture in obtaining informed consent. The American Journal of Bioethics, 6(1), 20–21. https://doi.org/10.1080/15265160500394671 see also: Ekmekci, P. E., & Arda, B. (2017). Interculturalism and Informed Consent: Respecting Cultural Differences without Breaching Human Rights.  Cultura (Iasi, Romania) ,  14 (2), 159–172.; For why trust is important in research, see also: Gray, B., Hilder, J., Macdonald, L., Tester, R., Dowell, A., & Stubbe, M. (2017). Are research ethics guidelines culturally competent?  Research Ethics ,  13 (1), 23-41.  https://doi.org/10.1177/1747016116650235

[52] The Qur'an  (M. Khattab, Trans.). (1965). Al-Mu’minun, 23: 12-14. https://quran.com/23

[53] Lenfest, Y. (2017, December 8). Islam and the beginning of human life . Bill of Health. https://blog.petrieflom.law.harvard.edu/2017/12/08/islam-and-the-beginning-of-human-life/

[54] Aksoy, S. (2005). Making regulations and drawing up legislation in Islamic countries under conditions of uncertainty, with special reference to embryonic stem cell research. Journal of Medical Ethics , 31: 399-403.; see also: Mahmoud, Azza. "Islamic Bioethics: National Regulations and Guidelines of Human Stem Cell Research in the Muslim World." Master's thesis, Chapman University, 2022. https://doi.org/10.36837/ chapman.000386

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Mifrah Hayath

SM Candidate Harvard Medical School, MS Biotechnology Johns Hopkins University

Olivia Bowers

MS Bioethics Columbia University (Disclosure: affiliated with Voices in Bioethics)

Article Details

This work is licensed under a Creative Commons Attribution 4.0 International License .

• Open access
• Published: 21 May 2024

Sustainability consciousness among nursing students in Egypt: a cross-sectional study

• Mohamed Marwa Ahmed El-Sayed 1 ,
• Eman Ghallab 2 ,
• Hassan Ragaa Abdallah Ahmed 3 &
• Amin Shaimaa Mohamed 4  

BMC Nursing volume  23 , Article number:  343 ( 2024 ) Cite this article

Metrics details

Recognizing nurses as pivotal change agents and urgent preparation for the next generation is crucial for addressing sustainability issues and cultivating a sustainable healthcare system. Reports highlight gaps in the integration of sustainable development goals (SDGs) into nursing curricula, prompting the International Council of Nurses to stress the importance of sustainable development in nursing education. The extent to which nursing students are aware of sustainability issues remains to be determined. This study addresses a global and Egyptian research gap by evaluating and comparing Sustainability Consciousness (SC) levels among nursing students at three universities, providing insights into awareness, attitudes, and behaviors related to sustainability.

This descriptive comparative study was conducted across three nursing faculties within three Egyptian public universities. The target population for this study was undergraduate nursing students enrolled in these universities during the academic year 2022-2023. This study used the extended version of the Sustainability Consciousness Questionnaire (SCQ-L) to measure individuals' knowingness, attitudes, and behaviors related to the three dimensions of sustainable development: environmental, social, and economic.

More than half of the nursing students across the three universities expressed unfamiliarity with the SDGs. Social media was the most common source of information across the three universities. Sohag University recorded the highest median (IQR) scores in sustainability knowingness (72.0, IQR: 70.0-81.0), attitudes (56.0, IQR: 53.0-61.5), and behavior (65.0, IQR: 60.0-69.0) across their respective dimensions, as well as in overall SC (195, IQR: 184.5-208.5). This was followed by Damanhour University, with a median score of 179.0 (IQR: 124.5-194), and then Alexandria University, with a median score of 116.0 (IQR: 85.5-153), all of which were significantly different (all with p values=0.000). Older students from rural areas exhibited higher SC median scores, while students with insufficient family income and no familiarity with the SDGs had lower SC scores.

Conclusions

This study highlighted the prevalent reliance on social media for information among nursing students across these universities, emphasizing the pivotal role of academic institutions in integrating sustainability development concepts in nursing education. Sohag University's notable commitment to sustainability practices has contributed to the higher SC of its students compared to Alexandria and Damanhour Universities. The study also identified age, place of residence, family income, and familiarity with the SDGs as consistent predictors of sustainability consciousness.

Peer Review reports

Introduction

Humanity faces several sustainability issues, often resulting from human interaction and the environment [ 1 ]. Despite not being intentionally harmful, human behavior and lifestyle are significant contributors to these challenges, exacerbating environmental, economic, and social problems [ 2 , 3 ]. Addressing these challenges requires fundamental changes in how people think and act, which can be achieved through education [ 4 ]. At the same time, global actions are required to promote sustainable development to combat such challenges [ 5 ]. Sustainable development has been defined as "development that meets the needs of the present without compromising the ability of future generations to meet their own needs" (World Commission on Environment and Development WCED, 1987) [ 6 ]. For sustainable development to be attained, it is necessary to harmonize its three fundamental components: "economic growth, social inclusion, and environmental protection" [ 7 ]. This calls for collaborative efforts toward building a safer, more resilient, and equitable future on Earth for everyone [ 8 ].

In 2015, the United Nations General Assembly adopted the 2030 Agenda for Sustainable Development, incorporating 17 Sustainable Development Goals (SDGs). These goals are designed to address the economic, social, and environmental dimensions of sustainable development. These goals comprehensively address the significant global challenges that endanger human and planet survival [ 9 ]. Education is critical to achieving these SDGs, as outlined in UNESCO reports from 2006, 2009, and 2014a. Individuals in all societies should possess the knowledge, skills, and attitudes that help them deal with sustainability challenges. The 2030 Agenda recognizes education as an independent goal (SDG 4) and includes educational indicators in other SDGs [ 10 , 11 , 12 ]. This positionsposition education as a primary catalyst for equipping individuals with the competencies and knowledge needed for a sustainable world. Since 1992, UNESCO has promoted Education for Sustainable Development (ESD) to empower learners of all ages to make informed choices and act sustainably for societal and environmental change [ 13 ].

In this context, higher education institutions play a critical role. They are expected to actively apply educational measures to equip graduates with sustainability competencies, which are essential for achieving the SDGs [ 14 ]. This form of education is designed to bring about changes in learners' knowledge, skills, and attitudes, cultivating a society that is more sustainable and equitable [ 15 , 16 ]. Universities can educate students about sustainable development by integrating the concept into their education systems and curricula [ 17 , 18 ]. One of the primary goals of universities should be to ensure that all students, regardless of their field of study, achieve a high level of sustainability awareness, contributing to the broader goal of sustainable development [ 19 ].

As sustainable development and ESD have evolved, a new concept, Sustainability Consciousness, has emerged. This concept was developed by a Swedish research group to measure the effect of the implementation of ESD on students at Swedish schools [ 20 , 21 ]. Sustainability Consciousness can be simply defined as "the experience or awareness of sustainability phenomena" [ 20 ], including the individual's knowledge, actions, attitudes, and experiences that form their identity [ 22 ]. Thus, SC is a combination of knowledge, behaviors, and attitudes about sustainability [ 23 ]. It integrates the environmental, social, and economic dimensions of sustainable development, emphasizing the importance of knowingness, attitudes, and behaviors in these three dimensions [ 24 ].

Sustainability knowingness relates to an awareness of the theoretical aspects of sustainable development, while sustainability attitude refers to being concerned about sustainability that subsequently translates into sustainable behaviors. Sustainability behavior refers to actions that support and contribute to sustainable development. To measure SC, a questionnaire was developed to assess awareness, attitudes, or behaviors related to the environmental, social, or economic aspects of SD [ 23 , 25 ]. These dimensions are essential in evaluating a person's SC [ 26 ]. This is especially significant in fields such as healthcare, where SC directly impacts professional practices.

The healthcare sector, including nursing, has a clear mandate to fulfill the United Nations' SDGs. This mainly includes a commitment to achieve the goal of ensuring healthy lives and promoting the well-being of individuals, regardless of age [ 27 ]. Nurses are pivotal in responding to sustainability issues, as they are change agents capable of improving public health and managing health resources effectively [ 28 , 29 ]. There is a pressing need to prepare future nurses to address these issues and actively contribute to building a sustainable healthcare system [ 30 ]. This preparation is crucial to help them understand the impact of sustainability issues on public health, provide environmental health education, and offer informed counseling [ 31 , 32 , 33 ]. The International Council of Nurses (ICN) emphasizes that sustainable development should be part of nursing curricula and continuing education, aiming to empower nurses to assume leadership roles in fostering sustainable practices within healthcare organizations and lead initiatives in sustainable development in healthcare [ 29 ].

Despite these imperatives, reports indicate existing gaps in addressing sustainability issues, including the SDGs, within nursing curricula. The extent to which nursing students become aware of sustainability remains to be determined [ 15 , 34 ]. While some studies have explored sustainability awareness among university students globally, more research needs to investigate and measure the SC of nursing students specifically, both on a global scale and within Egypt [ 32 , 35 , 36 , 37 , 38 ]. Consequently, further research is essential to gain a deeper understanding of the SC of nursing students. Such insights will inform policies and practices and contribute to effectively preparing and shaping the future leaders of the nursing profession in the realm of sustainability.

In addition, previous research indicates that ESD varies according to cultural context, highlighting the need for more cross-cultural studies on diverse cultural perspectives and engagement with sustainable development [ 38 , 39 ]. This study seeks to fill this gap by conducting a comparative analysis of SC, encompassing awareness, attitudes, and behaviors, among nursing students at three distinct Egyptian public universities, each situated in culturally unique regions. This research is the first to explore the SC of nursing students across different universities in Egypt.

This study aimed to assess and compare the levels of sustainability consciousness, encompassing knowingness, attitudes, and behaviors, among nursing students across three Egyptian public universities. Moreover, this study aimed to investigate the predictors of SC among students at these universities.

Study design

This study utilized a descriptive comparative cross-sectional research design. This study adhered to the Strengthening the Reporting of Observational Studies in Epidemiology (STROBE) guidelines.

The study occurred in three nursing faculties within three Egyptian public universities in Alexandria, Damanhour, and Sohag. These universities were selected based on several criteria, including their high student enrollment during the 2022-2023 academic year, the diverse backgrounds of students hailing from both rural and urban areas, and the representation of students from both Lower and Upper Egypt. Lower Egypt and Upper Egypt are historical and geographical divisions of ancient Egypt. Lower Egypt refers to the northern region of Egypt, which is adjacent to the Mediterranean Sea and encompasses the Nile Delta. Conversely, Upper Egypt denotes the southern part of the country, situated further upstream along the Nile River. Each region has a unique culture, tradition, and religious significance. Alexandria, the second largest city in Egypt, is situated on the Mediterranean coast and lies at the western edge of the Nile River Delta. Damanhour, located in Lower Egypt, serves as the capital of El-Beheira Governorate and occupies a central position within the western Nile Delta. Sohag, positioned in Upper Egypt, rests on the west bank of the Nile River. The reason for selecting universities from Upper and Lower Egypt was to capture a diverse range of perspectives and experiences, thereby reducing the potential for bias from focusing solely on one region or demographic group.

Sampling and study population

The target population for this study was undergraduate nursing students enrolled in three Egyptian public universities during the 2022-2023 academic year. G power was employed to calculate the sample size considering a total population of 7554, a significance level of 0.05, a moderate effect size, a power of 0.80, and a 95% confidence interval. The minimum required sample size for each university was 390, which was rounded to 400 to compensate for possible non-response. Consequently, the total sample size was 1200 students, employing an equal allocation method that selected 100 students from each academic year using systematic random sampling. All students enrolled in the first through fourth levels were eligible to participate in the study.

Outcome measurement instrument

Sustainability consciousness.

The extended version of the Sustainability Consciousness Questionnaire (SCQ-L) developed by Gericke et al. 2019 was used in this study [ 20 ]. The questionnaire was developed to measure individuals' knowledge, attitudes, and behaviors related to the environmental, social, and economic dimensions of sustainable development. The SCQ-L comprises 49 items, each rated on a five-point Likert scale ranging from "strongly disagree" (1) to "strongly agree" (5), with "disagree" as 2, "neutral" as 3, and "agree" as 4. It is structured into three sections, with the items in each section corresponding to the three critical dimensions of sustainable development: environmental, social, and economic. The first section, the "Sustainability Knowingness Scale," consists of 18 items distributed across three dimensions: environmental (6 items), social (8 items), and economic (4 items). The second section, the "Sustainability Attitudes Scale," encompasses 14 items categorized into three dimensions: environmental (4 items), social (6 items), and economic (4 items). In the third section, the "Sustainability Behavior Scale," there are 17 items divided into three dimensions: environmental (7 items), social (6 items), and economic (4 items).

The items on sustainability knowingness, attitude, and behavior cover what people acknowledge as essential components of sustainability, feelings, attitudes toward sustainable development and sustainability issues, and people's actions and behaviors. The instrument's psychometric properties were assessed by Gericke et al. in 2019, who reported that it is a reliable and valid tool, with Cronbach's alpha coefficients of α = 0.82, 0.73, and 0.79 for the sustainability knowingness scale, sustainability attitudes scale, and sustainability behavior scale, respectively.

Data collection

The data were collected from September 2022 to December 2022. The SCQ-L questionnaire was distributed among students in various locations, including lecture rooms and libraries, from Saturday to Thursday between 9 am and 2 pm. The questionnaire was distributed to 1236 students to address incomplete or missing data. For each participant, completing the questionnaire took approximately 15-20 minutes. Additionally, demographic information, such as age, gender, academic year, place of residence, family income, and marital status, was collected using a demographic characteristics information form.

Data analysis

SPSS 20.0 software was used to perform descriptive and inferential statistical analyses. Demographic data were summarized using descriptive statistics and the chi-square test to identify significant differences between the three universities. Statistical significance p <0.05 was considered. Since the data did not follow a normal distribution, nonparametric tests such as the Kruskal–Wallis and Mann–Whitney tests were used to identify significant differences among the three universities. The sustainability consciousness domains were summarized using medians and interquartile ranges (IQRs). Multiple linear regression was utilized to identify predictors of SC among nursing students.

Sociodemographic characteristics and sources of SDG information

Of only 1236 student responses, 36 were eliminated due to incomplete data (i.e., failure to give consent, missing responses, and skipped question items). After the data were cleaned, a total of 1200 responses were analyzed (Fig. 1 ). Table 1 describes the demographic differences among Alexandria, Damanhour, and Sohag University students. There were significant differences between the three universities according to the students' sex, age, marital status, place of residence, family income ( p =0.000), familiarity with the SDGs ( p =0.002), and sources of information about the SDGs ( p =0.000). First, there is a significant gender difference, with the university having a relatively balanced gender distribution, while Alexandria and Damanhour Universities have a predominance of female students. Second, there was a greater percentage of students aged 20 to less than 22 years in all three universities. Moreover, the marital status significantly differed, with most single students across the three universities.

Participant recruitment flowchart

Regarding the place of residence, Alexandria University has a greater percentage of students living in urban areas than Sohag and Damanhour. Most students at Alexandria University reported sufficient income compared to those at Damanhour and Sohag. Familiarity with the SDGs also shows significant variations, with more students at Alexandria University indicating familiarity (45.5%). Moreover, sources of information about the SDGs varied significantly among the three universities, highlighting the prevalence of social media as the most common source across the three universities, with Alexandria having the highest percentage (62.6%).

Comparison of the sustainability dimensions and constructs among students at the three universities

The Kruskal‒Wallis test revealed significant variations among the three universities in terms of sustainability knowingness (H=348.72, p =0.000), sustainability attitudes (H=380.12, p =0.000), and sustainability behavior (H=500.91, p =0.000) across the environmental, social, and economic dimensions within each of them (all with p values=0.000). Additionally, differences were observed in the overall SC (H=782.49, p =0.000). Sohag University consistently recorded the highest median (IQR) scores for sustainability knowingness (72.0, IQR: 70.0-81.0), attitudes (56.0, IQR: 53.0-61.5), and behavior (65.0, IQR: 60.0-69.0) across their respective dimensions, as well as overall SC (195, IQR: 184.5-208.5), followed by Damanhour and then Alexandria University (Table 2 ).

Regarding the sustainability constructs, sustainability knowingness obtained the highest median scores among students at the three universities, followed by sustainability behavior, with sustainability attitudes registering the lowest median scores.

Within the knowingness construct, the social dimension achieved the highest median score across all three universities, followed by the environmental and economic dimensions. Concerning sustainability attitudes, the social dimension once again secured the highest median scores among students at all universities, followed by the economic dimension, with the environmental dimension registering its lowest scores. Regarding sustainability behavior, the environmental dimension obtained the highest median scores, closely followed by the social dimension, while the economic dimension recorded the lowest median scores among students across the three universities.

Associations between Demographic Characteristics and Sustainability Consciousness

Table 3 shows statistically significant differences in SC based on various demographics. Although there was no significant difference in SC between males and females, age emerged as a significant factor (H= 24.65, p =0.000); students aged 22-<24 years obtained the highest median consciousness scores, while those aged ≥24 years obtained the lowest scores. The academic year also had a significant impact (H =18.45, p = 0.000), revealing that second-year students exhibited the highest consciousness scores.

Additionally, a significant difference in SC was found between rural and urban students (Z=3.623, p =0.000), demonstrating that rural students had greater SC. Family income and SDG familiarity (Z= 3.866, p =0.000 and Z=3.234, p =0.001, respectively) also contributed significantly to SC. Students from families with sufficient income and those familiar with the SDGs demonstrated higher levels of consciousness.

Predictors of sustainability consciousness among nursing students

The findings of the multiple linear regression analysis revealed different patterns in the predictors of SC among nursing students across the three universities (Table 4 ).

At Alexandria University, none of the predictor variables demonstrated significant associations with SC. However, at the university, age, sex, academic year, family income, and familiarity with the SDGs emerged as significant predictors. Specifically, being female strongly predicted higher SC ( p =0.000), while having no familiarity with the SDGs and insufficient family income were robust predictors of lower SC (p=0.000). Furthermore, being in their fourth academic year was associated with greater consciousness ( p =0.005). At university, familiarity with the SDGs was a significant predictor, with students lacking this familiarity displaying lower SC.

When considering the total sample, which included students from all three universities, the predictors were consistent with those found in Damanhour and Sohag universities. Age, place of residence, family income, and familiarity with the SDGs all emerged as significant predictors of SC. Older students from rural areas exhibited greater consciousness, while students with insufficient family income and no familiarity with the SDGs displayed lower SC. Notably, these predictors collectively explain only a tiny proportion of the variance in SC, accounting for 3.5% (R2=0.035) of the observed differences.

The primary purpose of this study was to investigate the level of SC among nursing students across three Egyptian universities: Alexandria and Damanhour in Lower Egypt and Sohag in Upper Egypt. Interestingly, the findings of the present study highlighted that more than half of the nursing students across these universities expressed a lack of familiarity with the SDGs. Although this finding differs from that of Zainordin et al. (2017), who showed that 90% of students in their study were familiar with the SDGs [ 40 ], it is consistent with previous studies that revealed alarmingly low awareness levels regarding SDGs [ 35 , 36 , 37 , 41 ].

The findings also revealed that across the three universities, students primarily relied on social media for information about the SDGs. Mass media, academic courses, and websites were used as secondary sources. This finding aligns with earlier studies on sustainability issues, indicating that the internet, mainly through social media platforms, stands as the predominant channel for acquiring knowledge among university students in Egypt [ 37 , 42 ], Malaysia [ 43 , 44 ], and even among educators in Italy [ 45 ]. Although the prominence of social media as a source for acquiring knowledge about sustainability issues might not be surprising, it raises concerns about the inadequate coverage of sustainability issues in academic settings [ 46 , 47 ].

In the current study, sustainability knowingness emerged as the dominant construct, with students achieving the highest median scores across the three universities, closely followed by sustainability behavior, while sustainability attitudes received the lowest median scores. The findings indicate that while students fully grasp sustainability concepts, their attitudes toward sustainability in all dimensions need to be further developed. This finding is not unique to this study; similar trends have been identified in studies conducted across different countries, indicating that even when students possess good sustainability knowledge and behaviors, their attitudes may not be proportionally affected [ 36 , 37 , 48 , 49 ]. This predominance of knowledge may be attributed to the fact that while social media, the primary information source for the students in the current study, allows easy access to factual information, contributing to their knowledge, it may not inherently promote the development of attitudes. Social media content tends to offer brief, isolated information designed for quick consumption and needs more context. Moreover, students may passively scroll through content without actively engaging in in-depth discussions and debates related to the SDGs necessary for attitude development toward sustainability.

Furthermore, the findings of the present study consistently revealed that the social dimension had the highest score for sustainability knowingness, followed by the environmental dimension, with the economic dimension consistently receiving the lowest score across all three universities. This finding aligns with a study conducted by Marcos-Merino et al. (2020), who found that Spanish students tended to allocate the highest scores to their sustainability knowledge in the social dimension [ 50 ]. Similarly, the students in the present study displayed more favorable attitudes toward social sustainability than toward other dimensions, supporting the observations of Ebrahim et al. (2022) [ 37 ], El-Hamed et al., 2022 [ 51 ], and Marcos-Merino et al. (2020) [ 50 ]. The students exhibited greater knowledge and held more positive attitudes toward social sustainability due to the widespread exposure to information and discussions on social sustainability issues such as poverty, social inequalities, and social justice. These topics frequently receive significant attention in Egypt's media and public discourse.

The nursing curriculum in the three universities under study also strongly emphasized social sustainability issues. Academic exposure to these issues likely enhanced understanding and cultivated positive attitudes toward social sustainability. Finally, the Egyptian culture's emphasis on social support and helping those in need might have influenced students to prioritize social sustainability issues as a cultural duty. Moreover, Egypt has launched the "Decent Life Initiative," targeting 4,500 underprivileged villages to uplift their social conditions and potentially benefit 60 million Egyptians [ 52 ]. Therefore, the students in this study may have felt compelled to engage in practical actions to address these challenges despite holding less favorable attitudes.

Interestingly, the students in this study expressed less favorable attitudes while simultaneously demonstrating a higher level of engagement in environmentally sustainable behaviors. This finding aligns with previous studies indicating that nursing students exhibited the highest scores for sustainability behavior in the environmental dimension, followed by the social dimension, while the economic dimension received the lowest scores [ 36 , 50 ]. The complex and global nature of environmental sustainability issues, particularly those related to climate change and pollution, has received significant attention in both the global and Egyptian media. For instance, the "Go Green Initiative," launched by the Egyptian Ministry of Environment, aims to promote environmental awareness, encourage behavioral change, and urge citizens, especially young people, to protect the environment. This extensive media coverage and initiatives have emphasized the seriousness of environmental issues and the urgent need to address them. Therefore, the students in this study might have felt driven to engage in practical actions to tackle these challenges despite holding less favorable attitudes.

Regarding economic sustainability, there is an apparent knowledge gap and low behavioral engagement among the students across the three universities. This may be attributed to students perceiving economic sustainability as less directly relevant to their future roles as healthcare providers. Thus, they might need to find it more worthy of attention. Similar results have been observed in previous studies conducted in Egypt [ 36 , 37 ]. This trend is not unique to Egypt, as studies on university students in Spain [ 53 ], Sweden [ 54 ], and India [ 49 ] have reported similar results.

Furthermore, the findings of the present study identified four significant predictors of SC: age, place of residence, family income, and awareness of the SDGs. In line with previous research conducted among college students in different countries [ 19 , 51 , 55 ], older students consistently exhibited higher SC levels than did their younger counterparts. This trend is attributed to older students' increased knowledge and experiences throughout their academic journeys. Therefore, it is no surprise that a significant association was found between students' SC and their academic years. Family income and prior knowledge of the SDGs were identified as predictors of sustainability consciousness. Consistent with earlier research, students from families with sufficient income [ 56 , 57 ] and those with prior knowledge of the SDGs [ 40 , 58 ] demonstrated higher sustainability consciousness levels than did their peers.

Regarding the place of residence, students in rural areas showed greater SC than did their urban counterparts. Although this finding differs from that of Akhter & Malaviya (2015) [ 59 ], it is broadly consistent with that of El-Hamed et al. (2022), who found that students in rural areas had significantly higher attitude scores toward environmental goals than did those in urban areas [ 51 ]. Rural areas may provide students with a direct connection to nature, fostering daily interactions with ecosystems that deepen their environmental appreciation and understanding of sustainability. Conversely, urban areas often contend with higher industrialization and urbanization.

The variation in place of residence likely contributed to the significant variations observed among the students from the three universities. Specifically, nursing students at the university demonstrated the highest median scores across all SC constructs, dimensions, and total SC scores, whereas students at Alexandria University showed the lowest median scores. The geographical, cultural, and socioeconomic context in which the university is situated likely played a role in this pattern. University in Upper Egypt is characterized by a predominantly rural landscape, and certain areas within this region lack access to essential resources such as water and electricity. These circumstances may drive residents, including students, to adopt sustainable consumption practices, fostering a culture of sustainability. Additionally, initiatives focused on poverty alleviation and sustainability promotion in rural Upper Egypt may have played a significant role in shaping the SC of the nursing students at Sohag University regarding sustainable practices.

Sohag University's commitment to sustainability is evident in its global ranking as the 400th most sustainable university worldwide in 2021, while Alexandria University is ranked slightly lower at 432nd place. In contrast, Damanhour University must still be classified in green university rankings. Moreover, in 2022, Sohag university was recognized as one of Egypt's most environmentally sustainable universities [ 60 , 61 ]. It strongly emphasizes sustainability initiatives and maintaining a green environment. These efforts include implementing various sustainability seminars, activities (e.g., tree planting), and programs to raise environmental awareness and ensure proper waste disposal [ 62 ]. Previous studies have indicated that students' participation in sustainable development activities positively influences their SC [ 51 , 63 ].

Limitations of the study

This study has several strengths, as it offers insight into an underexplored demographic: Egyptian nursing students. The utilization of validated questionnaires and a substantial, randomly selected sample from three universities enhances the credibility of the findings. However, the study's exclusive focus on these universities limits its generalizability to broader populations or other countries. The unique cultural, geographical, and socioeconomic characteristics of these institutions may constrain the transferability of the results to different contexts. To enhance generalizability, future research could consider a more diverse sample, including faculty, staff, and alumni, and compare sustainability consciousness and practices across various Egyptian universities with those from diverse international settings. Another limitation stems from the reliance on self-reported measures, introducing the potential for response biases such as social desirability or recall bias. Employing objective measures or observational methods could augment the robustness of the findings.

Additionally, the cross-sectional design provides a snapshot of the situation but needs to catch up in tracking changes over time or establishing causality. To mitigate this limitation, longitudinal studies could be implemented. Despite these limitations, this study significantly contributes to the expanding body of research on sustainability issues.

This study highlighted the sustainability consciousness among nursing students at three Egyptian universities. The study also highlighted the prevalent reliance on social media for information among nursing students across these universities, raising concerns about potential gaps in sustainability coverage within academic settings. This underscores the pivotal role of academic institutions in delivering comprehensive sustainability education, including integrating the SDGs into nursing curricula, particularly as a significant proportion of students in this study needed more awareness about the SDGs. Compared to Alexandria and Damanhour universities, Sohag University's notable commitment to sustainable extracurricular activities and practices has contributed to the greater SC of its students across social, environmental, and economic dimensions. Furthermore, the study identified age, place of residence, family income, and familiarity with the SDGs as consistent predictors of sustainability consciousness.

Implications of the study

The findings of this study hold significant implications across various domains including research, education, and practice. Firstly, Egyptian universities are urged to integrate Sustainable Development Goals (SDGs) into their nursing curricula, offering culturally sensitive sustainability education to tackle both local and global sustainability challenges effectively. Collaboration between policymakers and educators is imperative to develop interdisciplinary sustainability modules that foster holistic comprehension of sustainability, emphasizing the interconnectedness of environmental, social, and economic dimensions. Nursing programs should incorporate hands-on experiences like clinical placements and projects to facilitate the implementation of sustainable practices among students. Moreover, community engagement initiatives can be instrumental in addressing sustainability issues, allowing students to apply their knowledge in real-world scenarios. It is essential to provide comprehensive training for nursing educators to effectively impart sustainability concepts, thereby fostering a more sustainability-conscious mindset among students. Policymakers can facilitate knowledge dissemination by sharing successful strategies and case studies in sustainability education and healthcare sustainability with universities. In terms of research, identifying educational gaps in nursing curricula, conducting longitudinal studies to track the evolution of students' sustainability consciousness, and undertaking comparative research across different regions or countries are crucial avenues for advancing our understanding of sustainability in nursing education and practice.

Availability of data and materials

All data generated or analyzed during this study are included in this published article and its supplementary information files.

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Acknowledgments

We extend our sincere gratitude to all the nursing students at the research locations for their invaluable contributions and collaboration in this study.

Open access funding provided by The Science, Technology & Innovation Funding Authority (STDF) in cooperation with The Egyptian Knowledge Bank (EKB). No funding body was involved in the development and implementation of the study or the interpretation of the findings.

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Marwa Ahmed El-Sayed Mohamed: Conceptualization, design of methodology, investigation, data curation, Writing- Original draft preparation, Writing - Review & Editing.

Eman Ghallab: Conceptualization, Design of methodology, formal analysis, data curation, Writing-Original draft preparation, Writing - Review & Editing, Visualization.

Ragaa Abdullah Ahmed Hassan: Conceptualization, design of methodology, investigation, data curation, Writing- Original draft preparation, Writing - Review & Editing.

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Ethical approval was obtained from the Research Ethics Committee of the Faculty of Nursing at Alexandria University (Serial No: 2022-9-97) in Egypt. Permission to use the Sustainability Consciousness Questionnaire was obtained through email correspondence with the questionnaire's author. The rights and safety of the students are protected in line with the regulations, local laws, and ethical principles of the Declaration of Helsinki. The participants were clearly informed about the aim of the study. Students were explicitly informed that their participation in this study was voluntary and anonymous. They were assured that all the data would be treated with confidentiality and accessible only to authorized research team members. Informed consent was obtained from the students before the commencement of data collection.

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Mohamed, M.A.ES., Ghallab, E., Hassan, R.A.A. et al. Sustainability consciousness among nursing students in Egypt: a cross-sectional study. BMC Nurs 23 , 343 (2024). https://doi.org/10.1186/s12912-024-01990-1

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Maintaining health and well-being as we age

Although many older adults demonstrate high levels of resilience, they are also more prone to social isolation and loneliness than any other age group. Having strong social connections is especially important for mental health and well-being as we age, and is associated with lower instances of depression and anxiety.

Simon Fraser University (SFU) professor of mental health and aging Theodore D. Cosco researches a range of factors that promote healthy aging and resilience in older adults, from digital interventions to physical activity. He leads the Precision Mental Health Lab , a transdisciplinary research group dedicated to community-engaged and innovative technological approaches to improve well-being across all age groups.

One of his major research projects is studying data from the Canadian Longitudinal Study on Aging (CLSA). Cosco is a co-investigator on the CLSA, a national, long-term study of more than 50,000 Canadians who were 45 to 85 years old when the program began in 2009. Over 160 researchers from 26 universities across Canada are involved in the CLSA.

Cosco and colleagues, including three PhD students he supervises:  Lucy Kervin , Shawna Hopper , and Indira Riadi have found that during the coronavirus pandemic, the decreased ability to participate in social and physical activity was associated with increased risk of depression and anxiety in older adults.

These findings are outlined in Worsened ability to engage in social and physical activity during the COVID-19 pandemic and older adults’ mental health ,   published in Innovation in Aging .

We spoke to professor Cosco about his research.

What did your research reveal about older adults’ diminished ability to engage in physical and social activities during the coronavirus pandemic?

Our team used data from 24,108 participants surveyed during the first nine months of the COVID-19 pandemic and found roughly 22% screened positively for depression and 5% for anxiety.

Generally, older adults who reported worsened ability to participate in social and physical activities during the pandemic had poorer mental health outcomes than those whose ability remained the same or improved. We also found that participating in these activities had a buffering effect on depression and anxiety.

How does this research apply now that the pandemic is behind us? Do you have recommendations?

Our findings highlight the importance of fostering social and physical activity resources to mitigate the negative mental health impacts of future pandemics or other major life stressors that may affect the mental health of older adults. Beyond the pandemic these results highlight the importance of staying socially and physically active. You do not need to be socializing seven nights a week, nor do you need to be running marathons. Doing anything is better than nothing, so finding ways to integrate socializing and exercising into one’s life is an excellent strategy. Pick up the phone, walk to the shops, or find a way that you can integrate activity into one’s own life.

How do you approach the study of vast amounts of data from the CLSA? Do you have specific research questions to investigate, or does the study reveal topics that you want to pursue?

When working with large datasets, it is crucial to understand the types of data included, their collection dates and their sources. Once familiar with the available data, you can delve into current research and literature to formulate hypotheses. With extensive datasets, specificity in your initial hypotheses and deliberate in your analysis approaches are vital. Because of the dataset's size and the significant statistical power it provides, running numerous models to explore every possible outcome can often lead to “statistically significant” findings that occur by chance. This practice, known as “fishing” or “data dredging,” is discouraged because it may result in misleading associations. Therefore, it's important for us to be very purposeful in testing our hypotheses to avoid these issues.

In a previous Scholarly Impact of the Week, you discussed how during the pandemic older adults and their families quickly adopted the use of technology to increase connectedness. Is this trend still going strong, and do you have new insights on technology and older people?  

During the pandemic, older adults and their families rapidly embraced technology to stay connected, a trend that remains strong today. This period really spotlighted both the advantages and limitations of our current technology. It became clear that tech companies need to move away from a one-size-fits-all approach. Products specifically designed with older adults in mind—taking into account their unique needs and preferences tend to be more successful. These intentionally crafted tools are not only more widely accepted but also have a more significant impact. The pandemic has shown us the importance of such tailored technology solutions in enhancing social connectedness for older populations.

For more: See professor Cosco’s previous Scholarly Impact of the Week article, Understanding the impacts of COVID-19 on older adults , and visit the Precision Mental Health Lab web page.  

SFU's Scholarly Impact of the Week series does not reflect the opinions or viewpoints of the university, but those of the scholars. The timing of articles in the series is chosen weeks or months in advance, based on a published set of criteria. Any correspondence with university or world events at the time of publication is purely coincidental.

For more information, please see  SFU's Code of Faculty Ethics and Responsibilities  and the  statement on academic freedom .