Jacq Attacqs: Sustainable Nursing Literature

Empowering a Nurse-Led Fight Against Climate Change: A Financial Analysis of a Retention and Waste Reduction Strategy (excerpt)

by   Jacqueline Marois, BSN, RN-BC, MEDSURG-

BC, CN IV

       Masters in Public Administration (MPA) in Sustainability Candidate

Abstract

The nursing profession has evolved alongside human health needs, and conditions have certainly changed since Florence Nightingale carried her lamp. Becoming ever more holistic, the modern nurse expands to fit the needs of the population she serves. The United Nations, The World Health Organization, and scientific researchers across the board cite climate change as one of the biggest current threats to human health: complicit in an expected 250,000 extra human deaths annually over the next 25 years (WHO.int, 2025), yet common health care practices still contribute to rising temperatures and growing landfills. Therefore, environmentally-conscious nursing is a natural next stage of the profession’s evolution.

Climate change factors like supply chain disruptions and excess waste are compounded by costly nursing retention issues. To be viable as a business and optimize nurse talent utilization, health systems should consider supporting nurse-led inquiry projects, particularly in the realm of sustainability. At present, nurses have no formal training on—or responsibility for—sustainable practices, though they are well-suited for insightful environmental leadership roles (Luque-Alcaraz & Aparicio-Martínez, 2024). A dedicated nursing position to properly assess health care waste--and develop solutions--is warranted. Further exploration of the nursing role in this field is needed, as well as the development of financial and program models for optimal staff utilization in projects.

The financial impact of healthcare waste has been made clear in the literature, but what lurks beneath is the cost of poor nurse retention. High-demand programs for nurse development have been successful in reducing hospital operating expenditure by retaining nurse hires (Moran, et al., 2020; Roush & Opsahl, 2023). Nurses surveyed at Stanford Health Care indicated an interest in improving sustainability in their practice, and nurse-led research identified an annual $851,000.00 of unnecessary waste in the form of unused supplies from one care region. The investment in nurse-led ecological research is a lucrative opportunity on the healthcare horizon, and its value cannot be understated in the fight to save the planet. This paper presents a financial model for evaluating the net financial impact of creating a sustainability-focused nursing role at Stanford Health Care, leveraging the dual opportunity of waste reduction and nurse retention.

Literature Survey

The purpose of this review is to identify assumptions used to analyze the financial viability of bridging nursing and sustainability at Stanford Health Care (SHC).

A literature review was conducted using search terms including: “eco-conscious nursing”, "nurses as environmental leaders”, "sustainability in nursing”, "eco-friendly nursing”, "supply waste in healthcare”, "healthcare waste costs”, "sustainability practice supervising”, “sustainability health care frameworks”, “nurse retention”, “the cost of a nurse”, “hiring and training the new nurse”, and “nurse specialists”

Five relevant umbrella topics emerged covering what the literature had to share, including: 

• Health Care Waste and the Call to Action

• Nurses are Uniquely Poised as Environmental Leaders

• Nurse Institutional Value and Cost

• The Nurse’s Role in Financial Decision Making

• Nurse-Driven Quality Improvement Projects (QIPs)

  
  

But the true financial problem interwoven throughout nursing and sustainable health literature is nurse employee retention. A well-documented cost-saving benefit exists in retaining nurses, particularly given the profession’s high turnover rate—19.5% of nurses do not make it past the first year (Roush & Opshal, 2023). The cost of turnover in nursing, according to the American Organization for Nursing Leadership, is approximately $40,038 per bedside nurse (AONL, 2025), and in the San Francisco Bay Area where the cost of living is high, this number is likely a very conservative representation. Nurses seeking to leave the field for one reason or another may be persuaded to stay if their work area, focus or role changes, especially if they were able to retain their income. 

Examples of nurse retention efforts exist: the most effective ones support nurse-led quality improvement projects (QIPs) (Roush & Opsahl, 2023), but barriers exist to nurse involvement in evidence-based practice research (Watson, 2022). This review seeks to demonstrate that nurse retention improves by engaging resources toward nurse project management in relevant, impactful work. It may even result in waste reduction and a net cost savings for the health system.

Health Care Waste - A global issue

Health care waste (HCW) is a growing global concern with serious environmental and financial implications. If healthcare were a country, it would rank fifth in global emissions, due in large part to incineration and landfill practices (Gray et al., 2025). Medical waste makes up 1–2% of total urban waste (Janik-Karpinska et al., 2024), and nearly all of it passes through the hands of nurses. Due to this proximity to the problem, a dedicated nursing role focused on optimizing bedside supply practices aligns directly with HCW reduction strategies.

In the United States, hospitals produce immense volumes of preventable and often recyclable waste. At Stanford Health Care (SHC), data from 2023 revealed that nearly 30 tons of unused medical supplies were discarded annually from Adaptive Acuity Units (AAUs), equating to 1.96 lbs of unnecessary waste per patient, or $851,100 in supplies never used. This data, gathered through a nurse-led waste reduction fellowship in partnership with the Sustainability Program Office (SPO), suggests a compelling opportunity for further financial analysis and targeted, nurse-led interventions.

This snapshot reveals only part of a much larger issue. Many hospital departments—especially those with higher waste volumes and stricter infection protocols—contribute even more to HCW. Most existing literature focuses narrowly on high-waste areas like operating rooms or ICUs, often in small samples. This leaves a major data gap in large, less-studied regions such as AAUs, which include medical-surgical, step-down, telemetry, and non-ICU specialties. These units may contribute less per patient but are more adaptable and scalable for system-wide change, making them ideal testing grounds for nurse-led sustainability projects.

Global public health organizations have long warned about the risks of poorly managed medical waste. According to the WHO, 15% of HCW is hazardous and poses threats to soil, water, and human health (WHO, 2025). Yet many institutions lack robust waste protocols, leading to the incineration of benign materials and unsafe disposal of hazardous ones. The growing use of single-use devices, while critical for hygiene, further escalates the problem. Janik-Karpinska et al. (2023) note hospitals can generate up to 11 kg of hazardous waste per bed per day—most of which ends up in landfills or incinerators.

Bentley et al. (2008) proposed a conceptual framework for addressing HCW through reduction, reuse, recycling, and improved inventory systems, yet much of the literature is outdated or fails to address AAU environments. A more systemic approach is needed—not only for environmental reasons but also for the financial benefit of healthcare systems, which can achieve substantial savings through localized, specialist-led waste reduction strategies.

The real-world findings from SHC reinforce a broader health care provider call to action. Health systems already prioritize sustainable waste management as a core operational goal. Nurse-led initiatives, grounded in practical data and implemented in adaptable units like the AAUs, offer a path forward that is both environmentally and financially responsible.

Nurses as Environmental Leaders

As the largest group of healthcare workers, nurses are uniquely positioned to lead the transformation toward sustainable practice. Their direct contact with patients and medical supplies gives them firsthand insight into daily waste and inefficiencies. Positioned at the center of care delivery, nurses are well-suited to identify environmental challenges and assess the feasibility of proposed changes. Yet, despite their proximity to the problem, they often lack formal training or support to lead sustainability initiatives (Watson, 2022). This gap presents an opportunity: with the right infrastructure, nurses can become powerful agents of change in areas such as waste reduction, recycling, and eco-conscious practice adoption.

Recent studies, including research conducted during the Nurse Fellowship program at Stanford Health Care (SHC), demonstrate that nurses are not only aware of the environmental challenges within their institutions but are eager to engage in improvement initiatives (Akore Yeboah, et al., 2024). When surveyed, a significant number of SHC nurses expressed interest in participating in sustainability efforts at work, indicating a clear readiness to become environmental leaders. This aligns with findings in literature that nurses, when provided with the tools and platforms to engage in sustainability, show strong motivation to contribute to organizational change (Watson, 2022).

Institutional culture plays a key role in supporting nurse engagement. Research shows that hospitals with strong quality systems, opportunities for professional growth, and high social capital tend to foster nurse engagement and retention (Moran, 2020; Roush & Opshal, 2023). These same factors create fertile ground for embedding sustainability into organizational culture. Globally, nurses are already taking on environmental leadership roles. In the United Kingdom, the Green Healthcare Leadership Programme—a partnership between Nuffield Health and the Florence Nightingale Foundation—showcases nurse-led sustainability projects, such as replacing single-use laryngoscope handles with reusable alternatives in the OR, reducing battery and plastic waste (Stables, 2024). These interventions, implemented in a nurse’s own work area, model how change can begin on the unit level, and results can be shared far and wide.

SHC has shown institutional support for such types of leadership in approving the nurse-led Sustainability Fellowship. Receiving the Joint Commission’s Sustainable Health Care Certification reflects SHC’s commitment to sustainability, particularly through leadership engagement (Moskal, 2024). These actions set the stage for nurses to lead future change.

Gray et al. (2025) emphasize that interdisciplinary communication and collaboration are key to successful sustainability efforts. Nurses, as essential team members, can lead initiatives ranging from waste reduction to green procurement and policy advocacy. The “Triple C” model—Consultation, Collaboration, and Consolidation—offers a simple framework to ensure nurse-led projects are impactful and enduring (Khalil, 2021). With formal education and dedicated roles, nurses could be fully equipped to lead sustainability strategies throughout the health system.

Despite their capacity and interest, nurses often lack the institutional support and training needed to lead these efforts. By creating structured roles and providing the necessary resources, healthcare systems can unlock the untapped potential of nurses as environmental leaders—empowering them to champion sustainable practices at every level of care.

The Institutional Value and Cost of Nurses

Nurses are a vital asset to any healthcare institution, but their financial value is often overlooked. The cost of hiring and onboarding a new nurse—between $28,400 to $51,700 (NSI Nursing Solutions, 2025)—can strain budgets, with high turnover rates exacerbating the situation. Despite this, in times of belt-cinching, many hospitals cut nursing budgets first. Retaining nurses through engagement in sustainability initiatives could result in a significant reduction in nurse turnover costs AND, if utilized appropriately, waste minimization.

The U.S. Bureau of Labor Statistics (BLS) hourly mean cost for employing civilian nurses in 2024 was $75.51 (with a relative standard error of 0.3), with a mean salary of $126,030 (U.S. Bureau of Labor Statistics, 2025). The BLS also released the Employer Cost for Compensation as of December 2024, which shares that for U.S. nurses an average of 65.4% of the total income went to wages, and the remaining 34.6% was paid as benefits, including: paid leave, supplemental pay, insurance, and retirement (U.S. Bureau of Labor Statistics, 2025). While the BLS provides data on wages and compensation, it doesn't specify hiring costs.

Industry estimates suggest that costs of replacing a nurse, as expected, can vary greatly based on location and facility size. Nurses at SHC can make upwards of $200,000.00 gross annually, so national averages are helpful when building models for nurse sustainability roles that can be applied or imagined elsewhere. Nurse leaders, on the other hand, make significantly less than those at the bedside, especially in California (comparison of average salaries by location and timeframe can be found at https://www.ziprecruiter.com/Salaries/Nurse-Leadership-Salary). These nurse leaders, in positions that already exist, would have a portion of their work expectations allocated to first program design and ultimately advising the Sustainability Nurse through her project(s) (Begley, et al., 2020).

If the long reign of nursing as the most trusted profession (Walker, 2025) is any indicator, nurses are wise advisors on a number of topics, specifically in regards to their speciality. The Nursing Human Capital Value Model, as proposed in the International Journal of Nursing Studies, “recognizes nursing as an essential, revenue-generating, human capital asset”, and with concordant effort, nursing professional development can optimize and maximize a nurse’s true value (Yakusheva, et al, 2024). A critical aspect of nurses' potential value lies in their human capital, though it is more difficult to quantify. According to Yakusheva et al. (2024), nurses are not just frontline caregivers but valuable human capital assets that can drive organizational performance. They propose that recognizing and investing in nursing leadership, particularly in sustainability initiatives, could yield significant returns. However, while the potential is clear, further research is needed to quantify the economic impact of nurses in sustainability roles and development of a program model that provides optimal support for the position. Specifically, studies on the cost-benefit analysis of employing nurses as sustainability leaders and their long-term financial return to hospitals remain sparse. This highlights a need for EBP research that quantifies nurse-driven sustainability projects' financial impact, which could ultimately reshape the way healthcare institutions view and invest in their nursing staff. Such research could be the catalyst for proving that nurses, as human capital, are pivotal in both enhancing healthcare quality and reducing healthcare costs.

The Nurse’s Role in Financial Decision Making

Bedside nurses, despite being integral to daily operations, are often excluded from high-level financial decision-making processes, yet their proximity to patient care and hospital operations uniquely positions them to analyze and guide cost-saving plans (Begley, et al, 2020). These nurses are expected to be involved in major health care decision making at the bedside, but only a select few engage in institutional decision making. Leadership courses in nursing school claim that nurses have a stake in policy making and house-wide educational initiatives. But where do nurses actually stand in the finance and budgeting sector of health care? Nurse management has some say in the budget for their specific units, and nurses have the opportunity to make their voice heard in Shared Leadership Council or union contract voting. Nurse managers can directly influence budgets in areas like staffing, supplies acquisition, and patient care delivery models, potentially reducing waste…but does this come from the lens of sustainability, or simply the most immediate cost reduction? And are we really operating at our most efficient or productive?

The typical healthcare system's failure to operate like a business may contribute to undervaluing nurses capacity for financial analysis, and explains why they may shy away from novel opportunities with potential return on investment in favor of meeting regulations and standards [though, these should be viewed as compliments to each other “rather than mutually exclusive”, according to Begley, et al. (2020)]. This gap underscores the need for more rigorous research, particularly in areas like the AAUs where nurses with specialized knowledge in data analysis or finance could drive meaningful improvements in operating expenditures. 

Reduced nursing budgets lead to understaffing and fewer professional development opportunities—two major contributors to nurse turnover. As Teisberg et al. (2020) point out, health systems often fail to operate with the long-term investment mindset of typical businesses, prioritizing short-term savings over strategies that offer greater present value. Financial decision-makers may gain clarity on the return of investing in nurse-led initiatives through cost-benefit tools like Net Present Value (NPV) and the simpler but less comprehensive Payback Period analysis. Compared to reactive cost-cutting or hiring costly travel nurses, long-term investment in nurse retention and waste reduction is both financially and operationally smarter.

The evolving role of nurses in interdisciplinary leadership teams is promising (Gray, et al., 2025), where they can be more actively involved in cost-related decisions. Nurses with specialized training are well-fit for choosing other decision-making partners, depending on their experience and goals. For example, the Middlebury Institute of International Studies' MPA in Sustainability blends sustainability management with skills in data analysis and finance, providing professionals with expertise that can connect their professional work requirements and sustainability budgetary choices.

The potential for nurses to participate more in financial decision-making, particularly when it comes to cost containment (e.g., inventory management, optimizing staff retention, and reducing waste) increases as more research shows their potential for such work. Nurses' hands-on knowledge of operational inefficiencies gives them valuable insight into reducing unnecessary spending, but this is not reflected in current practice.

Nurse-Driven QIPs

Nurse-led quality improvement projects (QIPs), especially those focused on sustainability, offer an innovative approach to reducing healthcare waste, improving nurse retention, and generating substantial financial savings. These initiatives not only enhance patient care but also produce measurable cost reductions for hospitals. High levels of nurse engagement in QIPs are strongly linked to improved retention (Watson, 2022). One study found that a 10% increase in nurse retention can save a hospital $2.6 million or more annually in recruitment and training expenses (NSI Nursing Solutions, Inc., 2025). This makes a convincing case for structured support of nurses as they lead performance improvement efforts. Hospitals need professionals who understand both clinical operations and the associated financial and environmental data. As Watson (2022) elaborates, gaps in nursing environmental science research need filling, and though the perspective of the nurse is valuable, their capacity for scientific EBP work is lacking. At institutions like Stanford Health Care, there is significant enthusiasm for sustainability, but nurses are rarely given formal roles or responsibilities to lead these efforts. This lack of structure slows meaningful progress. 

A dedicated, researcher- and leadership-supported role for nurses in sustainability leadership is essential to effectively reduce healthcare waste in the form of QIPs. As Gray et al. (2025) has shown, nurses are integral to the success of QIPs, especially when supported with high-functioning interdisciplinary teams. When nurses are empowered to lead or participate in sustainability projects, organizations can improve their environmental impact, reduce operational costs (particularly in waste management) and strengthen nurse retention. This, in turn, fosters a deeper sense of purpose, connection, and engagement among staff—factors that are critical for building a resilient and financially sustainable healthcare workforce (Moran et al., 2020).

Summary of Key Assumptions

This review identifies several key assumptions to inform financial model development for a Sustainability Nurse role:

Unused supply waste currently costs SHC approximately $850,000 annually;

the average cost of replacing a nurse is approximately $40,000;

and nurse-led quality improvement projects both reduce waste and increase retention.

Nurses are well-positioned to be adept leaders in hospital cost-saving projects, and such projects have been successful at improving nurse institutional buy-in. These findings provide the foundation for assessing whether investing in a full-time Sustainability Nurse role yields a positive return on investment over time. 

*omitted financial review to protect Stanford Health Care research and my own Masters financial analysis work

Call to Action

By integrating sustainability into nursing practice, SHC can simultaneously: reduce costs; improve nurse retention; build organizational capacity for innovation; and lead the industry in climate-conscious care delivery. Healthcare’s climate impact is immense, but so is the opportunity for change. Nurses, with the right support, can lead that change—benefiting both the bottom line and the health of our communities. The time to bring nurses to the sustainability table has arrived, and the profession will never be the same. 

What other ideas or practices do you have for engaging nurses in sustainable practice? Please share your thoughts with me: jacqattacqs@gmail.com.

Author is not sponsored by any of the referenced websites or journals. Intended for entertainment purposes only, not to diagnose, treat, advise or instruct. Please contact directly for editing and citation requests @ jacqattacqs@gmail.com

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