Climate-Responsive Nursing: Meta-Analysis and Revision of Nightingale’s Framework

This study addresses the urgent intersection between climate change and nursing, recognizing nurses as both frontline caregivers during environmental crises and a workforce uniquely vulnerable to climate hazards. Climate change intensifies stress on health systems through heatwaves, floods, wildfires, and air pollution, all of which directly affect the well-being, performance, and safety of nurses. Despite increasing evidence of these impacts, the literature had remained fragmented, and nursing theory had not adequately accounted for climate instability.

We conducted a systematic review and meta-analysis of studies published between 2000 and March 2025, following PRISMA 2020 guidelines. Thirty-eight studies from 16 countries, involving over 45,000 nurses, were included. Data were analyzed using random-effects models with REML estimation. Risk of bias was appraised with ROBINS-I, and certainty of evidence graded using GRADE. Outcomes of interest included burnout, absenteeism, missed care, and medication errors under climate hazards.

The findings were striking: heatwaves increased the risk of nurse burnout by 45%, wildfire smoke exposure raised absenteeism by 32%, floods doubled the odds of missed care, and extreme heat increased medication errors by 28%. Effects were stronger in intensive care settings and in low- and middle-income countries, highlighting inequities in health system resilience. Publication bias was evident, and most evidence was of moderate to low certainty, but the overall trends were consistent across contexts.

Beyond empirical synthesis, this study advances theory by revising Florence Nightingale’s Environmental Framework. We propose the Climate-Responsive Environmental Theory of Nursing, which adds “climate stability” as a sixth pillar alongside Nightingale’s original five (air, water, drainage, cleanliness, and light). This update situates nursing within the planetary health paradigm, ensuring the discipline remains conceptually relevant in an era of environmental instability.

Policy implications are immediate: climate adaptation must be embedded in nursing education, workforce planning, and hospital preparedness. For Israel in particular — a climate hotspot exposed to recurrent heatwaves and desert dust storms — protecting nurses means protecting patients and safeguarding the resilience of the health system.