Climate Change and Sustainability in Health Professions Education: A Realist Review Protocol

Defining the scope of the review

This realist review will focus on CC&S education interventions across various formats—including online, in-person, workplace, classroom, and group-based settings—targeting healthcare professionals and students from disciplines such as medicine, nursing, dentistry, pharmacy, and allied health. By including studies from undergraduate, postgraduate, and continuing professional development contexts, the review aims to capture a comprehensive picture of how CC&S education is being implemented and evaluated globally. The scope is further defined to incorporate empirical research—both published journal articles and relevant grey literature—that assesses intervention effectiveness, using quantitative, qualitative, or mixed-method approaches. This focus and these boundaries ensure that the review concentrates on interventions directly impacting educational practices and outcomes, while excluding non-empirical work, studies outside healthcare, non-educational interventions, and theoretical papers without practical implementation. This deliberate framing facilitates a nuanced understanding of what works, for whom, and under what conditions in CC&S education within HPE, thereby providing actionable insights for curriculum design and policy development.

Initial Programme Theory

The Initial Programme Theory (IPT) for this realist review was developed through an iterative process, integrating existing literature, curricular documents, and theoretical frameworks. The IPT serves as the starting framework for the review, outlining how CC&S education interventions are expected to work, for whom, and under what conditions.

A structured theoretical approach guided the development of the IPT, focusing on three key dimensions necessary for embedding CC&S education: (1) behavioural change, (2) effective learning, and (3) institutional integration.

To address behavioural change, the COM-B Model was selected for its focus on how Capability, Opportunity, and Motivation interact to shape learners' ability to engage with CC&S practices⁴². Additionally, the Theory of Planned Behaviour explains how attitudes, social norms, and perceived behavioural control influence whether learners adopt CC&S behaviours in their professional practice⁴¹.

For effective learning, multiple theories were incorporated. Social Constructivist Learning Theory emphasises collaborative learning, experiential knowledge-building, and social interactions, all of which are critical for CC&S education. Transformative Learning Theory highlights how learners undergo perspective shifts through critical reflection and real-world engagement⁴⁰, that could lead to long-term commitment to CC&S principles. Sociocultural Learning Theory emphasise learning takes place through engagement within a social context, encompassing both formal education (structured, intentional instruction) and informal learning (implicit understanding of norms and practices within a given setting)³⁹. It underscores that individuals are part of a larger social whole, where learning occurs through active participation in meaningful activities. In CC&S education, this means not just acquiring knowledge but continuously shaping and being shaped by one’s professional and environmental context.

For institutional integration, Normalisation Process Theory⁴³ can be used to examine how CC&S education can become embedded in healthcare curricula and professional practices, focusing on processes of adoption, implementation, and sustainability. The Consolidated Framework for Implementation Research⁴⁷ provides a structured way to assess barriers and facilitators at multiple levels, including organisational culture, leadership engagement, and policy alignment.

A key step in developing the IPT involved reviewing curricular documents from HPE to identify intended learning outcomes, pedagogical approaches, and competency frameworks related to CC&S education⁴⁸. This helped establish potential contexts for CC&S education, such as interprofessional learning environments, problem-based learning approaches, and experiential simulations. Additionally, it outlined anticipated outcomes, including enhanced sustainability literacy, clinical decision-making informed by planetary health principles, and advocacy for sustainable healthcare practices.

This refined IPT will guide the analysis of evidence, ensuring that CMO configurations are systematically explored to understand what works, for whom, and under what conditions in CC&S education.

Search strategy

For this review, an initial comprehensive electronic literature search will be conducted across relevant databases, including Academic Search Complete, Australian Education Index, British Education Index, Business Source Complete, CINAHL, Embase, ERIC, PsycINFO, PubMed, Scopus, and SocINDEX, as well as grey literature sources. The search will target literature discussing climate change and sustainability interventions aimed at enhancing health professions education.

The systematic search strategy is built around three keyword groups: (1) healthcare professionals, (2) climate change and sustainability, and (3) education interventions, linked using Boolean operators (OR and AND). Wherever possible, a combination of free-text terms and Medical Subject Headings (MeSH) terms will be used to optimise search sensitivity. The final search strategy is detailed in Appendix 2, with adaptations made for different databases to ensure transparency and reproducibility. Searches will be restricted to titles and abstracts, and the process may involve multiple rounds of searching to refine and investigate specific areas of interest in greater detail.

Additionally, backward and forward citation tracking will be employed to enhance the comprehensiveness of the review. Backward citation tracking will be done by checking reference lists of selected articles and forward citation tracking will be done by using citation indexes such as Scopus and Web of Science to identify more recent studies that have cited key articles, ensuring the inclusion of the latest research developments in CC&S education in HPE.

Selection criteria

Inclusion criteria:

•    Studies reporting on CC&S educational interventions in any format, e.g. online, in-person, workplace, classroom, small group, large group, any duration, etc.,

•    Studies reporting on health professionals and students from a range of health disciplines, such as medical doctors, nurses, dentists, pharmacists, dietitians, dispensing opticians, medical scientists, occupational therapists, optometrists, physical therapists, physiotherapists, podiatrists, chiropodists, radiographers, radiation therapists, speech and language therapists and clinical biochemists. Various levels of training (e.g., undergraduate, postgraduate, CPD) will be included,

•    Studies reporting on evaluation of the intervention,

•    Studies that are empirical journal articles or grey literature containing empirical data,

•    Quantitative, qualitative, and mixed-method studies,

•    Studies published between January 2014 and October 2024,

•    Studies published in English.

Exclusion criteria:

•    Non-empirical studies including commentaries, letters, editorials, and reviews,

•    Studies not related to healthcare students or professionals.

•    Non-educational interventions (e.g., clinical interventions, policy interventions)

•    Papers reporting on educational frameworks or curriculums without implementing an intervention.

Selection process

Studies identified through the database search will be exported to Covidence for screening. Duplicate records will be removed automatically by Covidence and manually verified by one reviewer. The title and abstract screening will be conducted independently by two reviewers, who will regularly meet with the research team to discuss progress and resolve any uncertainties. If disagreements arise, a third reviewer will be consulted to make a final decision. Articles will be excluded if they do not meet the inclusion criteria.

During screening, reviewers will have access to bibliographic fields, including title, abstract, authors, journal name, and year of publication, and will not be blinded to these details. For full-text screening, the research team will first conduct a pilot screening with a sample of studies to ensure consistency. Full-text screening will also be performed by two independent reviewers, who will be blinded to each other’s decisions.

If full-text access is unavailable, the research team will attempt to contact the corresponding authors via email. These communications will remain confidential, and no metadata will be shared. However, efforts to obtain full texts will be documented, including the number of authors contacted and the outcomes of these requests.

This screening process balances methodological rigour with researcher resources, ensuring a systematic and transparent selection of studies while maintaining consistency and reliability in the inclusion process.

Data extraction

A structured data extraction process will be implemented to systematically collect study characteristics, intervention details, evaluation methods, and Context-Mechanism-Outcome (CMO) configurations. Data extraction will be conducted using two tools: a Microsoft Excel spreadsheet to document general study characteristics and a CMO Data Extraction Template specifically designed to identify and record CMO configurations.

The Excel spreadsheet will capture key study characteristics, including title, author(s), year of publication, study type, a description of the intervention (including format, duration, and delivery method), details on how the intervention was evaluated, and the population involved (e.g., healthcare discipline, student or professional level).

In parallel, the CMO Data Extraction Template will focus on identifying mechanisms and contextual factors influencing the effectiveness of CC&S education interventions. This template consists of two primary components: a Contextual Information Table, which captures key details such as the target population and educational format used (e.g., online, in-person, workshop, integrated curriculum), and a CMO Table, where explicitly stated or inferred CMO configurations are recorded, providing insight into how specific contexts influence mechanisms to produce particular outcomes.

Additionally, the template includes a quality and relevance assessment section, where reviewers will evaluate the strengths and limitations of each study, assess its richness in identifying CMO configurations, and determine its usefulness in refining the programme theory. To ensure rigour and reliability, two independent reviewers will extract data from each study. Regular team discussions will be conducted to review and refine the CMOs, resolve any disagreements regarding what constitutes a CMO, and ensure a systematic approach to data extraction. This iterative process will help refine the programme theory, ensuring that the evidence collected contributes meaningfully to understanding what works, for whom, and under what conditions in CC&S education interventions.

Analyses and synthesis

The analysis and synthesis process will involve systematically reviewing all Context-Mechanism-Outcome configurations extracted from individual studies to identify patterns and regularities across the dataset and to identify common mechanisms, the contexts in which they operate, and the outcomes they produce. This process will be iterative, allowing for continuous refinement of the initial programme theory as new insights emerge.

The refined programme theory will be developed based on the evidence, integrating key findings from the literature to enhance its explanatory power. Results will be reported in a narrative synthesis, supported by summarised data in table format to present key contextual information, mechanisms, and outcomes in a structured manner. Additionally, a graphic representation of the final programme theory will be created to visually illustrate the relationships between contexts, mechanisms, and outcomes, providing a clear and accessible framework for understanding the findings.

Ethics approval and consent to participate

Not applicable

Consent for publication

Not applicable