Still Rowing Upstream in Climate Health Advocacy and Nursing Reform

Despite widespread recognition of climate change as the most significant health threat of the 21st century (World Health Organization 2025), efforts to address its health impacts remain fragmented, reactive, and marginalised within dominant global healthcare systems structured around curative and episodic care (Kern et al. 2024). For nurses leading climate-responsive healthcare reform, this context evokes a sense of déjà vu. Much like the historical struggle to integrate both health promotion and prevention into mainstream healthcare, addressing climate change continues to feel like rowing ‘upstream’. The metaphor of rowing ‘upstream’ has long been used in public health to describe the challenge of addressing the root causes of ill health, particularly within systems that privilege treatment over prevention (McMahon 2021). Climate change, as a health determinant, has added complexity to this analogy. Nurses, the largest and most trusted health workforce, are uniquely positioned at the frontlines of the climate crisis, not only witnessing its health impacts firsthand but actively responding with ingenuity and care (Ward et al. 2024). Across diverse settings, they adapt rapidly to emerging challenges, advocate for the needs of vulnerable populations and deliver continuity of care in the face of disruption. Yet, their capacity to lead systemic change is often limited by structures that undervalue prevention, silo responsibility and prioritise short-term responses over long-term resilience. Despite this, nurses continue to push boundaries by modelling low-emission care, innovating within communities and building bridges across sectors. This commentary calls for that leadership to be fully recognised, resourced and embedded at every level of climate-health policy and practice. Calls for a ‘Health in All Policies’ approach from global health authorities - including the World Health Organization (2025) and The Lancet Countdown (Romanello et al. 2024) have yet to be fully realised in practice. Even where national strategies now include climate and health considerations, such as the Australian Health and Climate Strategy (Australian Government Department of Health and Aged Care 2024a), funding and implementation mechanisms remain overwhelmingly reactive and curative. Nurses seeking to lead climate-health adaptation and resilience responses find themselves in a space that is underfunded, undervalued and misaligned with mainstream health priorities. Climate change has a profound direct, indirect and intergenerational impacts on human health. These include increased morbidity and mortality from heatwaves, respiratory issues from bushfire smoke, rising rates of vector-borne diseases, mental health distress following extreme weather events and disruption to food and water security (Beggs et al. 2025). Marginalised communities, including First Nations peoples, are disproportionately affected due to deep connections to land, historical dislocation and structural inequities that amplify vulnerability to climate extremes (Redvers et al. 2022). Despite a growing evidence base, climate change remains largely peripheral within mainstream health policy and service planning. Across many jurisdictions, systemic responses continue to prioritise downstream clinical interventions, while upstream, preventative and equity-driven climate-health strategies remain underdeveloped, underfunded and politically sidelined (Dixit and Sambasivan 2018). This persistent misalignment reflects longstanding tendencies to privilege acute, episodic care over holistic, preventative models capable of building resilience at the community level. While recent investments in some countries, such as commitments to renewable energy and infrastructure in Australia signal some movement towards broader climate resilience, explicit, sustained investment in climate-resilient health systems remains minimal in most settings (World Economic Forum 2025). Health sector adaptation is often assumed to occur by proxy, rather than being the focus of dedicated planning and funding. Without targeted strategies that centre prevention, community-led adaptation and health equity, health systems globally will remain poorly positioned to manage the escalating and unequal impacts of climate change. The field of health promotion has long struggled under the shadow of curative medicine. Since the Ottawa Charter (World Health Organization 1986), health promotion advocates have pushed for upstream investment, action on social determinants and greater community agency. However, these efforts have often been relegated to the margins of health system priorities – valued rhetorically but rarely embedded structurally. Climate-health initiatives, while sharing some parallels with health promotion, extend beyond traditional frameworks. Addressing the health impacts of climate change requires cross-sectoral collaboration, long-term planning and community engagement, which are foundational to health promotion. Environmental degradation demands systemic attention, through an approach that prioritises planetary health and intergenerational justice. Despite these urgent imperatives, climate-health initiatives like health promotion, are often characterised by short-term, project-based funding, siloed implementation and limited integration into mainstream health planning. Leadership roles for nurses in these spaces are underdeveloped, and their capacity to influence systems change is limited by institutional and structural barriers (Kalogirou et al. 2021; Rempel et al. 2024; Terry and Bowman 2020). As with preventative healthcare more broadly, nurses seeking to embed climate considerations into practice frequently find themselves operating on the periphery of decision-making structures and funding priorities, despite their potential to drive transformational change. Nurses bring deep expertise in advocacy, prevention and systems thinking—capabilities that are essential in addressing the complex health impacts of climate change. As trusted professionals embedded across communities and health systems, nurses offer unique insights into the vulnerabilities, strengths and opportunities for resilience that might otherwise be overlooked (Levett-Jones et al. 2024). Climate-responsive nursing leadership must extend beyond the clinical setting to influence policy, funding decisions and service design. Advocating for integrated models of care that prioritise sustainability, resilience and health equity is no longer optional. It is fundamental to supporting community wellbeing. Nurse-led initiatives, particularly in primary healthcare, disaster preparedness and community-based adaptation, offer critical insights into what adaptive, community-centred and low-emission responses could look like (Ward et al. 2024). However, systemic barriers persist. In many jurisdictions, funding models still lack mechanisms to recognise environmental health risk assessment, place-based adaptation initiatives, or interprofessional climate-health collaboration (Australian Government Department of Health and Aged Care 2024b). Nurses are often expected to integrate climate resilience work into often already overstretched roles, frequently without remuneration, recognition, formal education pathways, or structural support. Regulatory frameworks and funding structures built around traditional models of acute, physician-led care have struggled to adapt to the demands of the climate era. Optimising the full contribution of all healthcare professionals, including advanced practice nurses, is critical to designing sustainable, equitable and resilient health systems. Removing outdated barriers to full scope of practice, enabling nurses to lead and innovate, and fostering respectful interdisciplinary collaboration will be essential to building the healthcare systems needed for a climate-affected future (Australian Government Department of Health and Aged Care 2024a; Romanello et al. 2024). To address the health impacts of climate change, healthcare systems must rapidly shift toward low-emission, prevention-focused models of care. The environmental footprint of healthcare is substantial, with emissions arising not only from clinical activities but also from travel, supply chains, infrastructure and waste (Barraclough et al. 2019; Talbot et al. 2022). Models of care that are community-based, digitally enabled and prevention-oriented may offer promising opportunities to reduce emissions while enhancing health outcomes. Nurses are ideally positioned to lead this transition. Nurse-led models of care, such as hospital-in-the-home programs, community nursing, primary healthcare outreach and telehealth, have all demonstrated capacity to reduce unnecessary hospital presentations, decentralise care and cut emissions associated with patient transport and acute interventions (Australian College of Nursing ACN 2023). During the COVID-19 pandemic, virtual wards and telehealth services not only maintained access to care but also significantly lowered the environmental impact of healthcare delivery (van der Zee et al. 2024; Jalilian et al. 2024). Expanding nurse-led telehealth, mobile outreach services and community-based clinics can contribute meaningfully to climate mitigation efforts. Critically, a systems-thinking approach is required. Low-emission models cannot simply be added onto existing healthcare structures; they demand redesigns that centre prevention, equity and sustainability. Engaging nurses in climate-resilient design, integrating environmental risk assessments into care planning, and empowering interdisciplinary teams to innovate locally are essential strategies for sustainable health system transformation (Ward et al. 2022). Optimising the full scope of advanced practice nurses is vital to this effort. Advanced practice nursing, drawing on clinical, systems, educational and research expertise, offers a model for holistic, adaptive and low-carbon healthcare delivery (Australian College of Nursing ACN 2023). Supporting nurses to lead as autonomous practitioners, with access to appropriate remuneration pathways and interdisciplinary support structures, will be key to embedding resilience and sustainability into everyday practice. Finally, building the evidence base for nurse-led low-emission models must be prioritised. Implementation science, comparative-effective research and rigorous evaluation frameworks are needed to demonstrate the clinical, economic and environmental benefits of these models. The success of midwifery group practice models in improving maternal outcomes and reducing intervention rates provides a valuable precedent for what nurse-led climate-health innovation could achieve at scale (Hewitt et al. 2022). Redefine Nursing Scope of Practice to Embed Planetary Health: Formally integrate environmental and planetary health responsibilities, into scopes of practice, supported by credentialing, continuing professional development and workforce strategy frameworks. Policy Advocacy: Leverage the trusted public voice of nurses to advocate for the integration of climate-health priorities into national and international health policies, standards and funding frameworks. Invest in Systems Thinking Education: Embed systems thinking, planetary health and cultural safety into undergraduate and postgraduate nursing education to prepare the future workforce for complex, interdisciplinary challenges. Support First Nations and Community-Led Leadership: Resource and elevate Indigenous-led, place-based models of care that centre ecological knowledge, self-determination and community-centred worldviews. Integrate Climate Metrics Into Health Service Planning: Ensure that service delivery models, accreditation standards and quality improvement systems explicitly address climate mitigation, adaptation, and health equity outcomes. Build Evidence for Nurse-Led Low-Emissions Care: Prioritise research that evaluates the clinical, environmental and economic impacts of nurse-led models of care, supporting the scalability of effective interventions. Still rowing upstream, nurses remain at the forefront of public trust and community connection and frontline care. Yet their capacity to deliver climate-responsive, equity-driven health solutions continues to be constrained by structural barriers in policy, funding and system design. Recognising climate change as both a health emergency and a structural justice issue demands more than adaptation. It requires a fundamental shift in how health systems are governed, funded and led. Without systemic reform, climate-health initiatives risk following the trajectory of early health promotion efforts. Celebrated rhetorically, yet marginalised in practice, with promising pilots that fail to achieve enduring structural change. Nursing leadership is not merely capable of navigating this transformation, it is central to achieving it. Empowering nurses to lead integrated, preventative and sustainable health models is critical to building resilient health systems that can respond to the climate crisis and ensure that equity, justice and planetary health are placed at the heart of healthcare's future. The authors declare no conflicts of interest. The authors have nothing to report.