Intensive care units (ICUs) are among the most resource-intensive healthcare settings and represent a strategic priority for environmental sustainability policies. While technological solutions are increasingly promoted, sustainable practice in ICUs also depends on nurses’ knowledge, attitudes, and behaviors, which remain insufficiently studied using validated, context-specific tools and longitudinal designs. This research protocol describes a multi-phase, theory-driven study aimed at developing and validating the Knowledge, Attitudes, and Behaviors Questionnaire on Environmental Sustainability in Intensive Care Units (KABQES-ICU) and at evaluating the longitudinal impact of a structured sustainability training program. Phase 1 focuses on instrument development and psychometric validation, grounded in a conceptual framework integrating individual, psychological, and organizational determinants and informed by qualitative evidence from ICU nurses. Phase 2 consists of a longitudinal intervention study assessing changes in sustainability-related competencies and their effects on nurse, patient, caregiver, organizational, and environmental outcomes. This protocol is designed to generate robust evidence to support the integration of sustainability into ICU quality improvement strategies and health policy frameworks without compromising patient safety.

Intensive care units (ICUs) are among the most resource-intensive clinical settings, contributing substantially to healthcare-related environmental impacts. Although nurses play a central role in shaping sustainable clinical practice, no validated instruments currently exist to comprehensively assess knowledge, behaviors, and perceived barriers related to environmental sustainability in ICU settings. To develop and psychometrically validate the Knowledge, Attitudes, and Behaviors Questionnaire on Environmental Sustainability in Intensive Care Units (KABQES-ICU) for use among ICU nurses. A multicentre, cross-sectional study was conducted among Italian ICU nurses using an online survey. Item generation was theory-driven, informed by a prior content analysis and the M-COM-B behavioral model, and refined through expert review and pilot testing. Psychometric evaluation included exploratory factor analysis (EFA), confirmatory factor analysis (CFA) using WLSMV estimation, and assessment of internal consistency, composite reliability, and convergent and discriminant validity. Data from 278 nurses were analysed. EFA supported a five-factor structure encompassing climate change knowledge, home-based sustainability behaviors, work-based sustainability behaviors, workload and time-pressure barriers, and organizational infrastructure barriers, explaining 58.9% of total variance. CFA confirmed excellent model fit (CFI = 0.932-0.944; TLI = 0.925-0.937; RMSEA = 0.059-0.064). Internal consistency was satisfactory across all domains (Cronbach's α = 0.74-0.86; composite reliability >0.78). Factorial distinctiveness was supported, despite marginal convergent validity for selected behavioral domains. The KABQES-ICU is a conceptually robust and psychometrically sound instrument for assessing sustainability-related knowledge, behaviors, and barriers among ICU nurses. The KABQES-ICU enables systematic identification of educational, organizational, and structural needs, supporting the design of targeted interventions to integrate environmental sustainability into routine intensive care practice without compromising patient safety.

IntroductionIntensive care units (ICUs) are among the most resource-intensive clinical settings, contributing substantially to healthcare-related environmental impacts. Although nurses play a central role in shaping sustainable clinical practice, no validated instruments currently exist to comprehensively assess knowledge, behaviors, and perceived barriers related to environmental sustainability in ICU settings.AimTo develop and psychometrically validate the Knowledge, Attitudes, and Behaviors Questionnaire on Environmental Sustainability in Intensive Care Units (KABQES-ICU) for use among ICU nurses.MethodsA multicenter, cross-sectional study was conducted among Italian ICU nurses using an online survey. Item generation was theory-driven, informed by a prior content analysis and the M-COM-B behavioral model, and refined through expert review and pilot testing. Psychometric evaluation included exploratory factor analysis (EFA), confirmatory factor analysis (CFA) using WLSMV estimation, and assessment of internal consistency, composite reliability, and convergent and discriminant validity.ResultsData from 278 nurses were analyzed. EFA supported a five-factor structure encompassing climate change knowledge, home-based sustainability behaviors, work-based sustainability behaviors, workload and time-pressure barriers, and organizational infrastructure barriers, explaining 58.9% of total variance. CFA confirmed excellent model fit (CFI = 0.932–0.944; TLI = 0.925–0.937; RMSEA = 0.059–0.064). Internal consistency was satisfactory across all domains (Cronbach’s α = 0.74–0.86; composite reliability > 0.78). Factorial distinctiveness was supported, despite marginal convergent validity for selected behavioral domains.ConclusionThe KABQES-ICU is a conceptually robust and psychometrically sound instrument for assessing sustainability-related knowledge, behaviors, and barriers among ICU nurses.Implications for Clinical PracticeThe KABQES-ICU enables systematic identification of educational, organizational, and structural needs, supporting the design of targeted interventions to integrate environmental sustainability into routine intensive care practice without compromising patient safety.

Background/Objectives: Intensive care is resource-intensive, and routine nursing hygiene contributes substantially to material consumption. This systematic review synthesised evidence comparing single-use and reusable or traditional reusable products in hygiene-related nursing care in intensive and critical care settings, considering clinical, economic, and environmental outcomes. Methods: A systematic review with structured narrative synthesis was conducted in accordance with PRISMA 2020. MEDLINE via PubMed, Scopus, Web of Science Core Collection, and CINAHL Ultimate via EBSCOhost were searched from inception to 25 August 2026. No language, date, or publication-type filters were applied at the database level. Primary empirical comparative studies and process-based life cycle assessments reporting original inventory data were eligible; English or Italian full text was required for inclusion. Two reviewers independently screened studies, extracted data, and performed design-appropriate methodological appraisal, with a third reviewer available to resolve disagreements. The review was registered in PROSPERO (CRD420261376160). Results: Eight studies were included: four quasi-experimental or before–after studies, three randomized trials, and one process-based life cycle assessment. The seven patient-based studies included 2665 participants across adult, paediatric, and neonatal intensive care settings. Environmental evidence was limited to two complementary studies from a single Australian ICU: reusable linen was associated with a 50% reduction in carbon emissions, from 7206 to 3605 kg CO₂e, and substantial reductions in landfill waste. Economic findings were product- and context-dependent; disposable bathing systems and diapers were generally less costly in the settings examined, whereas reusable linen increased overall expenditure by approximately 3%. Clinical findings showed no uniform advantage for either product category. After adjustment, linen type was not independently associated with pressure injury, bathing studies showed heterogeneous microbiological findings and no consistent physiological advantage between methods, and one neonatal before–after study reported lower probable sepsis with disposable diapers. Conclusions: Current evidence does not support a general advantage of either reusable or single-use hygiene products across intensive care. Environmental benefits were demonstrated for reusable linen, whereas economic and clinical outcomes varied by product, setting, and analytical approach. The evidence base remains small and heterogeneous, and no included study assessed clinical, economic, and environmental outcomes concurrently. Integrated comparative studies, particularly in European intensive care settings, are needed.