Background: Delivering health care negatively influ-ences the environment and contributes to climate change. This study examined how nursing students in England and Sweden can make changes in clinical practice to enhance environmental sustainability. Method: Third-year under-graduate nursing students at English and Swedish universities responded to open-ended questions on the Sustainability Attitudes in Nursing Survey. Data were analyzed using inductive content analysis. Results: Students in both countries identified lack of confidence as the main barrier to challenging unsustainable practice, followed by a resistance to change in practice. English students predominantly changed their own behavior or influenced the practice of others. Swedish students either changed their own behavior or their own attitudes to sustainability. Conclusion:There is a need to ensure students have confidence to act as change agents to enhance sustainable practice in the clinical environment.