Barriers and facilitators to sustainable operating theatres: a systematic review using the Theoretical Domains Framework

BACKGROUND

The health sector contributes significantly to the climate crisis. Operating theatres (OTs) in particular are a major contributor of greenhouse gas emissions and waste, and while there are several evidence-based guidelines to reduce this impact, these are often not followed. The authors systematically reviewed the literature to identify barriers and facilitators of sustainable behaviour in OTs, categorising these using the Theoretical Domains Framework (TDF).

MATERIALS AND METHODS

Medline, Embase, PsychInfo, and Global Health databases were searched for articles published between January 2000 and June 2023, using the concepts: barriers and facilitators, sustainability, and surgery. Two reviewers screened abstracts from identified studies, evaluated quality, and extracted data. Identified determinants were mapped to TDF domains and further themes as required. The results were reported in line with PRISMA (Preferred Reporting Items for Systematic reviews and Meta-Analyses) and AMSTAR (A MeaSurement Tool to Assess Systematic Reviews) guidelines.

RESULTS

Twenty-one studies were selected for analysis and assessment (17 surveys and four interview studies) comprising 8286 participants, including surgeons, nurses, and anaesthetists. Eighteen themes across 10 TDF domains were identified. The most common barriers to adoption of green behaviours in OTs were in domains of: 'knowledge' ( N =18), for example knowledge of sustainable practices; 'environmental context and resources' ( N =16) for example personnel shortage and workload and inadequate recycling facilities; 'social influences' ( N =9) for example lack of leadership/organisational mandate or support; 'beliefs about consequences' ( N =9) for example concerns regarding safety. Intention was the most common facilitator, with 11 studies citing it.

CONCLUSIONS

Despite intentions to adopt sustainable practices in OTs, this review identified several barriers to doing so. Interventions should focus on mitigating these, especially by improving staff's knowledge of sustainability practices and working within the environmental context and time pressures. Furthermore, institutional change programmes and policies are needed to prioritise sustainability at the hospital and trust level. Additional qualitative work should also be conducted using behavioural frameworks, to more comprehensively investigate barriers and determinants to decarbonise OTs.

The impact of regulatory complexity upon self-regulation: Evidence from the adoption and certification of environmental management systems

This article focuses on environmental management systems (EMS) and aims to enhance our understanding of the relationship between environmental state regulation and self-regulation. Unlike previous studies that treat state regulation as uni-dimensional and focus on externally certified forms of environmental self-regulation, this article takes a more nuanced approach. It looks at how direct and indirect state regulation and its stringency influence both non-certified in-house and externally certified adoption of EMS. Methodologically, the study differentiates from previous research by acknowledging the interconnected nature of in-house and external certification decisions, viewing these decisions as sequential. Based on a survey of 2076 UK firms, findings show that effective environmental protection entails collaboration between environmental state regulation and in-house adoption of EMS. Results also reveal that externally certified EMS substitute for state environmental regulation, filling the void that results from weakening state regulation in the context of neoliberalism.