The role of environmental impact assessments in hospital care: Healthcare professionals’ views on research and implementation priorities

Abstract

Background

The crossing of planetary boundaries, such as climate change and biosphere integrity, threatens human health, while healthcare systems paradoxically contribute substantially to these environmental challenges. Although research on the environmental impact of care activities and pathways is expanding, it remains unclear how this information is used in clinical practice. This study explores healthcare professionals’ views on the environmental impact of hospital care, the role of environmental impact data and research and implementation priorities to support sustainability in clinical practice.

Methods

Semi-structured focus groups and interviews were conducted between April and July 2024 with 31 Dutch healthcare professionals working across 12 medical (hospital) specialities with the highest care volumes and expenditures. Participants were selected on the basis of their involvement or interest in green healthcare initiatives. Focus groups and interviews were transcribed verbatim and analysed using reflexive thematic analysis.

Results

Participants have a general sense of environmentally impactful care activities, including surgical procedures, medication and outpatient visits. However, they reported a lack of quantitative environmental impact data at the clinical level, limiting their ability to make informed, sustainable choices. While participants recognized multiple uses for environmental impact data and supported integrating sustainability considerations into healthcare decision-making, they emphasized the need to balance these factors with other priorities, such as clinical effectiveness, patient safety and costs. Several research gaps were identified, including the need for comparative pathway analyses and standardized metrics. Additionally, implementation priorities, such as focusing on high-volume care, leveraging healthcare co-benefits and driving systemic changes to overcome barriers in the sustainability transition, were defined.

Conclusions

Healthcare professionals lack the quantitative data needed for sustainable healthcare decision-making. Targeted research and implementation efforts should focus on high-impact, modifiable care. These findings may support better alignment between environmental research and clinical priorities, thereby informing evidence-based sustainability efforts in hospital care.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12961-025-01386-w.

Introduction

More planetary boundaries are being crossed than ever before [1], including climate change and biosphere integrity, impacting human health in various ways [2, 3]. Paradoxically, healthcare systems contribute significantly to these issues [4–6]. Presently, awareness amongst healthcare professionals about the sector’s role in the planetary crisis is growing [7]. Given the scale of the problem and the complexity of healthcare, it is necessary to prioritize mitigation efforts [8] in the areas of care with the greatest environmental impact.

Current information on the environmental impact of healthcare is limited due to several reasons. While national-level top-down studies often highlight high-impact areas within healthcare systems, such as hospital care [9, 10] or pharmaceuticals and chemicals [11–13], these assessments are typically not detailed enough to be applicable in practice for healthcare professionals. More detailed analyses of healthcare’s contribution to environmental changes, including pathway analyses to estimate greenhouse gas emissions, have therefore been highlighted as an important research priority [14–16]. Although granular data at the healthcare service and care pathway levels have become available in recent years [17], these assessments remain difficult to interpret and apply in clinical settings. Major limitations include their methodologic heterogeneity [18, 19], differences in clinical relevance and regional variations in energy and resource use, leading to findings that may not align with real-world clinical workflows or decision-making needs [20]. Additionally, it is currently unclear how healthcare professionals perceive the environmental impact of the care they deliver and how they engage with existing environmental impact data in their daily practice.

While certain important medical disciplines, such as surgical care, have received considerable attention in environmental studies [19, 21–24], other important areas of care, complete care pathways in particular, remain largely unexplored [18, 25]. This hinders the ability to draw robust conclusions regarding sustainable healthcare practices because the individual healthcare activities that patients receive might have a much lower environmental footprint than their complete care pathways. Lastly, the complexities of environmental trade-offs – for example, lowering the carbon footprint by switching to bio-based materials, which also leads to land use change – require the use of comprehensive but time-consuming methods such as life cycle assessment (LCA) [19]. Due to the need for these labour-intensive methods, it is important to identify priority areas for future footprint studies of hospital services and care pathways [18].

As the number of healthcare assessment studies continues to grow [17], there remains a limited understanding of healthcare professionals’ perceptions regarding the environmental impact of care and their views on the purpose and use of environmental impact data. To better align environmental research with clinical practice and ensure its effective application in healthcare’s sustainability transition, it is essential to explore healthcare professionals’ perspectives on research and implementation priorities. In this study, we set out to investigate the extent to which healthcare professionals have insight into the environmental impact of specific care activities and pathways, and what this implies for setting a research agenda and guiding practical sustainability efforts in hospital care.

Methods

This qualitative study employed focus groups as the primary data collection method. Focus groups were chosen for their ability to facilitate in-depth discussions among participants, encouraging them to engage in critical reflection through interaction with peers [26]. If assembling multiple participants was not feasible, individual interviews were conducted. The Consolidated Criteria for Reporting Qualitative Research (COREQ) guideline was followed for explicit and comprehensive reporting [27] (Additional file 1).

Study population

The study focused on healthcare professionals working in hospitals in the Netherlands, specifically those interested or engaged in national sustainability working groups. Participants were purposively sampled on the basis of their involvement in medical specialities with potentially high environmental impacts, based upon highest annual patient volumes and care expenditures in the Netherlands [Electronic Supplementary Material (ESM) Fig. S1, Additional file 2]. This allowed for a comprehensive exploration of diverse care pathways across a variety of large-volume medical disciplines.

Medical specialists and nurses from 13 specialities were approached by e-mail through nationally active sustainability-focused working groups. Since sustainability working groups did not exist for every medical speciality, participants were also recruited through regular medical associations, local green teams and personal networks of the research team.

Data generation

Data were collected through digital focus groups and interviews, which were clustered by medical speciality. Both focus groups and interviews were facilitated by a junior researcher experienced and trained in conducting focus groups and interviews (L.K.), with a second junior researcher present for assistance (J.N., A.W.). All three researchers had a medical background, which allowed for further inquiry into the specific details of suggested care activities and pathways. The other research team members included a junior researcher (E.C.) with a medical background who was trained in qualitative research, senior researchers (D.K., W.H.) with experience in qualitative research, and medical specialists (W.H., N.S.W.). The research team also had experience with environmental impact studies in healthcare. A reflexivity statement is included in Additional file 3. Focus groups were video-recorded and transcribed verbatim using Microsoft Teams (version 25007.607.3371.8436). The goal was not to achieve data saturation, as its relevance to reflexive thematic analysis has been debated [28], and it is less applicable to the current research aim, which focuses on identifying sustainability questions that are likely to vary across medical specialities.

A semi-structured guide was developed by the research team (L.K., D.K. and N.S.W.) through iterative discussions and was informed by relevant literature on environmental sustainability in healthcare, environmental impact assessments and quality of care. Questions were divided by topic, as presented in Table 1. In the initial phase of the focus group or interview, participants were asked to briefly introduce themselves, including stating their function and the type of hospital they were working in. They received a short introduction about this study and the operationalization and definitions of environmental impact and hospital care activities and pathways (Fig. 1). “Hospital care” was defined as the care patients receive from healthcare professionals in a hospital. “Care activities” referred to specific clinical interventions or moments of care (for example, a surgery), while “care pathway” focused on a combination of interconnected services provided throughout a patient’s healthcare trajectory. Participants were then asked open-ended questions about the types of care activities they believed had a significant environmental impact within their medical speciality. During the subsequent brainstorm, participants shared cases and examples of care activities and pathways they believed to have a high environmental impact, and the reasons behind their choices were explored. We did not use predefined vignettes or exemplar clinical pathways; instead, participants were invited to draw upon their own clinical experience to identify examples they perceived as environmentally impactful. Participants were asked to share to what extent they felt they had quantitative insight into the environmental impact of the mentioned care activities and pathways. If the interviewers felt that certain types of care potentially relevant within a medical discipline had not been addressed, a list of highest care volumes was used to ensure that these areas were covered. Field notes were taken during each focus group and interview.

Table 1.

Interview topics

Main topic	Explanation
Environmental impact of hospital care activities	Knowledge and ideas about environmental impact of specific care activities
	Reasons for mentioning these care activities
	Quantitative insight into environmental impact
Environmental impact of hospital care pathways	Knowledge and ideas about environmental impact of specific care pathways
	Reasons for mentioning these care pathways
	Quantitative insight into environmental impact
Prioritizing information needs	Prioritizing healthcare activities and care pathways for future environmental impact research
	Arguments for prioritization
	Alternative choices with comparable clinical effectiveness
	Other preferences for future research
Barriers to implementing climate change mitigation initiatives	Specific barriers
	What is needed to overcome barriers

Fig. 1.

Picture shown to participants during the focus group or interview to illustrate the concepts of care activities, care pathways and environmental impact

In the second part of the focus group, participants were asked to prioritize care activities and pathways they believed should be the focus of future research into environmental impact. The third part focused on other types of research that may aid sustainability initiatives and reduce barriers encountered when implementing mitigation strategies. The full interview guide is included in ESM Additional file 4.

Ethical considerations

Written or verbally recorded consent was obtained at the start of the focus group/interview. Participants were informed that only the research team would have access to the recordings and transcripts of their interviews, ensuring the confidentiality of their information. Quotes illustrating the themes were selected and translated by L.K. using Google Translate. The translations were then reviewed by A.W. and refined to ensure clarity and readability. Quotes from participants were only used if approved by participants themselves. Although focus group and interview transcripts were not shared with participants, the developed sustainability questions were shared to improve their accuracy and ensure further refinement. No additional responses were received. This study was deemed exempt from the Medical Research Involving Human Subjects Act (WMO; Wet Medisch-wetenschappelijk Onderzoek met mensen) by the non-WMO Committee of the Medical Ethics Review Committee of Amsterdam University Medical Centres (IRB00013752, document number: 2024.0089).

Data analysis

Basic participant characteristics (for example, type of healthcare provider, medical speciality and type of hospital) were summarized and presented in a descriptive table.

The transcripts of the focus groups were analysed using reflexive thematic analysis – a method rooted in constructivism for identifying, analysing and reporting patterns (themes) within data [29, 30]. Transcripts were primarily coded inductively, with deductive coding only specifically applied to focus on participants’ research needs. The first five transcripts were double-coded by two different researchers (L.K. and A.W.) to gain a deeper and more nuanced understanding of the data. The remaining transcripts were coded by one researcher (L.K. or A.W.). MAXQDA 2022 (VERBI Software, 2021) was used for data analysis [31]. To further analyse the coded text, coded segments were grouped and summarized by two researchers (L.K. and A.W.). This information was then discussed with the entire research team to identify main themes.

Results

In total, six focus groups, with three to six participants per group, and six interviews, with one or two participants per interview, were conducted between April 2024 and July 2024. A total of 22 medical specialists or residents-in-training and 9 other healthcare professionals, including nurses and researchers, from twelve different medical specialities participated (Table 2). For one medical speciality (Dermatology), the contacted healthcare professionals refused to participate in the study because of time constraints.

Table 2.

Participant characteristics

	n	Percentage (%)
Medical speciality
Cardiology	4	13
Gastroenterology	3	10
Gynaecology and obstetrics	3	10
Internal medicine	2	6
Neurology	1	3
Ophthalmology	1	3
Orthopaedics	2	6
Otorhinolaryngology/ENT surgery	3	10
Paediatrics	3	10
Pulmonary medicine	2	6
Surgery	6	19
Urology	1	3
Total	31	100
Type of healthcare provider
Medical specialist	18	58
Resident-in-training	4	13
Other (for example, researcher, nurse and technician)	9	29
Type of hospital
Academic	15	48
Non-academic	14	45
Independent treatment centre	2	6
Participants’ engagement with sustainability initiatives
National sustainability working group	26	84
Local green team	5	16

ENT, ears, nose and throat

The focus group recordings averaged 51 min (range 43–56), while the interviews averaged 46 min (range 31–56), excluding the personal introduction of interviewers and participants. Four main themes were developed in this study:

• Theme 1: Shared perceptions on environmentally impactful care.

• Theme 2: Limited environmental impact data to navigate sustainability.

• Theme 3: Balancing environmental impact with other priorities in healthcare decision-making.

• Theme 4: Focusing on sustainability efforts where the impact is greatest.

Theme 1: Shared perceptions on environmentally impactful care

Participants from various medical specialities all identified similar types of care activities as having a high environmental impact, such as medication, surgical procedures and outpatient visits. Within these generic categories, many specific care activities were named to be relevant, for example transcatheter aortic valve implantation (TAVI), robotic surgery for uterine fibroids, esophagogastroduodenoscopy and cataract surgery. However, there were variations in which types of care activities different medical specialities identified as having a high environmental relevance. In general, surgical disciplines mentioned procedures and interventions, while medical specialities focused mostly on medication, outpatient care and inpatient hospital stays. A complete list of all mentioned examples is included in ESM Additional file 5. The underlying reasons for naming the generic and specific care activities were diverse but largely overlapped between specialities. Many participants mentioned high volumes of care, or expected increases in disease prevalence, sometimes because of environmental reasons, such as pesticide use and its linkage to Parkinson’s disease. Others referred to the high volumes of resources used that are known to be hotspots (for example, materials, energy and travel movements) or waste created, including medication residue in wastewater. Some named specific examples because they saw potential for improvement, for example, to reduce care or optimize resource usage – often on the basis of observed variation in practice between medical facilities. Less frequently mentioned reasons included high costs or the care activities being “typical” or characteristic and distinctive for the medical speciality, such as tonsillectomy for ear, nose, and throat (ENT) surgery.

A major theme is medication use, right? That’s something we use a lot as internal medicine physicians or prescribe a lot. … Of course, a large group is antibiotics. I think about half of the patients admitted in our ward are using antibiotics. Another large group is chemotherapy. And then we also have painkillers, which is an important category. – medical specialist, internal medicine focus group (participant 1, lines 6–8).

Although participants initially struggled to identify environmentally impactful care pathways, they later unwittingly described pathways when discussing impactful care activities, mentioning extended hospital stays and multiple follow-up visits in chronic care. When intentionally mentioning care pathway examples, underlying reasons included the chronic nature of some care pathways, the availability of multiple care alternatives within the pathway with potentially different environmental impact, suboptimal organization of pathways such as diagnostic appointments scheduled on different days or pathways that included low-value and inappropriate care1 [for example, follow-up endoscopies for stable gastrointestinal conditions, or frequent control magnetic resonance imaging (MRI) scans in neurology].

And that of course also includes all the other steps a patient goes through, so indeed, how often they are seen at the outpatient clinic and how often such a patient is seen in advance or must come in afterwards for extra tests. So yes, I think that process part is always a bit overlooked in terms of what impact it has and what you can do with it. – green team member and sustainability consultant, cardiology focus group (participant 2, line 129).

Theme 2: Limited environmental impact data to navigate sustainability

While healthcare professionals were aware of high-impact care activities and hotspots, most acknowledged having little to no understanding of the actual magnitude of these impacts. They typically lacked quantitative insights into specific treatments, especially regarding medication. According to participants, the sustainable transition is currently hindered by this lack of information on the environmental impact of healthcare. It often acts as a barrier to lowering environmental impact at the care pathway level, for example, when trying to make sustainability-based choices between treatment options or deciding to refrain from certain activities for environmental reasons.

Well, I think we really lack the information to make certain choices. So, with our speciality, antibiotics, as [participant 1] just mentioned, we simply do not know which choice we should make there. – medical specialist, internal medicine focus group (participant 2, line 286).

The lack of quantitative data made it difficult for professionals to determine the relative scale of the environmental impacts and the way in which specific care activities related to one another. For example, they struggled to compare the environmental impact of individual treatments with the cumulative impact of those treatments based on patient numbers, or to evaluate the relative impact of different types of hotspots or treatments. While some believed that environmental impact data would primarily validate existing assumptions about impactful care, others expressed that the findings frequently challenged initial expectations. Changed insights shifted the focus of sustainability efforts, as seen in cardiology, where attention moved from material use to travel-related emissions owing to new evidence about environmental hotspots.

I do not think it would result in many unexpected findings, because of course as a healthcare professional you know what the care pathways entail. And by using common sense you will definitely have a feeling about which things have a lot or little impact. But the added value of conducting that research is to really confirm and support it. – medical specialist, ophthalmology interview (line 89).

There was a recent impact study on the carbon footprint of an endoscopy. I believe it was for a colonoscopy. And it clearly showed that travel had the largest impact. Which is actually a bit surprising, because as you mentioned, there are so many materials used for these endoscopies. And that is very visible, and it is definitely an important factor. But apparently, the travel is also really, well, a major culprit. – resident-in-training, gastroenterology focus group (participant 3, line 50).

Well, you really have to calculate it. It is truly a science, isn’t it? You really notice it, and every time you do an LCA analysis, you think, I am assuming this is the biggest factor, but it turns out completely different than you expected. So, it is really something you need to approach very scientifically. – surgeon, surgery focus group (participant 3, line 120).

Participants highlighted various information needs, including the environmental impact of individual clinical activities and care pathways within their field. Information needs also included comparisons between different care activities within a care pathway. This could comprise types of diagnostics or treatments with similar effectiveness or safety, such as medication versus surgery, or different techniques for performing procedures. Other areas of interest included comparing procedures using different equipment or brands, which in some cases also influenced the care pathway.2 Some participants were interested in care organization, for example, comparing in-hospital visits with care delivered at-home using e-health. Many of these comparative sustainability questions originated from practice variation. Participants had numerous examples where they observed differences in organization and delivery of care between hospitals, for instance, the number of follow-up appointments in chronic care pathways, the performance of procedures with or without additional sterility measures or with different volumes of materials used. Finally, some expressed interest in the environmental benefits of lifestyle-focused care activities and prevention programs. Example sustainability questions are included in ESM File F.

Subtheme 2.1: Moving forward with general hotspots, using pragmatic, common-sense strategies

While limited care-activity- or care-pathway-level data were recognized as a barrier in healthcare’s sustainability transition, it did not always hinder sustainability projects. Participants mentioned many ongoing sustainability projects that focused on general hotspots, some of which even aimed at care pathway improvements. Initiatives typically relied on practical, “common sense” approaches, following circularity principles. The data gap also motivated some participants to conduct their own research, or to adopt creative approaches to address the lack of pathway-specific studies. For example, in ophthalmology, participants added estimated transport emissions from other studies to the reported impact of cataract surgery in literature to better capture the broader environmental footprint of the entire cataract care pathway.

It is also partly “common sense.” In the sense that, even if we do not have the answer yet, you can still figure out based on the circularity model that reusable options are already a better choice, or that there are other ways in which we can make things more sustainable. So, you can always incorporate it, even if we do not yet have solid scientific evidence for every specific aspect. – junior doctor and sustainability researcher, surgery focus group (participant 2, line 191).

Notably, several mentioned sustainability initiatives were initially driven by other factors, such as cost savings, improved patient comfort, improved working conditions for staff or reducing antibiotic resistance. Changes initiated during the coronavirus disease 2019 (COVID-19) pandemic have also, in some cases, supported sustainability goals. Making use of these alternative motivations which coincidentally lead to sustainability improvements, including the need for appropriate care, was highlighted by participants as a (sometimes) more efficient approach to achieving progress in sustainability.

For ablations, we use precious metals in the tips of those ablation catheters, and those are all recycled – and we get a nice little extra income from that. – cardiologist–electrophysiologist, cardiology focus group (participant 4, line 69).

It is mainly about choosing appropriate care, which is of course very closely connected to sustainable care. So, yeah, another example: they do a lot of endoscopies in IBD [inflammatory bowel disease] patients, and nowadays, especially at [name of hospital], they often perform ultrasounds of the intestines. I think that is something [sustainable] as well. But that is also driven by the fact that it is cheaper and easier to perform than a full endoscopy. – resident-in-training, gastroenterology focus group (participant 3, line 74).

…it’s better to focus on themes like appropriate care, limited healthcare availability, and quality of life. Those themes are easier to address than sustainability. … But you do not need to bring [sustainability] forward as the main argument, because I think that could backfire on us. And then we might end up empty-handed. – surgeon, surgery focus group (participant 3, line 233).

Theme 3: Balancing environmental impact with other priorities in healthcare decision-making

Healthcare professionals saw various purposes for information on the environmental impact of care activities and pathways in healthcare decision-making. For clinical decisions, sustainability information could help underpin guideline recommendations or set benchmarks within specialities to reduce practice variation, for instance, by highlighting the “lowest common denominator” for follow-up outpatient consultations. Comparative information on environmental impacts could be used as an argument to choose between two clinical alternatives, though such alternatives did not seem prevalent in all medical specialities. A high environmental impact could also support efforts to reduce low-value care or narrow down indications, providing additional justification for limiting care in specific cases.

I do think that there is a very large practice variation between hysteroscopies, between colposcopies, between all those procedures that we do quite frequently, but that everyone has their own protocol to do it. And you simply work according to your protocol, so then you use all the things that are in it, while if you were to make it a bit more uniform, I think you could really gain a lot on the entire care pathway. – gynaecologist, gynaecology focus group (participant 3, line 186).

Well, so, sometimes I feel unsure whether or not I should do, for example, a tonsillectomy on a patient and then, suppose there is a number of so many kilograms of CO₂ that procedure would generate, and it lingers somewhere in the back of my mind. Then I might be more inclined not to do it. – resident-in-training, otolaryngology focus group (participant 1, line 260).

While most participants agreed that environmental impact information could play a role in clinical decision-making, they also questioned whether it would be a decisive factor. Environmental sustainability should be weighed alongside other criteria such as effectiveness, safety, costs, patient comfort and ethics. Effectiveness and safety were seen as key factors that outweigh environmental considerations, and many participants stated that their primary duty is to provide the highest quality of care. Ethical concerns were raised regarding withholding care or opting for a clinical alternative solely on the basis of environmental impact, without taking into account such other considerations. There were also differences in views among participants. While some participants viewed reducing care for high-burden diseases such as oncology as ethically challenging, others were open to exploring this. Some also questioned whether minor reductions in effectiveness could be justified by significant environmental benefits. However, remarks were made that less effective care could also inadvertently lead to negative environmental consequences, as suboptimal outcomes may require additional interventions later.

Yes, I think it is always insightful to actually know the impact of a certain intervention, medicine, or action that you do. But I agree with you all, you are not going to omit everything for the sake of sustainability. – resident-in-training, gastroenterology focus group (participant 3, line 67).

Well, I cannot easily imagine that if there is a medicine that has an environmental impact, that it will be omitted entirely for that reason, then it should really have an extreme environmental impact. And then, I think, we would have already known. – cardiologist–electrophysiologist, cardiology focus group (participant 4, line 77).

Besides using environmental information in clinical decisions, participants saw many broader applications of environmental data related to healthcare decision-making, including priority-setting for mitigation strategies, raising support for taking sustainability measures, incorporating it into education and initiating conversations with colleagues, the general public, patients or manufacturers. Participants referred to co-benefits of environmental information, including its potential to drive broader healthcare transitions, such as promoting appropriate care, preventative strategies or improving efficiency by reducing waiting times.

For both clinical decision-making and decisions in healthcare more generally, costs and quality aspects such as clinical effectiveness were highlighted as important factors that could outweigh environmental considerations in decision-making. For instance, in ophthalmology, the cost of medications influenced the choice of treatment for macular degeneration, while in gastroenterology, the quality and cost of stents also dictated purchasing decisions. Finally, practical barriers, such as the availability of certain technologies or treatments at local hospitals, existing waiting lists and trends in medical practice (for example, the popularity of robotic surgery), influenced the feasibility of environmentally informed decision-making. Overall, the sentiment was that sustainability information could serve as a useful addition, though not the most important factor to be considered in healthcare decision-making. Many participants suggested incorporating it as an additional consideration, to be weighed alongside prevailing factors such as effectiveness and costs in decision-making processes.

Theme 4: Focusing on sustainability efforts where the impact is greatest

Given the large amount of information needs and the challenging task of making healthcare more sustainable, participants acknowledged the need for further prioritization. Healthcare professionals provided examples of care activities and pathways that should be given priority for both research and implementation in practice, using varying arguments, though all focused on maximizing the expected impact. High volumes were often highlighted as a logical starting point. Ophthalmology prioritized three high-volume care pathways, each with a distinct focus, though they acknowledged these recommendations could apply to other pathways as well. However, this focus on high volumes was not universal; for example, neurology gave less priority to the herniated disc pathway due to its short duration, self-resolving nature and low care intensity.

We thought it was important to focus so as not to lose yourself in too many things, for which there is simply no data. And those choices were made very consciously. Not only care volumes, but also what I said: surgeries, most outpatient procedures, and a large part of the outpatient check-ups. … Yes, well, you could also have said, we will do something with that sicca [care pathway], I think you could have. But I think that certain recommendations can also be applied to other disciplines, yes. – medical specialist, ophthalmology interview (lines 116–119).

Care activities or pathways with clear mitigation opportunities were prioritized, while others with high expected environmental impact were sometimes deprioritized due to perceived limited opportunities for change, for example, in oncology care. The opportunity for change was considered greater when viable alternatives were available, for example, when patients were already advocating for change, or when other healthcare priorities (as previously discussed in Theme 3) did not strongly favour a specific option. It was stated that care pathways without equally effective clinical alternatives should be deprioritized, as promoting less effective care for sustainability reasons is not appealing and could slow down the sustainable transition. The perception of available alternatives varied among participants: some considered completely alternative treatment decisions, while others focused primarily on optimizations, such as types of materials, or waste separation. When other priorities, such as healthcare safety, remained uncertain, specific clinical research questions regarding infection prevention were highlighted as research priorities. Furthermore, certain pathways were deprioritized because they followed prevailing trends, such as the growing adoption of robotic surgery, or care pathways that have already largely shifted towards appropriate and more sustainable care. In these cases, environmental information was deemed unlikely to inspire meaningful change. Regarding technological developments, timing also played a role. For example, environmental data could still influence the adoption of e-health technologies, as these innovations have not yet been fully implemented. Others advocated prioritizing common individual care activities over entire pathways, as these “building blocks” were seen as more generalizable. Finally, some product-level comparisons, such as different brands of TAVI devices, orthopaedic implants or fertility medications, were considered less impactful because their relative impacts were considered similar. However, other product-level comparisons, such as preserved versus non-preserved chronic eye drops, were viewed as more meaningful because there are large differences in material use between options.

And when I sometimes think about robot procedures, I think we might be able to replace that by a regular, non-robot-assisted procedure or not do it, but with a caesarean section that would be a lot more difficult. – gynaecologist, gynaecology focus group (participant 1, line 22).

Interviewer: “Because otherwise, you mean, if it is not equal in terms of effectiveness or has different social consequences, then it would be a more difficult discussion, you mean? If it were more sustainable?”

Participant: “Yes, in that case it is less easy to get the conversation started. While the greater the impact, the better you often get the conversation going. And by getting a conversation started, you also force people to think about it more broadly. And doctors are quite conservative, so getting them to change sometimes takes some time.” – medical specialist, orthopaedics interview (line 103).

Finally, unrelated to any specific clinical area, systemic changes to address barriers for implementing sustainable practices, such as resistance from colleagues and a lack of awareness, were named as priorities. While participants in this study seemed to have a general understanding of the environmental impact of care, they noted that colleagues outside of sustainability working groups have limited to no awareness, though some may recognize the visible waste accumulation of certain types of care or have a sense of healthcare costs. Awareness seems to be growing among certain groups, especially younger professionals, but participants also expressed doubts about whether this translates into sustainability action. This highlights the importance of not only generating new environmental impact data but also disseminating this knowledge to medical professionals and policy-makers and implementing changes. Suggestions to promote sustainable practices more broadly included hospital-led nudges, collaboration with stakeholders and public support from prominent figures to increase visibility. To further reduce resistance, several participants mentioned the importance of reliable and standardized environmental impact assessment methods. In some specialities with greater availability of environmental impact data from LCAs of specific care activities, the variability in study results raised questions and uncertainties, highlighting the need for more consistency and clarity.

Other barriers included reliance on existing protocols or equipment, and legal or financial constraints, which could be addressed by standardized nation-wide protocols to replace inconsistent local approaches, updating regulations and financial business cases to demonstrate the feasibility of sustainable practices.

Participants also described the need to better equip healthcare professionals to act on sustainability, particularly through increased awareness, integration of sustainability into clinical decision-making and alignment with existing healthcare values such as efficiency, patient safety and appropriateness of care. Although participants did not identify specific formats, the general message was that environmental data must be accessible, credible and relevant to everyday clinical choices.

Research on behaviour change, patient preferences and effective policy interventions, including education and training programs, could assist in the sustainability transition. Finally, research should focus on how to weigh sustainability alongside other criteria such as effectiveness and costs in decision-making processes.

So, it would also be interesting to just talk with those silos. Not the industry, but a silo of pharmaceutical people or a silo of chemists. Because it does feel very harsh if you have to set up a study and an LCA for certain medication, while that data may simply be there at the manufacturer and is not shared for whatever reason. – medical specialist, ophthalmology interview (line 59).

Discussion

This study explored healthcare professionals’ views of hospital care’s environmental impact, use of impact data and priorities for research and implementation. Four themes were developed, highlighting shared perceptions among healthcare professionals about the environmental impact of healthcare, the lack of quantitative information hindering the sustainability transition, the need for balancing environmental impact outcomes with other healthcare priorities and the importance of focusing efforts where the impact is largest. These findings inform future research and implementation efforts to reduce hospital care’s footprint.

Participants’ perceptions of environmentally impactful care were largely aligned with the existing literature [9, 11, 12, 18], unlike previous studies involving stakeholders less engaged in sustainability [32]. In some disciplines, more detailed data on the environmental footprint of services and care pathways are available [18, 19, 33, 34], and participants in this study also referred to such research, indicating that this information is reaching clinical practice. While some information needs raised by participants have already been studied [35], most remain unaddressed [18], hindering progress [36–38]. Advancing towards low-carbon or net-zero health systems [39] requires prioritizing environmental research in high-impact hospital care. This approach ensures that research effectively informs healthcare decision-making, while also avoiding the tendency to carbon footprint everything [40]. Although high patient volumes are often cited as a reason for assessing the environmental impact of specific hospital services, many studies currently mention other reasons, or no specific reasons are provided at all [18]. Conducting research based on well-founded reasoning and aligned with the priorities of research users can increase the likelihood that the generated evidence is used in clinical decision-making and help prevent research waste [41]. This study not only provided insight into possible prioritization criteria but also highlighted specific care activities and pathways that meet these criteria according to key research users actively engaged in sustainability improvements.

Healthcare professionals saw environmental impact data as useful in clinical decision-making. Others have argued that environmental impact comparisons should not determine preferred treatments, as these decisions should always be guided by evidence-based considerations of risks and benefits and shaped by patient preferences [20]. Our data suggest that professionals are open to integrating environmental data into care decisions – so long as it is balanced with clinical effectiveness and patient safety. Research indicates that this perspective is shared by various stakeholders, including patients [42–45]. Participants expressed differing views on the relative importance of environmental sustainability compared with other priorities. Some expressed ethical concerns about incorporating environmental impact into care decisions if it compromised quality, emphasizing their primary duty to provide high-quality care. Others only prioritized specific aspects of quality, such as effectiveness, over environmental sustainability and were willing to consider trade-offs in other areas. The integration of environmental sustainability as a domain of quality in healthcare has only recently been explored in the literature [46, 47]. To facilitate discussions about how environmental sustainability relates to other system goals, it is important to clarify the conceptual positioning of environmental sustainability within frameworks of quality of care, which is currently unclear [48].

The other purposes of environmental impact data described by healthcare professionals in this study largely align with those described for carbon footprint research [40], such as identifying hotspots and comparing alternatives. However, the purpose of establishing a baseline and monitoring progress was not mentioned by participants, indicating that the purposes identified in this study are not exhaustive. Findings also pointed to broader applications of environmental impact data, such as agenda-setting, awareness-raising and education [49]. The lack of environmental data in many specialities, such as internal medicine and neurology [18], perhaps therefore also partly explains the variation in sustainability engagement observed across different focus groups and interviews. While some specialities had already established active working groups and developed guiding documents (for example, urology, gynaecology, surgery and ophthalmology), others were still in the early stages of exploring sustainability initiatives (for example, cardiology). Conducting more environmental impact research therefore presents an opportunity for co-benefits: the findings can not only inform clinical decision-making but also help raise awareness about the topic. This is important, as participants noted that colleagues outside sustainability working groups often lack awareness of healthcare’s environmental impact.

However, evidence alone rarely changes behaviour [50, 51]. While environmental impact research is useful, studies often point to familiar factors, such as energy use, and medical disposables [49, 52]. Few address implementation, leaving a gap between understanding environmental impacts and acting on them [24, 37, 53–58]. Bridging this gap may involve aligning environmental data with clinical workflows – through guideline development, education or accessible tools such as infographics or dashboards. In the Dutch context, hospital green teams and speciality-specific guidance [59–61] may offer practical entry points. Sustainability measures include process optimizations and clinical alternatives – the latter requiring robust impact comparisons. Despite limited data, many initiatives are already in practice. This study highlights clinical areas with large potential gains, guiding action. Many improvements were driven by non-sustainability factors, consistent with findings on pro-environmental behaviour [51, 62]. Initiatives such as integrating sustainability into protocols reflect healthcare professionals’ critical bottom-up role, complementing system-level policy efforts. Framing sustainability as appropriate care may aid acceptability, particularly in sensitive areas such as oncology. Co-benefits – improved efficiency, reduced low-value care and costs and better outcomes – should be leveraged [32, 63]. Achieving this requires diverse initiatives: engaging policy-makers, collaborating with industry, developing cross-speciality protocols, business cases and disseminating targeted knowledge.

Strengths and limitations

A key strength of this study was its engagement with healthcare professionals from a wide range of specialities, many of whom were actively involved in sustainability initiatives and had deep insight into clinical practice. By including 12 medical specialities – several of which are under-researched for environmental impact – and focusing on high-volume, high-cost care, we ensured the relevance of identified sustainability questions. However, some relevant disciplines and sub-specialities were not represented (for example, anaesthesiology, radiology, nephrology and oncology), which may have influenced the selection of priorities. Moreover, the exclusive focus on clinicians excluded policy-makers and managers, whose perspectives on care organization and structural barriers could complement clinical views. This gap was also reflected in participants’ examples of variation in how care is organized. The Dutch setting may limit the generalizability of findings. Most participants were already engaged in sustainability initiatives, which may have influenced the priorities identified. Additionally, some focus groups were less interactive due to low attendance or late arrivals. Although we aimed to organize groups of at least five participants, this was not always feasible. Finally, the focus on hospital-based care excluded prevention, primary care and public health settings, which may also offer significant sustainability benefits – for example, human papillomavirus (HPV) screening or chronic fatigue prevention.

Future research

Future sustainability research should be guided by the information needs identified in this study. To enhance its credibility and relevance, environmental impact research must be methodologically sound. Many existing studies lack quality and comparability [18], leading to research waste – and potentially to further environmental harm. Developing standardized guidelines for sustainability assessments (for example, LCAs) is essential and currently underway [64, 65]. There is also growing demand for simplified, user-friendly methods [64]. Participants in this study proposed creating modular “building blocks” of LCAs for separate care activities, which could be assembled into complete care pathway assessments. While initial efforts exist [66, 67], they remain limited and often omit key areas such as medication. Future research should therefore focus on rigorous yet practical tools that support timely and relevant decision-making.

While the results of this study can be seen as a first step towards a research agenda, research priorities were only assessed by healthcare professionals present during the focus groups and interviews. This study offers a first step towards a research agenda, based on the preferences of participating healthcare professionals, which varied depending on the perceived availability of alternatives and the usefulness of environmental data for clinical decision-making. These differences reflect broader clinical debates. A comprehensive research agenda should incorporate the perspectives of other stakeholders, including patients [42], and apply established research priority-setting methods [8, 68].

Conclusions

Healthcare professionals recognize the environmental impact of various types of care activities, but limited data and guidance constrain sustainable healthcare decision-making. This study identifies prioritization criteria and specific care examples for future research. While environmental impact data should be balanced with other healthcare priorities, healthcare professionals believe it can also inform clinical decision-making. In addition to investigating environmental impacts, the implementation of good practices should not be forgotten, including “common sense” circularity strategies that ideally leverage co-benefits. This study highlights clinical areas with potential for improvement, guiding healthcare professionals, scientific organizations and policy-makers in prioritizing sustainability initiatives while acknowledging the current limitations in data availability, generalizability and stakeholder representation. Better alignment between environmental research and policy could lower research waste and accelerate the sustainability transition, which can no longer be postponed.

Author contributions

L.H.J.A. Kouwenberg: conceptualization, methodology, investigation, data curation, formal analysis, writing – original draft preparation, writing – reviewing and editing and project administration; A.M. Wijnhoven: investigation, data curation, formal analysis, writing – original draft preparation and writing – reviewing and editing; E.S. Cohen: investigation and writing – reviewing and editing; W.J.K. Hehenkamp: conceptualization, methodology and writing – reviewing and editing; N.H. Sperna Weiland: conceptualization, methodology, writing – reviewing and editing and supervision; D.S. Kringos: conceptualization, methodology, writing – reviewing and editing, supervision and funding acquisition.

Funding

This project was supported by a grant from Amsterdam Public Health (APH) Research Institute and a seed grant from the University of Amsterdam. The funder of the study had no role in study design, data collection, data analysis, data interpretation or writing of the report.

Data availability

The data that support the findings of this study are available from the research team, but restrictions apply to the availability of these data, which were used under license for the current study, and so are not publicly available. Data are however available from the authors upon reasonable request and with permission of study participants.

Declarations

Ethics approval and consent to participate

This study was found exempt from the Medical Research Involving Human Subjects Act (WMO; Wet Medisch-wetenschappelijk Onderzoek met mensen) by the non-WMO Committee of the Medical Ethics Review Committee of Amsterdam University Medical Centres (IRB00013752, document number: 2024.0089).

Consent for publication

Consent was obtained for all published quotes.

Competing interests

The authors declare no competing interests.