The perceptions and adoption of environmentally sustainable practices among anesthesiologists—a qualitative study

Abstract

Purpose

Previous surveys of anesthesiologists showed that despite a strong interest in implementing environmentally sustainable anesthetic practices, less than a third do so. Qualitative understanding of the capability, opportunity, and motivational factors that influence “green” behavior will inform the design of effective interventions to promote environmentally sustainable practices in the operating room (OR).

Methods

We conducted 23 semistructured interviews with anesthesiologists, with data saturation achieved. Applying the Behavior Change Wheel, interview questions addressed “capability,” “opportunity,” and “motivation” determinants of behavior.

Results

Preference for sevoflurane and syringe reuse were most commonly cited as existing environmentally sustainable anesthetic practices. Several participants reported lack of knowledge and feedback as impediments to sustainable anesthetic practices. Reported physical barriers included inadequate recycling facilities and abundance of supplies. Interviewees also discussed the importance of habitual behavior in improving skill sets and reducing cognitive load required to perform environmentally sustainable practices. General awareness of environmental issues and aggregation of marginal gains were reasons for environmentally sustainable measures in the OR. Organizational practice and culture played a significant role in the propagation of sustainable anesthetic practices, with senior staff often carrying a greater influence. While the majority preferred a top-down approach to effect change, others favored the use of incentives.

Conclusion

This study provides insight into the factors that influence the adoption of environmentally sustainable practices in the OR. Measures to promote these practices include education and training, feedback on efforts, engagement of senior anesthetists as role models and for change management, environmental restructuring, and policy designs that balance a top-down vs bottom-up approach to influencing change.

Supplementary Information

The online version contains supplementary material available at 10.1007/s12630-022-02392-0.

Climate change poses significant public health risks,¹ and health care contributes up to 9.8% of greenhouse emissions.² The COVID-19 pandemic escalated the use of disposable items, with almost 129 billion face masks and 65 billion gloves disposed globally each month.³ In our country, Singapore, the amount of biohazardous waste disposed increased from 4,400 to 5,700 tons between 2016 and 2020 (approximately 5% per annum).⁴ More research is needed to improve sustainability in health care, especially in operating rooms (ORs), which contribute up to 30% of daily medical waste. Twenty-five percent of this waste is contributed by anesthesia, and 40% of this is potentially recyclable.⁵

Surveys of anesthesiologists in various countries have suggested that, despite strong interests in implementing environmentally sustainable anesthetic practices, less than a third do so.^6–8 Barriers to widespread adoption of “green” practices as identified by these surveys included lack of hospital leadership support, staff attitudes, and inadequate information on recycling. These prior surveys, however, were subject to selection bias and variable response rates. A two-week nonparticipant observation in our ORs similarly showed that environmentally sustainable practices were uncommon (Electronic Supplementary Material [ESM] eAppendix 1). Nevertheless, systematic investigation of the barriers and facilitators to green behavior that is guided by a relevant theoretical framework is lacking. Such systematic understanding is important in developing policies and recommendations to improve environmentally sustainable OR practices.

In this study, we sought to address this gap by analyzing barriers and facilitators to green practices among anesthesiologists through the lenses of the Behavioral Change Wheel (BCW) framework (Figure).⁹ The BCW is a comprehensive framework based on the synthesis of 19 pre-existing behavioral change frameworks. It affords the integration of behavior theory with intervention designs by understanding and targeting mechanisms of action within the intervention. The capability, opportunity, and motivation sources of behavior (COM-B) model forms the hub of the BCW. We selected this framework as we believe that these domains provide a logical approach to the study question—for behavioral change to occur, individuals must be psychological and physically capable, possess social and physical opportunities, and be intrinsically motivated. The domains, hence, provide the foundation for interpretation of barriers and facilitators to environmentally sustainable practices that were revealed from the interviews.

Figure.

The Behavior Change Wheel.

Reproduced with permission from Michie S, Van Stralen MM, West R. The behavior change wheel: a new method for characterizing and designing behavior change interventions. Implement Sci 2011; 6: 42. https://doi.org/10.1186/1748-5908-6-42

Methods

Study setting

This study was conducted at the Singapore General Hospital (SGH), the largest tertiary hospital in Singapore, with 50,715 day surgeries and 47,583 in-patient surgeries performed in 2018.¹⁰ Internal unpublished data showed annual carbon footprints of 6,437,008 kg CO₂ equivalents (CO₂e) within ORs, including 1,900,136 kg CO₂e/year attributable to volatile anesthetic use.

Study participants

SingHealth Centralized Institutional Review Board (CIRB Ref: 2021/2453) granted ethical approval for this study. Participants were selected using the purposive sampling method¹¹ to reach maximum variation in terms of gender, seniority, and prior work experience in other institutions. No participant was known to campaign actively on environmental issues. After obtaining written informed consent, 23 semistructured interviews were conducted one-to-one and were audio-recorded, transcribed, and proofread prior to analysis. Interview questions included current practices and perceptions of anesthesiologists in adopting recycling and other sustainable practices in the OR. As all anesthesiologists interviewed also practiced in another public hospital under a combined department, participants were asked to share their experiences and perceptions specific to their practices in SGH, but were allowed to draw comparisons of experiences in other hospitals. An interview guide organized along the six domains of the COM-B model was developed and used to conduct the interviews; this allowed interviewers the freedom to “explore, probe, and ask questions that will elucidate and illuminate that particular subject,”¹¹ and enabled emergence of new themes not otherwise covered by the COM-B framework. In line with the framework and the interview approach we adopted, the most suitable method of thematic analysis was the framework method,¹² which allows both deductive (analysis according to the COM-B framework) and inductive (analysis of the emergent theme) reasoning in making sense of the data. The questions were modified in an iterative process to address new topics that surfaced during the course of the interviews (ESM eAppendix 2). We used NVivo (March 2020 version; QSR International, Doncaster, VIC, Australia)¹³ to organize the transcribed data and the coding process to facilitate thematic analysis using the framework method. The five steps of the framework analysis method by Pope et al. were followed: familiarization, framework identification, indexing, charting, mapping, and interpretation.^14,15 The BCW framework was selected a priori. Initial coding was undertaken by the first author, with all decisions discussed, shared, and agreed upon by all investigators. Subsequent coding and analysis were performed by two authors (M. W. W. Z., L. K. M.). Data saturation was determined when no new codes or information emerged from further interviews.¹⁶ Study methods and results are reported using the consolidated criteria for reporting qualitative research checklist¹⁷ to ensure rigor and transparency.

Reflexivity

Three of the authors (M. W. W. Z., S. L., L. S. A.) are practicing anesthesiologists at SGH; the first author is currently pursuing a Master of Public Health degree. Two other authors (C. H., L. K. M.) are anesthesiology trainees rotating within the health care cluster, including SGH. This topic was collectively explored after observing that, despite growing literature on green anesthesia and general departmental sentiments in favor of improving environmental sustainability in the workplace, little has been translated effectively into clinical practice. The analysis approach, thus, stems from our desire to bridge our understanding of anesthesiologists’ attitudes and behavior with subsequent selection of contextually appropriate interventions for successful implementation.

All the authors also had working relationships with all of the participants before the study began. The authors were mindful of potential hierarchical differences affecting responses, so interviewers and interviewees were matched by rank to encourage open discussion.

Results

An overview of interviewee profiles is shown in Table 1. Green practices in the OR were identified as reusing plastic syringes and wrappers used to contain individual drug trays, reusing personal protective equipment (PPE) during the COVID-19 pandemic, reducing waste in terms of the number of needles and intravenous extension lines used, and to a lesser extent a shift in practice favoring sevoflurane over desflurane or nitrous oxide. Barriers and enablers to engaging green practices in the OR are presented below using the COM-B domains; findings are summarized in Table 2 with illustrative quotes.

Table 1.

Participant characteristics

Total number of participants	23
Sex
Male	9
Female	14
Current designation
Medical officer*	6
Resident	3
Senior resident	3
Associate consultant	2
Consultant	4
Senior consultant	5
Years of anesthetic experience
< 5	9
5–10	7
11–15	3
16–20	0
> 20	4
Prior anesthetic experience(s) outside the SingHealth cluster of hospitals
No	17
Yes
Australia	1
UK	2
TTSH	1
KTPH	2
NUH	1
NTFGH	1
Total interview duration	9 hr 34 min
Mean interview duration	24 min 58 sec

^*Medical officers are junior doctors who have completed a basic medical degree and internship but have not yet entered specialist training

KTPH = Khoo Teck Puat Hospital; NTFGH = Ng Teng Fong General Hospital; NUH = National University Hospital; TTSH = Tan Tock Seng Hospital; UK = United Kingdom

Table 2.

Summary of findings

COM component	Barriers/themes	Illustrative quotes
CAPABILITY—physical*	• Patient factors (e.g., demographics, risk factors, and hemodynamic stability) and surgical suitability (e.g., duration and type of surgery) • Infection control (especially during pandemics)	“If it is going to be a long operation, the patient is on the higher BMI [body mass index] side, I will choose to use desflurane even though I am fully aware that it is supposedly more environmentally damaging than sevo [sevoflurane].” (I11)
CAPABILITY—psychological	• General awareness present concerning environmental impact of anesthesia practices, OR consumption, and waste management	“… yes, from the research that I did, it seems like anesthesia itself does seem to have a fair share of in terms of pollution, from anesthetic waste gases, from the single use plastics that we use, even to the drugs in terms of the disposal of drugs itself, causing impact to the environment.” (I23)
	• Lack of awareness regarding head-to-head comparisons between volatiles and TIVA, in terms of their environmental impact	“I do not specifically choose TIVA just for environmental concerns, because I have not seen or I’m not aware of any paper that studies… the equipment for TIVA itself, whether it causes more CO2 production than using sevoflurane or desflurane… So if there’s any study that shows this, if you use TIVA the whole set costs, produces less CO2 than sevoflurane or desflurane… maybe they will convince people like myself and others to switch…” (I14)
	• Lack of translation from awareness and knowledge into self-confidence to practice green anesthesia	“Like, a lot of times I want to recycle, but I’m not so sure if, if this is recyclable, yeah. And so, I mean, I remember having a talk with my friend who’s actually in sustainability and she does, like, you know, she works for this plastic company. And so, I was really amazed, like, you know, the number of different plastics they are and some are not recyclable, some are recyclable, and some, you know, you may throw them into the bin you contaminate everything. So, there’s really a lot of details into recycling and some knowledge that's required. It's not so simple as like all the plastics in the same, or all the papers are the same etc.” (I04)
	• Lack of confidence in others in the larger system of green practice	“[I]f I make all the effort, I would like to know that it’s actually going to where it should go, which is to the recycling plant, rather than going to the rubbish dump or the incinerator, along with all the rubbish. If it’s going to go that way, why do I want to make all the effort to separate it?” (I15)
OPPORTUNITY—physical	• Lack of recycle bins in the ORs	“I think the main thing is that there’s no place that I know of to actually throw recyclable stuff. People have to actually go put a separate bag somewhere and collect these. But after I collect it, I don’t know where to put it anyway so it’s just going to end up in the dustbin at some point.” (I11)
	• OR space constraints	“Compared with other places, you know, they actually have like the dustbins set up to collect plastic waste, collect glass bottles. I don’t see that in our case yet... I guess there’s something that can be looked into, but then somehow our theatres are small. Like I can’t imagine having another bin, you know, even sometimes the anesthetic trolley has no space” (I14)
	• Abundance of supplies that are readily accessible may lead to unintended physical incentive to engage in wasteful practice	“I think that also, we need to educate. How not to waste all the extra equipment that we have. Just because it is so easily available does not mean you, you “cover backside” [do something to protect yourself from future blame/criticism] … It’s a bit like the Mepilex [dressing] when, you know, you pad the patient all over when it’s not logical because the patient is not lying on that part of the body.” (I15)
OPPORTUNITY—social	• Need for collective multidisciplinary efforts	“I feel like every little [bit] counts. So, if everyone thinks that their little bit won’t count, then they will never be involved in this, you know, this major movement. But if everybody thinks and like do their part, I’m sure it will help” (I13)
	• Social organization of work with influence by senior anesthesiologists’ preferences	[106]	“So there was once where we were like running three EOTs [emergency operating theatres] at one go trying to clear the load, and I did turn up sevo after we put the patient down and my boss was like “why did you choose to turn up sevo” and I said I’m just trying to be more green…” [laughs]
		[Interviewer]	“And what did your boss say?”
		[I06]	“It ended up being des and nitrous.”
	• Respecting “professional boundaries” and individual preferences	“Sometimes I have to be quite respectful of other people’s… How should I say… Professional judgment and opinion as to what anesthetic is more suitable, so I try not to impose… I do want to respect that everyone has their own judgment with regards to this” (I20)
	• Production pressure (high caseload, demand for timely start and end times, and quick turnover) coupled with sick patients	“it is difficult to be double covering a cardiac OT [OR] and then preparing the drugs, and at the same time, you need to set lines. So then when that’s the case, then it will be a lower priority for me to then separate the plastic… because I’m aware that you need to… not all the packaging can be thrown in the same bag… The plastic, the paper… So it is very challenging to do that, especially early in the morning, when you have other things to do, to complete. And, and because you also don’t want to delay the start of the operation...” (I09)
MOTIVATION—automatic	• Benefits of automaticity in reducing cognitive effort required to perform the behavior	“if you remind somebody to do it, enough times people will start doing it. And once they do it enough times, it becomes a habit and it is easy to do they will to continue doing it.” (I04)
	• Entrenched habits in traditional practices as barrier to adopting green practices	“[T]o me, if I were to use certain things out of my normal practice, for example, using the same syringe for the same drugs it may affect… how should I put it… it is not my usual habit, then error may occur due to the change in practice, so I feel it is always safest to have a different syringe for different medication…” (I09)
MOTIVATION—reflective	• Aggregation of marginal gains	“World at large is full of examples of people adopting tiny, tiny practices, and changing the practice worldwide. You know, I remember many, many years ago, the aerosol spray cans with the CFC was, like universal, and then they started adopting CFC-free spray cans. And I thought this will never catch on, this will never catch on. But you know, within two or three years, suddenly, all the manufacturers were making CFC-free spray cans. And now it's become a lot of spray cans are... the number of spray cans we use for stuff have gone right down, and you know, so that's just a tiny example. But I think as individuals, you have to always believe that if you start practicing, there will be subtle and not so subtle way[s] that you can influence society.” (I17)
	• Versus scepticisms concerning magnitude of environmental impact contributed by anesthetic practices	“Like how much difference is this making? Or is it like miniscule compared…? It’s not going to make an impact? Like it is a miniscule effort/make no difference like a drop in the ocean, it’s not going to change any of this like environmental problem. But I mean obviously I guess if everyone thinks differently then it will have a greater impact, but that’s in a way what I think.” (I03)
	• Patient safety as a competing concern	“I do agree that in health care, we are a lot more clean [cleaner], not environmentally friendly but I think a lot of it is somewhat a necessary evil, because of how our day-to-day work requires [us] to be sterile… if not, there are life-threatening consequences too. So I guess providing high quality and standard of care also requires to a little extent being not environmentally friendly.” (I06)
	• Costs as a competing concern	“[L]ike switching from Des to Sevo, there is no new capital expenditure to buy new drugs or anything like that. It’s already right in front of you, you just turn it on or turn it off… so it’s just whether you want to change your own practice.” (I10)
	• Need for concrete feedback on the magnitude of environmental impact with existing OR practices	“I feel that I would more likely do that if I can see [a] positive effect from it. For example, if we recycle paper, there will be some feedback about where the recycled paper has gone to and has been recycled into something else. I would then be more convinced about the positive feedback and I will keep doing it.” (I08) “I think in addition to education, there should be a feedback on how much… maybe this one month, month of January, how much waste we have recycled.” (I14)
CULTURE	• Preference for top-down approach to drive green initiatives in the OR	“Well it has to come down from them to some extent, because they need to show that that’s what is to be done. And then to be very honest, that the middle management will toe the line…” (I15) “I think Singapore being the way that it is, a lot of the stuff… if it came from a management, came from government, I think people at large will follow more. This is unlike society elsewhere, where kind of individual [pauses] and then finally becomes a trend and people follow… if it came down from on high, I think more of my colleagues will follow.” (I17)
	• Versus participants with reservations for top-down approach	“I think most people are going to end up not doing it even if there is a directive, whereas even if there is no directive but it is convenient, most people wouldn’t mind doing it. They would just end up doing it anyway. So I think whether there is a directive doesn’t generally affect it, especially because this kind of directive can’t really be very compelling.” (I11)
	• Need for avenues to put environmental concerns into words, thereby increasing their symbolic presence	“I don’t think my peers routinely discuss it in the pantry, or among ourselves… in fact I also find it hard to…” (I10) “I don’t think we out rightly discuss about it.” (I14)

CFC = chlorofluorocarbons; COM = capability, opportunity and motivation components of the model; OR = operating room; TIVA = total intravenous anesthesia

Capability—physical

Physical capability/suitability of patients, rather than physical capability of anesthesiologists, was a consideration when applying some of the sustainable practices. For instance, some participants preferred desflurane and/or nitrous oxide for patients who were obese, hemodynamically unstable, or undergoing long operations. One participant favored the use of regional techniques where feasible to reduce waste. Several cited the use of low fresh gas flows as a means to conserve volatile anesthetic use.

Capability—psychological

Most participants reported general awareness about OR consumption and wastage through empiric observations, reading journal articles, or attending residency-based teachings. The COVID-19 pandemic increased OR consumption and waste because of ministry and institutional-level mandates on safe management measures and consumption of single-use items; this also heightened participants’ awareness of its environmental impact.

“I think it’s generated a lot of waste. But clearly, it was important at the start because when we have no idea how to deal with this virus... It’s natural that we overdo it at the start, but I think even now, we are already beginning to reduce our PPE requirements and it has reduced the amount of waste generated… it also highlights the need for reusable, recyclable things… it actually raises the issues of sustainability.” (I21)

Other sources of information included senior anesthesiologists’ practices, YouTube videos, and practices observed in other hospitals. The environmental impact of volatile anesthetics was the most commonly cited knowledge gained. Nevertheless, the awareness and knowledge had not translated into self-confidence in practicing green anesthesia.

“I think some of us want to be better, but we may not know what are the things that we’re doing is actually harmful. And what are the better alternatives? We may be aware of some, but we may not be aware of all so maybe there are some blind spots.” (I02)

The most expressed concern among junior anesthesiologists was the theoretical risk of compound A formation with sevoflurane use at lower fresh gas flows. Senior anesthesiologists generally alluded to lack of head-to-head comparisons between volatile anesthesia and total intravenous anesthesia (TIVA) in terms of the respective environmental impact. Participants also expressed doubts regarding which types of plastics are recyclable and whether recycled items “actually complete the journey” (I15) beyond the OR, indicating a lack of confidence in others in the larger system of green practice.

“I want to believe that by collecting all the plastic, after I remove them from the syringes, just throwing them into the recycling bin actually helps with climate change. Yeah. But I’m not so sure that it actually does. Do you?” (I19)

Opportunity—physical

Making recycling bins available in every OR and close to the anesthetic drug trolley emerged as the most important physical opportunity to promote recycling behavior. Nevertheless, space constraints can be a potential barrier to installing recycling bins.

“SGH rubbish bins are kind of like hooked onto the drug trolley… there’s just no space between there and your induction room door entrance to put another bin, and even on the other side where the other door is to wheel the patient out.” (I22)

The type of anesthetic machine was mentioned by one participant as a barrier to using lower fresh gas flows as it affected the actual volatile “concentration that is delivered” to the patient (I03). Interestingly, abundance of supplies resulting in supply-driven demand was also cited as a drawback; in this case, it provided an unintended physical incentive to engage in wasteful practice.

“I’m not sure [if] having too many… unwrapped syringes in your drug trolley itself, actually makes people more used to just use and throw... like when you have a full box of tissue paper…” (I14)

Naturally changing the physical environment of ORs with greater attention to environmental protection was offered as a main suggestion by participants. Suggestions included using visual reminders, making recycle bins easily accessible, refilling desflurane vaporizers only on demand or removing them completely from anesthetic machines, and increasing the ambient temperature in postanesthetic recovery units.

Opportunity—social

Many participants emphasized the importance of environmentally sustainable anesthesia as part of a collective multidisciplinary effort to “make a significant impact to the environmental system on a whole” (I05). Some alluded to the concept of “herd mentality” (I02, I20) as a means to generate momentum for green movement and to aggregate marginal gains.

“I think everyone must be involved… even the attendants and cleaners… and the sisters [nursing managers]…” (I02)

Various agents of change identified by participants included cleaning attendants who sort waste and nurses who open packaging for various equipment and infusion sets, highlighting the need for shared responsibility by all members in the OR. Anesthesiologists can also serve as role models; participants identified senior and junior anesthesiologists, anesthesiologists with prior exposure to green practices both locally and abroad, and peers through passive observations (e.g., through discussions or during relief breaks).

Social organization of work was also found to have a significant impact on the adoption of green practices in the OR. The anesthesiology team typically comprises a specialist anesthetist in charge with or without a dedicated junior doctor and an anesthetic nurse. Members assigned to individual ORs vary daily depending on availability of personnel and are, therefore, expected to have variable levels of psychological capability for green practice. For example, reusing syringes “may be confusing to the MOs [medical officers]” (I02) and, thereby, increase risks of medication error. It is conceivable that conventional practices will be favored over green practices.

On the other hand, senior anesthesiologists’ preferences individually and collectively played a significant role both in the availability of reusable equipment and in influencing the juniors’ and nurses’ anesthetic preparations.

“When I’m with my seniors, whatever they do, I will just follow suit… definitely influenced a lot by my seniors’ practice.” (I18)

“[G]etting hold of a classic LMA [laryngeal mask airway] versus a disposable LMA is not always so easy, because as a department we seem to have moved away from recyclable LMAs and we’ve gone down [with]the disposable LMA. So I’m kind of fighting against, you know a losing battle… if suddenly two or three of my colleagues all decide to do what I do then you know, the theatre supplies will be up in arms because already you know, just to accommodate my occasional needs, they will literally have to hunt high and low just for recyclable LMA.” (I17)

Interestingly, respecting “professional boundaries” (I20) and individual preferences were held as a tacit norm when working in a team. Those who adopted green practices felt uncomfortable imposing their individual practices on others for either not wishing to create “problems” with senior anesthesiologists who practiced differently (I11) or feeling a sense of learned helplessness after observing colleagues throwing the deliberately collected recycled plastics into general waste (I06).

“To change what they [the junior anesthesiologists] have been taught to some extent is to confuse them. And this is just my personal preference. It may not be what they’ve been taught, in which case, it’s not the right thing to do for them.” (I15)

Organizational norms of high caseload, demand for timely start and end times, and sick patients were additionally cited as barriers to green practices.

“… people are more preoccupied [with] starting a list on time, finishing the list, making sure patients are… I mean, some patients are really sick. So they were more interested in keeping patients hemodynamically stable than trying to think of [the] environmental impact of the anesthetic … so environmental concerns are perhaps not at the top of their minds doing the list.” (I04)

Motivation—automatic

Some participants performed environmentally sustainable practices out of habit and enjoyed the benefit of automaticity in reducing the cognitive effort required to perform the behavior.

“Perhaps for someone [in whom] this is already part of them it would be normal behaviour. They don’t have to like use part of their minds to think about doing this.” (I03)

Nevertheless, habit can be a double-sided sword—an entrenched habit in traditional practices can be a major barrier to applying environmentally sustainable practices.

“I don’t specifically try to use less than what I usually use for my elective cases... because I just don’t have the habit of doing that… And I haven’t thought of why I should change my practice.” (I09)

Motivation—reflective

Interest in making a difference to the environment, patient safety, and costs emerged as three main points affecting the participants’ decision to engage in sustainable practices.

Almost half the participants expressed the importance of “aggregation of marginal gains”¹⁸ in their decision to go green—whereby the sum of small but steady gains made in sustainable practices, if implemented on a wider scale and over time, could translate to a significant environmental impact.

“So the jury is still not out on whether what we do actually makes a difference, but to me… it is something that I can do to make a difference, however small I will go out and do it... like this environmental sustainability. If I just have to spend a bit more energy… I don’t mind doing it to make a difference.” (I05)

Conversely, fewer participants questioned the magnitude of environmental impact contributed by anesthetic practices.

“I don’t have much awareness on how bad is the harmful effect of that. And hence, I feel that the little things I do may not have much impact, hence, I continue my practice as what it is.” (I09)

Patient safety was a common concern hindering sustainable efforts. One given example was drug precipitation when reusing syringes for ondansetron and parecoxib administrations. Some participants also believed that the ubiquitous use of disposable items and waste generated were “engineered because of patient safety” (I22).

“[Our] practices have somewhat been environmentally unfriendly like the single-use syringes... but it’s an attempt to maintain sterility and patient safety… I think, for me, it’s more important that patient safety is upheld. I don’t really think of environmental consequences.” (I05)

While a few believed it costs more to be green, one participant contended that not all green practices meant increasing costs, and elaborated that the future rise in health care costs may be contributed by carbon taxations.

“If we don’t use anesthesia wisely, we also may generate increasing health care costs… I think the day will come when the spotlight will be on health care and anesthesia will definitely be one of the big contributors to health care waste and global warming… We will start measuring the emissions created by health care products or anesthesia care, and then there may be a dollar tax or cost incurred...” (I10)

Above all, many participants raised the need for concrete feedback on the magnitude of environmental impact with existing OR practices: how much waste is currently recycled, what actually happens to the recycled waste, and what it actually translated to (e.g., number of trees saved). The tangible nature of such information, coupled with the necessary skillsets and departmental support, could increase intrinsic motivation and in turn reinforce desired behaviors.¹⁹

Emergent theme: culture

While not a feature of the COM-B model, culture (or the lack of) emerged as a key player in influencing green anesthetic behavior. Here, culture refers to the “symbolic and learned, nonbiological aspects of human society, which include language, custom and convention.”²⁰

Firstly, a top-down approach, which was deemed by many participants as a trademark of local or “Asian” culture of getting things done, was perceived as a potentially effective way to drive sustainable anesthetic behavior.

“I do think it is something that we should force everyone to do, and I think if it comes with good reasons, and proven outcomes, then more people are more inclined to practice this.” (I19)

Participants also shared that the top-down approach entailed not only symbolic buy-in from hospital leadership but also active decision-making, for example, procuring equipment that were environmentally friendly.

Limitations of a top-down approach were expressed by a few participants; reasons included the impracticalities of applying them universally (e.g., due to competing priorities during emergency cases). Implementation would ultimately depend on the anesthesiologists’ perceptions and practices, for which the convenience of green initiatives would better facilitate the desired behavior.

“I think most people are going to end up not doing it even if there is a directive, whereas even if there is no directive but it is convenient, most people wouldn’t mind doing it. They would just end up doing it anyway. So I think whether there is a directive doesn’t generally affect it, especially because this kind of directive can’t really be very compelling.” (I11)

In addition to leveraging on existing cultural rules, the creation of avenues for people to discuss and put their environmental concerns into words, thereby increasing their symbolic presence, was perceived to be a valuable means to promote environmentally sustainable practices in the department.

“I don’t think my peers routinely discuss it in the pantry, or among ourselves… in fact I also find it hard to…” (I10)

“I think it’s a bit hard because we all practice independently, so [it’s] hard to see what other people are doing, but certainly if people are sharing what they’re doing, formally or informally, in the tea room, that can give people ideas of what can be done.” (I21)

Discussion

Using the COM-B model, this study has produced a comprehensive map of the current state of individual capabilities and motivations to engage in greener practice in the ORs in our hospital, and the physical, social, and cultural opportunities for them to do so. These theoretically informed findings form the basis for us to apply the intervention strategies in the outer rings of the BCW framework to change existing practices, to make them more environmentally friendly. Three broad directions of future interventions could be inferred from the results to promote sustainable practices in the OR (as summarized in Table 3): 1) using education, training, and feedback to promote psychological capability; 2) modifying the environment to increase physical opportunity; and 3) balancing a top-down vs bottom-up approach to influencing change in a given organization of practice to promote environmental conservation in the OR.

Table 3.

Proposed types of support (and associated intervention function) mapped against the three behavior-related components and relevant considerations

COM component	Considerations/barriers	Intervention function	Proposed type of support
CAPABILITY—physical*	• Patient factors (e.g., demographics, risk factors, and hemodynamic stability) and surgical suitability (e.g., duration and type of surgery) • Infection control (especially during pandemics)	Enablement Education Environmental restructuring	• Provide information on risks and benefits of various anesthetic techniques in various clinical scenarios, with focus on sustainability • Provide avenues for safe storage and reuse of disposable gowns and masks for each patient • Among the staff: use reusable goggles instead of disposable face shields
CAPABILITY—psychological	• Awareness about environmental impact of anesthesia practices, OR consumption, and waste management	Education Persuasion Enablement	• Develop anesthesiologists’ knowledge of sustainable anesthesia practices • Provide repeated opportunities to access information and support • Provide information that is tailored to different specialties operating within the OR environment • Prepare for challenges and difficulties in adopting sustainable practices
OPPORTUNITY—physical	• Lack of recycle bins in the ORs • OR space constraints • Abundance of supplies that are readily accessible may lead to unintended physical incentive to engage in wasteful practice	Environmental restructuring Enablement Restrictions	• Provide visual reminders • Provide recycle bins that are easily accessible • Refill desflurane vaporizers only on demand or remove them completely from anesthetic machines • Procure environmentally friendly equipment at departmental level • Increase the ambient temperature in postanesthetic recovery units
OPPORTUNITY—social	• Lack of collective multidisciplinary efforts • Social organization of work with influence by senior anesthesiologists’ preferences • Respecting “professional boundaries” and individual preferences • Production pressure (high caseload, demand for timely start and end times, and quick turnover) coupled with sick patients	Modeling Enablement Persuasion Training	• Identify and train agents of change (“green practice champions”) within and beyond the multidisciplinary OR medical team, involving support staff such as OR attendants, cleaners and environmental services • Identify and engage role models and peer supporters
CULTURE	• Lack of discussion among peers concerning green anesthetic practices Lack of leadership in driving sustainable practices	Incentivization Persuasion Restrictions Enablement	• Create avenues for discussion and providing continuity of support • Engage hospital leadership in driving sustainability programs within the local social and organizational context (“top-down approach”), exploring their roles in standardization of practices, equipment procurement and determining outcomes etc. Obtain stakeholder buy-in
MOTIVATION—automatic	Entrenched practices (green vs non-green)	Enablement	• Create avenues for discussion and provide continuity of support
MOTIVATION—reflective	• Interest in making a difference on the environment • Patient safety Costs	Enablement Persuasion Education	• Provide information on the magnitude of environment impact with OR practices and waste management statistics • Provide information on sustainable anesthesia practices and some of the translatable outcomes Provide repeated opportunities to access information and support

^*Physical capability/suitability of patients, rather than physical capability of anesthesiologists

Participants had generally received little formal training and shared uncertainties regarding “best green practices” or the impact of their current practices. Applying the BCW, this psychological capability can be augmented with education and training. Education entails addressing misconceptions, knowledge, and information gaps, which are recognized major barriers to participation in recycling measures²¹ and good recycling standards.²² This includes, for instance, addressing concerns of longer washout times with sevoflurane in obese patients or long surgeries, the perceived lack of comparative evidence regarding the environmental impact of volatile agents vs propofol,²³ and misconceptions regarding compound A formation and renal impairment risks with sevoflurane.²⁴ Interestingly, a greater proportion of participants cited plastic reuse than volatile mitigation in their current practices—this likely reflects a nascent understanding of the relative environmental impact of various strategies, as well as perpetuation of practices that are influenced by seniors. Training involves imparting skills and facilitates practical application of knowledge gained. An example could be reviewing the sequence of drug draws and minimizing the number of syringes required. Given the apprenticeship model of learning and inherent educational challenges in the OR,²⁵ attempts to standardize training on green anesthetic practices may not always be feasible. We recommend that departments begin by identifying and gathering positive agents of change from various disciplines within the OR community to collectively develop ways to impart sustainable practices through modeling in ORs. This team can obtain consensus for best practices adapted to practice context, which can also be turned into reading materials (e.g., recommendations) to educate others. Green practice champions should also work with leadership to provide dedicated time and space for providers to reflect and discuss in order to evolve their practice to one that is more sustainable. Such community engagement²⁶ will promote critical consciousness, increase community capacity, and ultimately lead to sustainable outcomes. If done well, education and training can reduce waste by 6.2% per month.²⁷

In terms of the physical environment, participants shared the need for accessible recycling bins and visual reminders, and attention to environmental sustainability at a department level when procuring and stocking supplies and equipment. As the anesthesiologists interviewed had work experience at at least two hospitals, it is worth noting that there were differences in the impetus and extent of green anesthetic practices described that are attributable to the environment. Choice architecture can therefore play a significant role in encouraging automatic behavior in favor of sustainable efforts.²⁸ Presence of and proximity to recycling bins as proposed by many participants would provide visual reminders and decrease inertia to recycle. Interventions in the form of enablement and restrictions were also proposed to address the physical opportunities of the COM-B domain. For instance, Patel et al. described a marked reduction in average desflurane consumption from 8.3% to 0.3% through education and removal of desflurane vaporizers from anesthetic machines in the department, with cost savings of over USD 200,000.²⁹

Systems-based practice is an important feature in the provision of anesthetic services and training, and encapsulates the interdependent roles of both the health care organization and members of the OR team.^30,31 Measures to improve environmentally sustainable behaviors in the OR would accordingly need to take into context the organizational culture and existing institutional practices. In this study, participants highlighted several social factors such as personnel shortage, senior–junior power distance, and a general aversion towards imposing individual practices on others. Organizational practice/culture played a significant role in the spread of sustainable anesthetic practices with senior staff often carrying more influence. It is therefore important to engage senior anesthesiologists as advocates and role models for desired practices during the change management process. Participants also called for collective efforts to increase environmentally sustainable anesthetic practices, and most preferred a top-down directives approach owing to its relative ease and greater likelihood of widespread execution. These responses suggest a collectivistic and tight organizational culture whereby individuals are more likely to use group performance as means of evaluating intervention effectiveness,³² and possess psychological traits in favor of social order and structure.³³ Nevertheless, organizational policies should also accommodate deviations in practice, e.g., in the interests of patient safety.

This is one of the first qualitative studies to elicit perceptions and adoption of environmentally sustainable practices among anesthesiologists, as informed by a theoretical framework that systematically and comprehensively evaluates reasons for behavior. We chose the use of BCW as it allowed extension of its application with implementation science frameworks to enable design of successful interventions. This framework, albeit relatively new, has been well applied in numerous studies on health behavior.^34–36 Findings from this study, triangulated with direct observations conducted prior to the interviews to assess the prevalence of green practices in the OR, support the potential for greater sustainability efforts by anesthesiologists. Challenges encountered by participants are congruent with previously described barriers to practice. Our study has also identified and discussed culture as an additional dimension that can potentially enrich the COM-B model. Future research is needed to explore the effects of culture in addition to physical, social, and psychological forces on behavioral change. Findings from the BCW may not necessarily lead to more effective intervention although it is the first step to exploring and understanding behaviors and help with policy change. Other study limitations include social desirability bias, as interviewees might have over-reported their green practices and attitudes to achieve social acceptance. While neutral, open-ended questions were used and responses kept strictly anonymous to avoid consequent risks of social sanctioning, the very nature of the topic discussed in the presence of an interviewer may conceivably prompt socially desirable responses. Although we made great efforts to include interviewees who do not support proenvironmental measures, a significant majority were still in favor of contributing to efforts to mitigate climate change. Nevertheless, similar sentiments are echoed in prior surveys where over 80% of anesthesiologists expressed intentions to recycle OR waste.

In conclusion, the present study has identified several areas using the BCW framework that can be strategically addressed through interventions and policies to promote environmentally sustainable anesthetic practices in the OR. These include engaging, educating, and training anesthesiologists on the magnitude of environmental impact with practical tips concerning green practices, modeling of desired behaviors, environmental nudging, and exploration of culturally sensitive solutions to promote green initiatives uptake. Further studies will be required to design and evaluate the efficacy of the above-proposed measures.

Supplementary Information

Below is the link to the electronic supplementary material.