Participants

Four hundred and fifty surgeons and physicians responded to the questionnaire.

The sample consisted of 89 female surgeons (20%), 356 male surgeons (79%), and five individuals who wished to remain anonymous. The majority of participants (339, or 75% of the sample) were from academic institutions. Although a diversity of roles was indicated, the majority of surgeons (180, or 40%) were senior consultants. Seventy four (16%) of the total sample were department directors. The majority of participants (385, or 86%) were members of a formalized emergency surgery team. The surgeons' years of experience in the discipline ranged from 1 to 36, with a mean of 15 years and a standard deviation of 9. Participants represented 55 different countries. However, the sample was not evenly distributed, with the majority of surgeons working in Italy (145, or 32,22%). In particular, 322 respondents (72%) were from the ten countries with the most aggregate participants.

Table 1 provides descriptive statistics regarding the individuals and institutions that participated in the study.

Table 1 Descriptive statistics about participantsPerception of environmental sustainability

Regarding the perception and understanding of the concept of green/environmental sustainability, participants were first asked if they were familiar with the term, using a “yes or no” question. Three hundred and six (68%) replied they were, and the remaining 144 (32%) declared they were not. Moreover, participants were asked to describe the meaning of green/environmental sustainability applied to surgery. As specified and in line with previous studies [28,29,30], two principal investigators rated each given statement as concordant, discordant, or inconclusive.

To be rated as concordant, definitions needed to stress at least some of the concepts, such as a wise use of resources, the reduction in carbon footprint, energy savings, or smart waste management. Interestingly, less than half of the participants (182, 40% of the sample) provided definitions that could be rated as concordant according to the abovementioned criterion. 129 participants (29% of the sample) were rated as inconclusive as they gave responses that were incomplete, showing only a partial view of the phenomenon. The remaining 139 surgeons (31%) gave answers that did not fit the general definition of environmental sustainability.

The following Table 2 reports some examples of answers that were rated as concordant, inconclusive, and discordant.

Table 2 Examples and ways of rating the given answers to the question: How would you describe green/environmental sustainability applied to surgery?Sustainability acceptance and change management

Concerning the first group of general items to measure acceptance, participants gave the best evaluation to general statements, such as the need for Governments to incentivize green surgical practices or the global importance of sustainability principles in all economic fields. They also focused on surgical instruments and on the requirement to reduce their environmental impacts. They were also optimistic about the potential contribution of technology to greener practices.

The items with a less favorable evaluation concerned the role of patients in appreciating and trusting greener surgical practices.

Table 3 reports the results of the item belonging to the first question.

Table 3 Results—Sustainability acceptance and change managementSustainability habits in surgical practice

Interestingly, when it came to rating sustainability habits (most of which borrowed from the Royal Colleges’ checklist), the mean ranking is pretty low, with the best-rated item at 3.68 with a standard deviation of 1.27 and the lowest-rated factor at 2.56 with a standard deviation of 1.2.

More generally, most items show a standard deviation higher than 1, meaning that the sample is widely distributed among those who claim that several green practices are in place in their institutions and those who declare the contrary.

It should be noted that the home institution “promotes greener clinical practices in general terms”was among the worst rated of factors.

Table 4 reports the results related to questions about sustainability habits in surgical practice.

Table 4 Results—Sustainability habits in surgical practiceSustainability measures in hospitals and institutions

A list of items related to measures was provided, with participants needing to declare their presence or absence. The “I do not know” option was also possible. The practice with more consensus was about the regular maintenance of surgical equipment and the presence of automatic or pedal-controlled water taps.

Several management issues like procurement, equipment lease, or the type of energy sources in use received mainly “I do not know” responses. Multidisciplinary green teams or committees are reported as either present at only a few institutions or participants are not aware of their existence.

Table 5 highlights the results of such measures.

Table 5 Results—Sustainability measures in hospitals and institutionsPromotion of green/environmental sustainability practices

Participants were asked to give their opinions about possible tools to promote green practices, according to a knowledge translation theoretical lens[26].

Interestingly, participants backed the presence of multidisciplinary green teams[27], and the participation in specific training modules. Digital solutions were also highly rated, while visual instruments like billboards and leaflets were rated as low.

Table 6 reports the results of the possible promotional tools.

Table 6 Results—Promotion of green/environmental sustainability practicesAims and impacts of green/environmental sustainability practices

Last but not least, participants were asked to rate the perceived aims and impacts of green practices. In accordance with the results of the other sections, general attention was granted to the topic, underling the positive contribution to the natural environment. Notably, the hospital’s reputation was also highly valued. Patient’s engagement was, on the other hand, the worst-rated factor.

Table 7 reports the findings of the question related to the aims and impacts of environmental sustainability practices.

Table 7 Results—Aims and impacts of green/environmental sustainability practicesDifferences by groups

The analysis of participants' perceptions and behaviors regarding environmental Sustainability revealed varying trends based on Gender (Sex), Institution, and Position, even if not too relevant also when statistically significant.

Specifically, females showed slightly more familiarity with the concepts (72% vs. 68% for males), but this difference was not statistically significant (p = 0.4). Acceptance scores differed by gender, with females reporting higher scores (4.08 vs. 3.88 for males, p = 0.019). Non-academic institutions demonstrated lower promotion practices (3.60 vs. 3.85 for academic institutions, p = 0.008), while "Board-certified surgeons" reported lower promotion (3.51) and aims (3.57) scores. Notably, differences in acceptance scores between "Senior consultants" and "Residents" (p = 0.026) and in aims scores between academic and non-academic institutions (p = 0.012) were statistically significant. Other comparisons across categories did not yield significant differences (p > 0.05). These results shed light on nuanced patterns within these groups' perceptions of, and engagement with, sustainable healthcare practices, as reported in the following Table 8.

Table 8 Results–Differences by groups