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

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 characteristicsTable 2 Summary of findingsCapability—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)

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