Siya Lodhia

Background

Global warming is a growing concern worldwide and healthcare sectors can be found to have a large carbon footprint. The NHS specifically contributes 4.4% of the countries carbon footprint and subsequent to the NHS announcing their aim to be Net-Zero by 2040 this is definitely an area that needs more work. Within hospitals operating theatres are an energy intensive area using 2-6times more energy than other areas. There has been a lot of research into what areas of the operating room to target to reduce the carbon footprint and including more recently The Royal College of Surgeons released a Green Checklist as a guide to a more sustainable operating room. However much of the evidence-based research has not made its way into most hospital operating rooms. 

Rationale for Study

Despite the growing body of evidence in the literature around sustainable practices in the operating room it does not seem these are being translated into practice.  We believe there needs to be a feasibility study to see how successfully it is able to be implemented and if not try to understand the barriers. Staff involvement is key when it comes to implementing new practices and making them successful.  In order to help effect change, it is important to understand the general attitudes of staff on the topic of sustainability, including both barriers and enablers that help in the implementation of sustainable measures into operating theatres. 

Research Question

A mixed methods feasibility study implementing a modified Green Theatre Checklist into Colorectal Theatres to work out how successful implementation can be and assessment staff barriers and enablers by using longitudinal interview analysis of staff to understand their perceptions 

Study design and Methodology

This is a feasibility study using a mixed methods design including (1) checklist implementation and quantitative data collection and (2) a longitudinal, qualitative interviews, preceded by a systematic literature review. Frameworks used for analysis include Consolidated Framework for Implementation Research (CFIR) and Thematic Analysis.

Systematic Review

The first piece of research conducted was a systematic literature review which then helped guide the methodology for the qualitative study. The systematic literature review was performed using three databases (Web of Science, Ovid and PubMed) last search June 2023. Original manuscripts discussing staff views regarding sustainable operating theatres were included. MMAT tool was used for quality appraisal and data analysed using thematic synthesis.  2933 articles were screened and 10 included a mix of qualitative, quantitative, and mixed methods. Attitudes of clinicians were compared amongst studies, a lack of enablers to implementation was shown. Barriers were broken down into themes including education and awareness, leadership, resistance to change, lack of facilities, lack of time and lack of incentive. This systematic review identified many barriers that clinicians face when implementing sustainable measures into operating theatres. It has also highlighted the lack of research focusing on enablers to implementation. A limitation of the review was all studies used a survey-based approach rather than interviews and only included clinicians.

Mixed methods feasibility study

This was a feasibility study to see how successfully the checklist could be implemented at one hospital in one specialty. Work package one included the implementation of an adapted checklist based off the Intercollegiate Green Surgical Checklist. This checklist included [discuss here what was included]. All clinical staff were given education and training on equipment before its introduction. The checklist was also completed for 2 months prior to introduction as some of the items on the checklist were sometimes being used sporadically, so we would be able to document the potential improvement in use of these items once the checklist was implemented. Duration of surgery and infection rate at 6 weeks and 3 months post operatively was also collected pre implementation. Once the checklist was introduced no changes were made to the checklist throughout the whole study. We also collated the number of operations where the checklist was not completed at all. Descriptive statistical analysis will be carried out every 3 months recording overall checklist compliance, checklist completion and individual changes improvement and compliance. Infection rate and duration of surgery will also be collected and compared. 

Work package two uses longitudinal qualitative methodology in interview form to explore staff views of enablers and barriers to the implementation. Semi-structured interviews and thematic analysis are used throughout. Three interview sessions have been scheduled starting in 2023, with the first taking place in April (pre checklist implementation), the second set in September and last set in January 2024. Between the first set and second set of interviews the sustainable checklist was introduced into the theatres. It was decided the second set of interviews would take place 4-5 months after checklist introduction. This would allow enough time for a range of barriers and enablers to be established. Ideally all the same stakeholders would be interviewed but due to staff retention and rotating job plans this was not always possible.  Subsequently the last set are planned to be 9 months after initial interviews as it normally takes less than a year to form a solid opinion and will show how things change from early implementation to later on.

Interviews were chosen for this project as most of the literature is presented in survey form and interviews allow for more in depth responses from participants. All stakeholders (clinical and non-clinical) were included in the study with purposive sampling and an estimated information power rather than data saturation was used. The interviews themselves were focused semi-structured interviews with the aim of mostly open-ended questions but sometimes closed for more focussed specific answers. A topic guide was also referred to, when necessary, as an aide memoir. The interviews were a mixture of face to face and virtual, were recorded and transcribed. They were then uploaded into NVivo to be coded. Thematic analysis was used to develop themes to further understand attitudes, enablers, and barriers to implementation of sustainability according to staff. This is useful to understand staff perspectives before any implementation of sustainability. Furthermore, it identified if there are any obvious differences in barriers or enablers between staff groups. Twenty-nine of the targeted 30 interviews were carried out. Early initial analysis shows that there is a lack of publicity of NHS aims to do with sustainability, most of the staff were not aware the hospital has a green plan and get their information from news headlines as opposed to internally. Some key barriers from initial analysis also indicate lack of education, lack of time and lack of communication between teams which are all interesting areas to explore further. 

Potential Implications for Future

The data will be tied together and analysed to try and understand which measures were easy to implement and can therefore be rolled out to other specialities and hospitals. Additionally for those parts of the checklists that were not successful we will evaluate the position of different staff members when it comes to sustainability and see if there are any recurring themes in terms of attitudes, enablers and barriers. This can then hopefully be used as a base in what enablers are useful to introduce when trying to implement something and how to overcome barriers. Overall helping hospital and the NHS reach the net-zero target.