Barriers and facilitators to sustainable operating theatres: a systematic review using the Theoretical Domains Framework.

Abstract

The health sector contributes significantly to the climate crisis. Operating theatres in particular are a major contributor of greenhouse gas emissions and waste, and while there are several evidence-based guidelines to reduce this impact, these are often not followed. We systematically reviewed the literature to identify barriers and facilitators of sustainable behaviour in operating theatres, categorising these using the Theoretical Domains Framework (TDF). Medline, Embase, PsychInfo, and Global Health databases were searched for articles published between January 2000 - June 2023, using the concepts: barriers and facilitators, sustainability, and surgery. Two reviewers screened abstracts from identified studies, evaluated quality, and extracted data. Identified determinants were mapped to TDF domains and further themes as required. The results were reported in line with PRISMA (Preferred Reporting Items for Systematic reviews and Meta-Analyses) and AMSTAR (A MeaSurement Tool to Assess Systematic Reviews) guidelines. Twenty-one studies were selected for analysis and assessment (seventeen surveys and four interview studies) comprising 8286 participants, including surgeons, nurses and anaesthetists. Eighteen themes across ten TDF domains were identified. The most common barriers to adoption of green behaviours in operating theatres were in domains of: 'knowledge' (N=18) e.g. knowledge of sustainable practices; 'environmental context and resources' (N=16) e.g.'personnel shortage and workload and inadequate recycling facilities; 'social influences' (N=9) e.g. lack of leadership/organisational mandate or support; 'beliefs about consequences' (N=9) e.g. concerns regarding safety. Intention was the most common facilitator, with eleven studies citing it. Despite intentions to adopt sustainable practices in operating theatres, this review identified several barriers to doing so. Interventions should focus on mitigating these, especially by improving staff's knowledge of sustainability practices and working within the environmental context and time pressures. Furthermore, institutional change programmes and policies are needed to prioritise sustainability at the Hospital and Trust level. Additional qualitative work should also be conducted using behavioural frameworks, to more comprehensively investigate barriers and determinants to decarbonise operating theatres.