Understanding Sustainability in Operating Theaters: An Ethnographic Study to Determine Drivers of Unsustainable Behaviors.

Background: Climate change is the biggest threat to human health. Paradoxically, the healthcare sector is a major contributor to climate change, and operating theaters are among the highest sources of emissions. Unsustainable practices are actions that compromise environmental, social, and financial sustainability, leading to unnecessary resource use, avoidable harm to the wider population, and reduced ability to provide effective healthcare in the future. Drivers of unsustainable practices and barriers to sustainability in practice (a top priority identified by the James Lind Alliance Priority Setting Partnership) are unexplored, hindering interventions that can help meet net-zero targets within healthcare. We conducted the first known ethnographic study to investigate behaviors related to sustainability in operating theaters, and their influences on those behaviors to inform the design of effective behavior change interventions. Methods: Nonparticipant ethnographic observations with opportunistic discussions in elective general surgical operating theaters were conducted between June and December 2023 at 2 university hospitals in Central London. Data were collected until saturation using a template developed during the initial observations. Inductive thematic analysis was conducted, with subthemes (influences) deductively mapped to the Theoretical Domains Framework. Results: Twenty-six procedures were observed (42 hours). Unsustainable behaviors included: (1) unnecessary and inappropriate glove use, potentially compromising safety (average 8-10 pairs per operation), (2) incorrect waste disposal, (3) unnecessary package opening, and (4) energy waste. Thematic analysis generated 6 themes and 16 influences (mapped to 9 Theoretical Domains Framework domains). Key themes were that sustainable practices are "infrequent and inconsistent" due to limited awareness (Knowledge) and low environmental concerns (Memory, Attention, and Decision Processes). Unsustainable behaviors were "habitual" and performed automatically (Lack of Attention). Drivers of unsustainable practices were: "Precaution" (Emotions, Beliefs About Consequences); "Efficiency" (Goals); "Past experiences" (Emotions and Social influences); and the "Physical environment" (Environmental Context and Resources). "Leadership" (Social Influences) was a driver of sustainable practices. Conclusions: This study identified widespread unsustainable culture and practices in operating theaters that compromise patient safety, and financial and environmental sustainability. It provides a nuanced understanding of contextual factors and their drivers, such as the strong impact of habit, knowledge, and the striving for efficiency, highlighting the need for both bottom-up engagement and top-down prioritization. The study provides a foundation for designing targeted interventions that integrate education, leadership engagement, and environmental restructuring to embed sustainability into routine surgical practice while ensuring patient safety and operational efficiency.