https://orcid.org/0000-0002-7715-6391
Abstract
This case study investigated waste management in a small, rural, Queensland hospital identifying areas where staff could reduce CO2e within the context of what is logistically possible. Phase I captured waste streams and disposal data for 1 May 2022–31 May 23 in a 20-bed Queensland Health hospital and included three audits of the hospital’s pharmaceutical waste bin. Phase II comprised semi-structured interviews with seven staff. Most potentially recyclable waste was being disposed of in the clinical, pharmaceutical, and general waste streams. All participants were interested in recycling more if appropriate bins were accessible in their work and lunch areas and recycling education was provided. Between 1 May 2022 and 31 May 2023, the CO2e were 44.53t, which equates to approximately 48,327 car km. This study identified opportunities for hospital-wide recycling which would reduce CO2e, waste collection fees, and landfill volume. A limitation was the small number of interviewees due to rural workforce shortages and a COVID-19 outbreak.
1. Introduction
The climate crisis presents a significant global health crisis (Romanello et al. Citation2021). To avoid the IPCC’s predicted devastating impacts if the global average temperature rise exceeds 1.5 °C compared with pre-industrial levels by the end of this century (Intergovernmental Panel on Climate Change (IPCC) Citation2018), we must achieve net-zero emissions globally by 2050 (Health Care Without Harm (HCWH) and ARUP Citation2021). Paradoxically, healthcare systems with their large carbon footprints are contributing significantly to this crisis (Karliner et al. Citation2019). Based on 2014 data, the global healthcare sector contributed 4.4% of global net emissions – if it were a country, it would be the fifth largest global emitter (Karliner et al. Citation2019). However, healthcare emissions continue to grow globally (Health Care without Harm and ARUP Citation2021). In 2014–2015, Australia’s healthcare system was the third highest healthcare emitter per capita globally (Health Care without Harm and ARUP Citation2021), contributing approximately 2% of global healthcare emissions (Health Care without Harm and ARUP Citation2021), and approximately 7% of Australia’s total emissions (Malik et al. Citation2018).
One of the most significant contributors to healthcare emissions is pharmaceuticals, which comprised approximately 19% of the Australian healthcare sector’s carbon footprint in 2014-15 (Malik et al. Citation2018), and approximately 22% of NHS England’s carbon footprint in 2019 (Tennison et al. Citation2021). This is through the embedded carbon in their manufacture and distribution, the emissions generated through the disposal of unwanted pharmaceuticals via high temperature incineration in the clinical waste stream, and the emissions generated through the disposal of packaging waste, either in the clinical waste stream or the general waste stream (Singleton et al. Citation2014). Hospitals cannot directly control the embedded carbon upstream, but they can reduce carbon emissions by reducing pharmaceutical waste and ensuring that the separate components of pharmaceutical waste are disposed of in the most environmentally responsible way (Singleton et al. Citation2014). According to the Queensland Government’s Guideline ‘Clinical and Related Waste Version 4.02’ (updated 3 February 2022), pharmaceutical waste is defined as unwanted pharmaceuticals, the original containers which are not deemed contaminated waste and the packaging waste (Queensland Government Department of Environment and Science Citation2019). Unwanted pharmaceuticals are to be treated as clinical waste and disposed of by high-temperature incineration, whereas original containers and any packaging waste may be disposed of in the commingled recycling stream or in general waste (Queensland Government Department of Environment and Science Citation2019). High-temperature incineration used for pharmaceuticals and clinical waste has the highest carbon footprint of any hospital waste stream, generating approximately 0.879 tCO2e/t (Department of Climate Change Energy the Environment and Water Citation2023). Other healthcare waste streams also contribute to carbon emissions e.g. paper, cardboard, and organic waste disposed of in landfill generate methane (Evangelisti et al. Citation2014; Department of Climate Change Energy the Environment and Water Citation2023). Methane has a global warming potential (GWP) of 27–30 over 100 years compared to CO2 which has a GWP of 1 (United States Environmental Protection Agency Citation2022). Available landfill space is also becoming an issue (Evangelisti et al. Citation2014). Segregation and improved recycling of hospital waste not only reduces GHGe but also enables recovery of materials such as glass, plastics, and metals (Mushtaq et al. Citation2022).
In 2021, the Queensland Government announced a target of net-zero emissions by 2050 (Queensland Government Citation2021). Queensland’s public healthcare system contributes 50% of all government emissions, and the Queensland Government has identified that more work is needed to reduce the carbon footprint of Queensland Health hospitals to reach the net-zero goal by 2050 (Queensland Government Citation2021). There are many peer-reviewed published papers that examine a specific hospital carbon hotspot or waste stream (for example, Shum et al. Citation2020; Tan and Lim Citation2021; McAlister et al. Citation2022; McAlister et al. Citation2023; Wyssusek et al. Citation2022) and most are based in large, metropolitan hospitals. Various hospital sustainability initiatives, including those at Princess Alexandra Hospital (Metro South Health Citation2019, Citation2021) and the Queensland Children’s Hospital (Renae McBrien Citation2023) (both located in Brisbane, Australia) and Western Health (Western Health Citation2020) (Melbourne, Australia) have been published in grey literature. However, there is a paucity of peer-reviewed literature investigating sustainability initiatives (including disposal of the various waste streams) in rural Australian public hospitals. Rural regions in Australia are already experiencing the effects of climate change (particularly drought) and rural health is impacted by climate change (Hanigan et al. Citation2022; Austin et al. Citation2020). Rural Australians are acutely aware of the link between greenhouse gas emissions (GHGe), the resultant global warming and climate change (Reser, Bradley, and Ellul Citation2014; Austin et al. Citation2020). Austin et al. (Citation2020) found rural residents’ greatest concerns regarding climate change were the environmental, financial, health, and social impacts. Therefore, since their communities are concerned about climate change, it is important that rural hospitals contribute to mitigation efforts by reducing their GHGe. This research aimed to address the gap in peer-reviewed literature by investigating the various waste streams and current methods of disposal in a rural Queensland public hospital. The purpose of this project was to identify areas where changes to waste disposal practices could reduce GHGe within the context of what is logistically possible for a small, rural Queensland hospital.
2. Methods
This exploratory case study research comprised two concurrent phases – a quantitative phase followed by a qualitative phase. Having qualitative and quantitative strands enabled us to view the research problem through different lenses. We adopted an interpretivist paradigm for this case study, accepting its assumption that reality is subjective, multiple, and socially constructed. The research team explored waste disposal through hospital staff’s experiences of that reality which, in turn, was shaped by their individual historical and social perspectives (Schoch Citation2019).
2.1. Hospital Site description
This research was conducted in a 20-bed Queensland Health hospital servicing a small rural town (Australian Bureau of Statistics (ABS) Citation2021). This hospital offers emergency care, outpatients, general medicine, general surgery, obstetrics, aged care, acute and high dependency care, and palliative care. It also offers allied health services, community health, home and community care services, and several outpatient clinics. Visiting specialists include a general surgeon, an obstetrician and gynaecologist.
2.2. Phase I (quantitative phase)
This phase involved scoping the various waste streams generated in each of the departments in the hospital, identification of the hospital’s waste disposal streams (types of waste bins) and bin audits. As depicted in , the clinical waste stream includes pharmaceutical waste and cytotoxic waste; however, hospitals have three different coloured bins for each of these streams and waste services managers receive separate waste collection data for each of these streams. Waste stream data for the clinical, cytotoxic, and P64 (pharmaceutical) waste streams provided by the hospital’s commercial waste contractor were obtained from the hospital’s waste services manager. Three random bin audits were conducted for the single P64 pharmaceutical waste bin in the hospital between June and August 2023 to identify the percentage of packaging waste that could have potentially been recycled. As it was not possible to physically visit some of the departments (e.g. Operating Theatre and Emergency Department) during our hospital visits, staff from these areas provided information on the various waste streams generated and the types of waste bins in their work areas. Visual audits of the general waste bins were also conducted to identify the various types of waste being disposed of in landfill. To calculate the CO2e generated, waste emissions data from the ‘Australian National Greenhouse Accounts Factors’ (Department of Climate Change Energy the Environment and Water Citation2023) were used – clinical waste generates 0.879 tCO2e/t and municipal waste generates 1.6 tCO2e/t (Department of Climate Change Energy the Environment and Water Citation2023).
Table 1. Queensland hospital waste streams.
2.3. Phase II (qualitative phase)
Phase II (qualitative phase) comprised semi-structured interviews with seven staff including clinical, administrative, and kitchen staff from different hospital operational levels. Both JS and AL conducted the interviews with AL asking the questions and JS taking field notes and asking additional questions to probe deeper or clarify some participants’ responses. JS is a registered pharmacist with previous experience working in several Queensland hospitals – this experience provided the research team with a more nuanced understanding of participants’ responses regarding waste streams generated and factors influencing waste disposal. JS has never worked in this hospital and did not know any of the participants.
Participants were recruited using a purposive sampling technique. The project’s sponsor in the hospital (the hospital pharmacist) was emailed information about the project, including its purpose and aim. Attached to the email were the Participants’ Information and Informed Consent documents. The sponsor then forwarded this email to all hospital staff and those interested in participating in the project emailed the research team directly with their signed consent forms. Interviews were conducted in a private meeting room in the hospital with only the interviewee and the research team present. Interviews were recorded using a digital recorder. Each participant was given a unique identifier code which was used in the recording rather than their name, thus ensuring confidentiality. As repetition was occurring in types of waste streams and bins reported by participants, after the seventh interview it was decided by the research team that data saturation had occurred, and no further interviews were organised. Participants were not offered the opportunity to listen to the audio recording of their interview nor read the interview transcript.
Interview questions (online Supplementary File 1) were adapted from questionnaires used in previous published research (Singleton, Lau, and Nissen Citation2018, Citation2021) and piloted on a small sample of pharmacists for readability and ease of understanding; only minor changes were required. Content analysis was undertaken on the interview data. JS and AL developed a coding framework for each question (e.g. types of waste streams, types of barriers to recycling) then each coded the data independently applying the coding framework for each question to the participants’ responses. Researcher subjectivity or ‘bias’ was managed through independent coding processes and then AL and JS discussed codes until consensus was reached on the final coding of each response for each question.
3. Results
3.1. Phase I – quantitative
3.1.1. Waste overview
Various waste streams and their disposal were identified in the scoping tour of the hospital (). A commercial waste contractor collects the clinical and cytotoxic waste, and the pharmaceutical waste (disposed of in secured P64 pharmaceutical waste bins), for high-temperature incineration. The municipal waste service collects the general waste bins weekly and the commingled waste bins fortnightly. Commingled recycling bins are located outside the kitchen and so are only used by kitchen staff; this is not a convenient location for use by staff working in other areas of the hospital. PVC tubing waste from products manufactured by Baxter International (American multinational healthcare company) is not collected by Baxter from this town. One of the visiting specialists personally takes it upon himself to take this waste with him when he visits another larger regional South-east Queensland town which is a Baxter collection point. Any other plastics generated in clinical practice are disposed of in general waste. Currently, there is minimal recycling with only the kitchen staff recycling via the commingled waste stream.
3.1.2. Pharmaceutical waste
Since pharmaceuticals have a large carbon footprint, pharmaceutical waste bin audits were conducted to determine whether emissions from this waste stream could be reduced. These audits must be conducted by, or in the presence of, a registered pharmacist (JS is registered with the Australian Health Practitioner Regulation Agency (AHPRA). In this hospital, most dispensing for inpatients is outsourced to a local community pharmacy. Instead, the hospital pharmacist performs a unique role within a Rural Multidisciplinary Medication Outreach Service (rMMOS) providing ongoing support to discharged patients including regular home visits. With minimal inpatient and ward dispensing, there was very little pharmaceutical waste generated at this site. Regardless, three pharmaceutical waste bin audits were conducted between June and August 2023 (). Each bin contained two weeks’ worth of pharmaceutical waste. Since this waste stream is disposed of by high-temperature incineration, total CO2e for these bins was 18.4 kgCO2e (Department of Climate Change Energy the Environment and Water Citation2023). To put this in perspective, the average Australian family car generates 0.1465 kgCO2e/km, so incineration of these three bins’ total waste is equivalent to 125.6 km of car travel (Department of Climate Change Energy the Environment and Water Citation2023). Removing the recyclable waste and incinerating the remainder would generate 15.73 kgCO2e (a reduction of 2.67 kgCO2e), which is equivalent to 107 km of car travel (Department of Climate Change Energy the Environment and Water Citation2023). Total pharmaceutical waste data for a 12-month period was obtained from the hospital’s waste services manager and was 126.23 kg. This equates to 111 kgCO2e or 757 km of car travel (Department of Climate Change Energy the Environment and Water Citation2023).
Table 2. Waste streams and disposal method at the case study site.
3.1.3. Single use stainless steel surgical implements
This waste stream and its disposal currently into landfill were an area of great concern to many of the clinical staff. These surgical implements (scissors, scalpels, forceps, etc) are made of magnetised surgical stainless steel. To identify the extent of the issue, staff collected all implements in this stream for six months and these were weighed on 3/8/23. Collected implements weighed 27.6 kg with some leakage from the Emergency Department which would have gone straight into general waste.
3.1.4. Total CO2e
This small rural hospital generated 44.53t of clinical and general waste for the period 1 May 2022 − 31 May 2023. Direct (Scope 1) emissions from the incineration of clinical waste are an estimated 0.879 tCO2e/t. Indirect (Scope 3) emissions from municipal solid waste disposed to landfill are 1.6 tCO2e/t (Department of Climate Change Energy the Environment and Water Citation2023). Disposal of this hospital waste in its various streams generated 70.08 tCO2e (). The hospital’s waste emissions data for one year are equivalent to 48,327 km of car travel () (Department of Climate Change Energy the Environment and Water Citation2023).
Table 3. Pharmaceutical waste bin audits.
Table 4. Waste emissions for general, clinical, cytotoxic, and pharmaceutical waste streams 1 May 2022–31 May 2023.
3.2. Phase II – qualitative
The semi-structured interviews also contributed to the compilation of the waste streams in . All interviewees identified waste generated in their work areas that were potentially recyclable but were being disposed of in the general waste stream destined for landfill: “… water bottles … I think every patient that we see usually goes through at least one …” (B17). “Yeah … most of our bottles and things could be recycled, but we don’t currently have a process to do that.” (P12).
The kitchen staff reported that the kitchen is reducing its use of plastics where possible and sourcing products with as little plastic packaging as possible.
“We try not to use plastic in the kitchen because since last year… we … banned plastic. So only water bottles because we’ve got no option at the moment …” (G07)
Lack of recycling of pharmaceutical waste (medications and packaging waste) was also raised by two participants.
“… outer packaging to a lot of our stuff. Yeah, so the cardboard, our outer packaging to IV fluids.” (G17)
“… we don’t recycle enough. Like, things go from … pharmacy to the ward, as a one off, for one particular patient. So, it’s not a standard imprest item, but I issue it from the hospital pharmacy. Then, instead of us bringing it back up into the pharmacy, it stays on the ward, and we end up with more and more and more things there.” (G29)
Barriers to recycling included a lack of recycling bins at point of waste generation.
“… just have a general waste bin, which everything goes into from paper, plastic, lunch items, that sort of stuff.” (G05)
“I had a little (battery) collection bin, and I know people have been using batteries and replacing them, but they don’t end up in the collection bin … leads me to believe that they’re just ending up in general waste.” (B17)
“… photocopier toner cartridges I think we probably already recycle, but we don’t have the collections up here for those.” (G05)
Participants working in clinical roles reported only two types of waste bins in their work area – general waste and clinical waste bins – whilst those in administrative roles reported only a general waste bin in their work area.
“Waste bins, so we have a general waste bin and a clinical waste bin.” (G17)
“So, we have general waste bins, which is where most of our waste ends up.” (B17)
Only the kitchen staff had access to and reported they actively used the commingled recycling bin.
“…we try to reduce our plastic waste as well so now … only thing we have is the milk bottles and water bottles.” (G07)
Several identified that water bottles could be recycled through the Containers for Change program which has a facility in the town; however, the hospital does not have a bank account into which the Containers for Change program can deposit payments. “… we used to take bottles home … some people (did), but not anymore, we’re not allowed to.” (G07).
All participants stated they would be interested in recycling more if commingled recycling bins and Containers-for-Change’ bins were available in their work areas and staff lunchrooms.
“… I had a lot of people approaching me and saying, there are … (recyclable containers redeemable through the Containers for Change program) just ending up in general waste bin. I was like, yes, and I’m sorry I can’t really do much about it. … recently we’ve had a few events … at the hospital and since then I’ve seen a lot of people show more interest … pretty much asking for recycling facilities …” (B17)
“Absolutely, everybody would I think, yeah.” (G17)
Composting of food waste was raised by one participant.
“One thing that I think about a lot is food wastage. We have gardens here that are maintained by the people that work here and I think about larger scale composting and processing of food waste.” (P21)
When asked if they felt confident knowing which items could be recycled, however, responses were mixed with some feeling confident while others felt they needed some education.
“Relatively confident …” (P21)
“I’d be interested to hear from you guys what sorts of things we can recycle, because I feel there’s things that we don’t even think of.” (G05)
“I mean, generally, I would say, yes, but there are obviously a few things which need a little bit more education … what can be recycled and what can’t be.” (B17)
“I think in the pharmacy, when I’ve got soft plastic, hard plastic, glass, tablets, you know, injectables that there is glass in. I would need some guidance and some education around what we can put and where.” (G29)
To support a hospital recycling initiative, most participants suggested a diverse range of educational resources such as signage above bins, in-service education sessions, and an online video presentation (online learning module) that can be watched at any time for those staff who can’t attend the in-service training sessions.
“… we will probably need some signage.” (B17)
“… rubbish bins, but it was clearly labelled PVC tubing, and those sorts of things … big sign … infographics …” (G29)
“… even a document would be great for people to refer back to. Because, obviously, not everyone’s going to be here every day when we run training. … nice labels on the bin would be great.” (P12)
“Yes, an in-service…” (G17)
To increase the likelihood of staff completing the online learning module, one participant suggested participants receive a “Certificate of Completion” so staff have evidence of education undertaken.
“Online training … via the online learning portal …It’s where we do all our mandatory training… I think something like that would be awesome ….staff can access at their leisure … get issued with a certificate of completion …… I think something like that would be great, because then at least I’ve done the module and I can say, hey, I’ve done this module and got the certificate … print it (though that’s not very environmental!) and put it on the wall to show that you are a waste friendly working area.” (G29)
4. Discussion
The key finding of this study was the large amount of potentially recyclable or reusable waste that was ending up in landfill due to a lack of suitable recycling or collection bins at the point of waste generation. Interviewed staff all expressed a desire to recycle but indicated that a lack of recycling bins in their work area made it impossible. Infrastructure considerations, such as the proximity (location and distance) of recycling bins, have been found in other studies to be a barrier to recycling in the workplace (Kollmuss and Agyeman Citation2002; Lee, De Young, and Marans Citation1995). For workplace recycling to become a normative behaviour, it must be convenient for employees to undertake and appropriate bins need to be provided (Oke et al. Citation2021; Singleton, Lau, and Nissen Citation2021). External conditions that make pro-environmental behaviours difficult, expensive or inconvenient will reduce the likelihood of them occurring (Stern, Dietz, and Guagnano Citation1995). Although the interviews revealed that many participants recycled at home, the infrastructural barriers in the workplace highlight the importance of context in predicting recycling behaviour (Oke et al. Citation2021; Blok et al. Citation2015b, Citation2015a). Most participants in this study were health professionals and all reported undertaking pro-environmental activities, including recycling and collecting containers for the “Containers for Change” program at home. However, as with Dunphy’s study of Australian health professionals (Dunphy Citation2014), this study found a disparity between home and workplace recycling behaviours.
Pharmaceutical waste was found to be disposed of as per Queensland Health guidelines (Queensland Government Department of Environment and Science Citation2019) in a secure, locked bin for disposal by high-temperature incineration. The pharmacist commented that poor inventory management of imprest stock on the wards contributed to pharmaceutical waste in this hospital. Wards over-order pharmaceuticals which then go out of date before they can be used. Unfortunately, this hospital does not have a pharmacy technician nor a ward pharmacist to manage ward pharmaceutical stock. This reduces the hospital’s ability to reduce pharmaceutical waste and emissions from its disposal via incineration. The bin audits did demonstrate, however, that recycling packaging waste can still contribute to emissions reductions.
Interestingly, whilst participants were concerned about the lack of recycling in the hospital, and professed to recycle at home, none had organised commingled recycling bins for work areas. This could be due to competing workplace goals and time pressures, in part due to staff shortages. Workplace pro-environmental behaviours such as reducing, reusing, or recycling waste are simply one set of goals (green goals) amidst numerous other competing goals that individuals have to choose between on a daily basis (Unsworth, Dmitrieva, and Adriasola Citation2013). Also, there is currently no staff member filling the substantive waste manager position at this hospital – only staff acting in the role. This may have precluded new or ‘extra’ pro-environmental waste initiatives. Another reason for no one taking leadership on recycling could be that staff who perceive the lack of bins as a barrier to recycling may attribute responsibility for recycling in the hospital to senior management (Oke et al. Citation2021).
Having senior management support and engage in pro-environmental behaviours (including recycling) in the workplace has been shown to have a significant impact on staff intentions to undertake pro-environmental actions (Ramus and Steger Citation2000; Blok et al. Citation2015a). This study identified a group of green champions who were trying to implement pro-environmental initiatives such as recycling at this hospital site. However, hospital-wide uptake of sustainable waste management, including recycling, will also require senior managers to behave pro-environmentally to encourage modelling of their behaviour by staff. (Wesselink, Blok, and Ringersma Citation2017). Leadership support for pro-environmental behaviours by actively demonstrating organisational commitment to sustainability will increase employee pro-environmental behaviours in the workplace (Blok et al. Citation2015a). This leadership support will reinforce behaviours that have already become habits at home. Non-workplace pro-environmental habits have been shown to increase an individual’s workplace pro-environmental behaviours (Sabbir and Taufique Citation2022; Fielding et al. Citation2012; Russell et al. Citation2017). This can have flow-on effects in the workplace – as more employees and leaders with pro-environmental personal habits behave sustainably in the workplace others will model their behaviour (Unsworth et al. Citation2021). Along with the reinforcing opinions of significant others, these pro-environmental behaviours can become workplace subjective norms, which in turn contribute to increased workplace pro-environmental behaviours and a more pro-environmental attitude amongst employees (Sabbir and Taufique Citation2022).
Whilst reporting that they recycled at home, participants acknowledged that they would need guidance on types of waste streams generated in the hospital and what can be recycled. Believing they lack sufficient knowledge of action strategies or expertise to undertake a pro-environmental action may deter people from acting (Hines, Hungerford, and Tomera Citation1986-87; Dunphy Citation2014) even though it contradicts their personal values (Dunphy Citation2014). Participants suggested education delivered in-service or via an online training module to all staff (clinical and non-clinical) would make them more confident to undertake recycling in the hospital which could increase their capacity to support the environment (Dunphy Citation2014). Signage on bins as well as hard copy documents that people could refer back to were also suggested by some participants as ways to guide hospital recycling behaviours. The amount and nature of the recycling information provided by organisations is more likely to engender employee recycling behaviours than simply knowing the organisation has a recycling program (Lee, De Young, and Marans Citation1995).
This study, whilst small, provided valuable insight into hospital waste streams and the emissions they generated and highlighted the opportunities for reducing emissions through recycling where possible. Removing recyclable waste from the clinical and pharmaceutical waste streams will also reduce hospital waste costs, as the incineration stream has the highest waste collection fees, and removing from the general waste stream will free up landfill space which is an issue in this rural community. In saying this, we recognise that Recycling sits below Prevent, Reduce, and Re-use on the Waste Management Hierarchy and, in itself, generates emissions. If the Queensland Government is to achieve its aim of transitioning Queensland to circular economy principles (Queensland Government Citation2024), then Queensland hospitals must find ways to re-use or repurpose some of this healthcare waste rather than recycling it or disposing of it in landfill.
This study also highlighted hospital waste streams that are potentially reusable, re-purposeable, or recyclable but are not collected by municipal waste services. These waste streams e.g. single-use, magnetised, stainless steel surgical equipment, surgical equipment containing copper wires, PVC tubing, medication blister strips, masks, and Kimguard waste require a sector-wide response at a national level due to the enormous amounts of waste generated. Finding environmentally responsible ways to handle waste streams which cannot be disposed of in the commingled recycling stream or handled by local waste facilities is problematic for rural and remote hospitals. This is largely due to economies of scale and logistical issues raised by third party recycling/repurposing companies and pharmaceutical companies. Hospital staffing shortages present an additional barrier, as competing workplace pressures inhibit waste segregation behaviours and time spent sourcing recycling companies. However, implementing a recycling intervention targeting waste streams that can be recycled locally and working within staff capacity still has the potential to make meaningful reductions in CO2e, waste fees, and landfill volume.
5. Limitations
A limitation to this study is that there may have been response bias whereby only participants interested in reducing waste and GHGe agreed to be interviewed. However, quantitative data reflected actual behaviours of all staff. A second limitation was the small number of participants due to staff shortages at this time (there was a COVID-19 outbreak at the hospital); however, data saturation was reached after seven interviews. Despite the small number of participants, we believe the findings are generalisable to other rural and remote hospitals in Australia and possibly in other countries with large geographical distances.
Author contributions
Judith Singleton: conceptualization, methodology, validation, formal analysis, investigation, data curation, writing – original draft, visualization, project administration. Alexander Letts: investigation, formal analysis, writing, assistance with project administration.
Supplemental Material
Download PDF (36.2 KB)Supplemental Material
Download PDF (136.8 KB)Acknowledgements
We would like to acknowledge the invaluable assistance and support for this research from Queensland Health, Professor Janet Davies, and Professor Kerrie Wilson from QUT.
Disclosure statement
No potential conflict of interest was reported by the author(s).
Supplementary material
Supplemental data for this article can be accessed here.
Additional information
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References
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