A Pilot Study into the Use of Qualitative Methods to Improve the Awareness of Barriers to Sustainable Medical Waste Segregation within the United Kingdom’s National Health Service

By inergency On Apr 5, 2024

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1. Introduction

It has been shown that around 85% of waste generated in hospitals globally is non-hazardous and does not need to be incinerated [1]. Studies across Europe show that over 70% of the contaminated waste stream contains waste which was uncontaminated prior to being discarded [2,3,4,5]. The issue lies where non-hazardous waste is incorrectly placed in waste streams designed for hazardous waste [6], resulting in it being incinerated or disposed via alternative treatment as dictated, in this case, by United Kingdom (UK) regulatory guidelines [7]. Over half of the non-hazardous medical waste being incinerated globally is made of recyclable materials such as paper and plastic [5].

Currently it is unknown why medical waste is incorrectly segregated across the UK because no studies have been conducted. The NHS has shown that the treatment of hazardous waste causes significant environmental and economic impact and is growing at a rate of 3% per year [8]. The UK’s NHS contributes around 4% of the country’s total carbon dioxide emissions with the government setting the target of the NHS being net zero by 2040 [8]. The sustainable management of clinical waste has been deemed “vital” in the recent NHS ‘Clinical waste strategy 2023’ for the continual operation of healthcare facilities, and yet, there has been no identification on what is causing incorrect segregation, and no data to validate studies [8]. Current approaches within the NHS focus on reducing device procurement and hiring more waste managers but fail to address why waste is being incorrectly segregated when disposed [8].

Outside of the UK, previous studies have used qualitative methods to explore healthcare workers’ views on sustainability and key issues regarding sustainable waste management. Refs. [9,10] used questionnaires and focus groups to interview nurses and found that they are aware of the need for sustainability and want to contribute but face many challenges. A key problem was the lack of clear instructions, training, and feedback [11,12] with 86% of nurses within one study expressing the need for refresher training [9]. Other studies also used questionnaires and focus groups to test the knowledge of healthcare workers and found them to have poor understanding around the correct disposal of waste [13,14]. Less is understood about the most effective way to provide and help nurses retain this knowledge.

When waste segregation interventions and educational trainings were introduced on the correct placing of non-hazardous waste within European and American hospitals, the volume of the hazardous waste stream reduced from half [15,16] up to three quarters [17,18,19] found correct identification of infected devices to be the greatest obstacle to establishing recycling within hospitals [19]. It was found that easy access to the correct waste stream bin required was crucial for effective waste segregation [20,21]. A study from six operating suites in Australia discovered that 60% of the general waste was actually recyclable [22]. Less than 10% of the waste generated by the UK National Health Service (NHS) is currently recycled and the main barriers to recycling include a lack of staff training on what is recyclable, logistical accessibility to recycling bins, and clear guidelines to identify when waste is infectious [3].

Within the UK, once medical waste is placed into a specific-coloured bag, it will be closed using security seals or ties and never reopened [7]. It is, therefore, key that waste is segregated to the appropriate container before it is sealed [23]. As seen in Table 1, yellow and orange-coloured bins are used for hazardous waste; yellow for infectious and contaminated, orange for just infectious. Infectious waste is defined as waste that can transmit infection whereas contaminated waste is waste containing a pharmaceutically active agent [24]. The yellow waste stream must be disposed of via incineration which is the most environmentally impactful and most expensive end-of-life method [25,26]. The orange waste stream may also be incinerated but could instead be rendered safe by alternative treatment (i.e., heated to disinfect the waste) as a less environmentally impactful alternative to incineration [24].

Black and yellow (tiger)-striped bins are for non-hazardous and non-infectious waste. Black bins for domestic, and clear bins for recycling. The tiger-striped, domestic, and recycling waste streams contain waste that cannot cause harm or infection and, therefore, can be landfilled or recycled (see descriptions in Table 1). These are environmentally favourable options to the hazardous (yellow and orange) waste streams [25]. Table 1 demonstrates the different coloured bins currently available within UK NHS hospitals, as well as their description and end-of-life treatment as defined by the regulatory Health Technical Memorandum 07-01 [24].

Understanding the reasons behind poor segregation is crucial in order to identify steps to address it. This study aims to provide evidence to support the NHS’ efforts to improve the clinical waste strategy by providing qualitative results of the reasons for inaccurate medical waste segregation by staff, as well as to identify the best way to communicate knowledge and guidelines on the matter. Finally, this pilot study will also provide recommendations for the NHS’s intended course of action and suggestions for future research.

2. Methodology

For this study, a focus group and semi-structured interviews were conducted with healthcare workers within the United Kingdom during June and July 2023. These qualitative approaches were chosen as they have been found effective in determining attitudes and experiences within medical and social settings within previous studies [9,10,11,12]. The goal of the study was ‘to explore barriers to correct medical waste segregation within the UK National Health Services (NHS) and investigate why medical waste is incorrectly identified as ‘hazardous’’.

The criteria for participation selection were that the participants currently worked within a United Kingdom-based NHS medical facility and that they handled and segregated hazardous and non-hazardous waste as part of their daily job duties. All participants were over the age of 18. Two participants were between the ages of 18 and 40 and four were between the ages of 40 and 60.

Participants were identified as potential candidates to partake in the study as well as initially contacted through communication leads within various NHS trusts across England. A total of six healthcare workers participated in the study: three as individual interviews and three within the focus group. Participants of varying job responsibilities were encouraged to contribute in order to provide a wide breadth of ideas and perspectives to the questions asked. Of the healthcare workers who contributed, one was a medical doctor, three were nurses, and two were previously nurses who then switched their primary job responsibilities to become head providers of nurse training. Four of the participants were female and two were male. Four of the participants had medical careers which exceeded 10 years, whereas the remaining two had been employed for between 5 and 10 years.

It was decided to conduct interviews and a focus group to allow a mixture of in-depth responses from participants as well as facilitate discussions, which could be checked for validity by a variety of sources [27]. This mixed approach then provided not only a variety of responses but also allowed elaboration on specific aspects if required whilst staying within a reasonable timeframe [28]. The focus group and interviews took place virtually via Microsoft Teams.

2.1. Focus Group

The focus group took place for over 90 min in July 2023. The focus groups began with an introductory warm-up exercise, to be followed by four questions. Each question was allocated roughly 15 min to allow for discussion. At the end, 15 min were allocated for closing statements. A brief PowerPoint was used during the focus group for visual aid. The PowerPoint used allowed for each question to be visually displayed in writing on screen to provide reminders and convenience for the participants. Some images were also shown where appropriate (the PowerPoint slides used for each question are provided in Figure S1 within the Supplementary Materials (SM)). The warm-up exercise consisted of a description of what each coloured waste stream is used for followed by three images of a blue face mask, plastic packaging, and a used bandage. The participants were then asked which coloured waste stream they would place these items into followed by a reveal of the correct response. This allowed for an ice-breaker style introduction to the topic as well as engagement from the participants prior to questioning. The images used during the icebreaker are provided in Figure S2 of the Supplementary Materials.

2.2. Semi-Structured Interviews

The interviews were conducted individually with three of the participants. The same questions asked during the focus group were also asked during the interviews, but no time limits were placed. Each interview did not last longer than one hour by request of the participants and were conducted over Microsoft Teams. No visual aid such as PowerPoint was used and, instead, were solely one-to-one conversations. A warm-up exercise was not conducted but the topic of discussion was briefly explained to the participants at the start of the interviews. The participants were also given time at the end of the interview to expand on any previous points discussed or to provide their own insight into the topic of sustainable healthcare.

2.3. Questionnaire

Four open-ended questions were provided to each participant for the interviews and focus group. These specific questions were chosen because they address the key aspects of waste segregation whilst also being open-ended and allowing fruitful discussion. Question 1 (Q1) opens the conversation by identifying the initial thought process the healthcare workers have without prompting or encouraging any specific response. Q2 and Q3 then go on to further explore barriers to this segregation process, specifically focusing on the incorrect segregation of non-hazardous waste and recyclable waste which are key problems as shown within current the literature. Finally, Q4 directly addresses which method of communication is most preferred, giving the participants some examples as a guide. During the interviews/focus group, participants were permitted to branch into other related topics if they so desired. The questions provided to the participants are as follows:

Q1: What questions do you consider when deciding whether a device is hazardous or not and, therefore, which coloured waste bin it will enter?
Q2: Are there situations where you are unsure whether waste is hazardous or not and so erred on the side of caution and placed it in the hazardous waste stream?
Q3: What barriers do you face when identifying if something is recyclable?
Q4: What method is best to communicate information and training on correct waste segregation (e.g., types of plastics that are recyclable, situations which make a device hazardous, etc.), which requires minimal distraction to your primary job role?

2.4. Ethical Considerations

Written consent (via consent forms) was received from all participants prior to the commencement of the study. The participants were provided with written details about the nature of the study as well as any information about what the study would entail and how the results would be used. Participation was completely voluntary, and the participants were allowed to withdraw from the study at any point with no need for explanation. Participants provided informed consent for the publication of this paper. Ethical approval was received prior to any contact with the participants from the Brunel University London research ethics committee. The aim of the study, how it was to be conducted, prepared participant information sheets, and risk assessment of any potential issues regarding the questions to be asked and how they were to be asked were all submitted to the committee for thorough review. Changes required were made prior to any recruitment of participants and were ensured to be designed to minimise any potential harm or issues that could arise due to this study. The assigned ethical approval reference number as set by the committee is 41309 and the ethics approval was given June 2023.

Information about the participants such as their names, job description, and location of employment were collected but only made available to the principal researcher. After the analysis was conducted, all participant data were anonymised so that no identifiable information was provided. Participants were labelled with general titles in order to aid the analysis within this paper without alluding to any specific descriptions of the participant. These titles are as follows: Doctor, Nurse 1, Nurse 2, Nurse 3, Head nurse, and Training lead. The appropriate title will be provided alongside any associated quotes provided within Section 3.

2.5. Analysis

To analyse the responses, the focus group and interviews were recorded and transcribed using Microsoft Teams, which were then manually checked by the primary researcher to ensure accuracy. These transcriptions were transferred to the qualitative analysis software NVivo 12 plus [29]. NVivo is a type of Computer-Assisted Qualitative Data Analysis Software (CAQDAS) which allows qualitative research to be coded and examined for occurring themes. The use of NVivo helps aid the systemic evaluation of qualitative research to provide additional structure and ensure scientific validity. The themes identified within the research are then ensured not to be arbitrarily decided by the researcher, but instead recognized as significant by the software due to the number of occurrences within the coded responses. The full steps of a thematic analysis performed using NVivo (as outlined within [30]) are as follows:

Familiarisation with the data (i.e., transcription, comprehension of the data, and general noting of initial identifiable themes).
Identify common themes whilst systematically reading through the data.
Collate all data associated with each theme and identify repetition.
Review themes.
Define the features of the themes and the research outcome they suggest.
Analyse the themes including the use of relevant quotes to produce meaningful findings.

From the data, eight themes were identified. Table 2 helps demonstrate how these themes have been generated using examples of quotes from the transcript.

5. Limitations of the Study

Despite the significance of the findings found during this study, the scale of which it was conducted limited the representation of the results. This small scale of participant responses may mean that the findings of this study are not consistent on a nationwide basis. This has been attempted to be minimised during this research by involving participants from a range of job subcategories and from various NHS trusts to increase the breadth of responses. A key suggestion is that this study is emulated on a larger scale to test the validity of the findings across the UK. A consensus on the problems faced could then be generated and compared. It is also important to note that a study like this has not been conducted within the UK previously and one reason may be how challenging it was to recruit participants. Having a study that demonstrates, even on a smaller scale, that qualitative methods can be implemented and be used to uncover valuable findings will help spur future research to conduct wider-reaching studies.

Ideally, running a statistical analysis of the responses would provide numerically backed findings, but the small number of responses and lack of current data within this field together with the difficulty in recruiting participants limited this as an option. Qualitative methods are currently the most popular approach in similar studies due to the lack of numerical data, but it is hoped that as future research is conducted, this will become a possibility.

It is also important to consider that the participants of this study were more likely to become involved due to a personal bias towards improving sustainability within healthcare. They may be more aware of issues within their trust that other healthcare workers have no knowledge of. It is, therefore, possible that potential participants who were disinterested and, therefore, decided not to become involved would have provided different responses. This study attempted to avoid any biases by inviting a variety of participants using various communication leads and not simply those who had an interest in sustainability. The effect of having previous knowledge of sustainability within healthcare was also deemed to have an insignificant effect on the answers provided. Many of the findings (e.g., lack of bins, lack of labelling, etc.) were problems faced by anyone within the field and not just those who are environmentally conscious. Preferably, the NHS could implement sustainability questionnaires and training as a core module, which would then ensure all healthcare workers participate, but the size of such an operation was outside the scope of this study.

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