Received: 9 February 2021 | Revised: 28 June 2021 | Accepted: 30 June 2021

DOI: 10.1111/jocn.15970

ORIGINAL ARTICLE

Nurses´ and nurse managers´ perceptions of sustainable

development in perioperative work: A qualitative study

Taava Leppänen MHSc, PhD Student, Nurse Manager1 | Tarja Kvist PhD, Professor2 |
Ruth McDermott-­Levy PhD, MPH, RN, FAAN, Professor, Co-­Director3 |
Päivi Kankkunen PhD, University Lecturer, Docent2

1
Department of Nursing Sciences,
University of Eastern Finland, Kuopio,
Finland
2
Department of Nursing Sciences,
University of Eastern Finland, Kuopio,
Finland
3
Villanova University M Louise Fitzpatrick
College of Nursing, M. Louise Fitzpatrick
College of Nursing, Villanova, PA, USA
Correspondence
Taava Leppänen, University of Eastern
Finland, Kuopio, Finland.
Email: taavar@uef.fi
Funding information
The author(s) received no financial
support for the research, authorship and/
or publication of this article
Abstract
Aims and objectives: To describe how nurses and nurse managers consider sustain-
able development principles in their daily work, how well they recognise these prin-
ciples and how these principles are considered in decision-­making in perioperative
work.
Background: Sustainable development involves interpersonal social and cultural re-
lations and long-­term economic and ecological thinking in societal decision-­making.
These dimensions are well-­suited for a foundation of decision-­making in acute health
care. No previous research has been performed on perioperative work from the sus-
tainable development perspective.
Design: Qualitative descriptive design was used. Data were collected from periopera-
tive nurses (n = 20) and nurse managers (n = 6) working in five surgical departments
in a Finnish university hospital. Data were analysed by content analysis. The reporting
follows qualitative research checklist (COREQ).
Results: The principles of sustainable development were poorly known among the
participants. Nurse managers considered their opportunities to influence decision-­
making were reduced by their limited economic knowledge. Resource use, individu-
ality, and ecological viewpoints were emphasised in the decision-­making process in
perioperative work.
Conclusions: Findings reveal that perioperative nurses and nurse managers are aware
of economic and ecological sustainability, but they do not actively consider it as part
of their work. Social and cultural sustainability must be developed further in decision-­
making in perioperative work.
Relevance to clinical practice: Perioperative nurses and nurse managers consider that
it is important to develop the principles of sustainable development in perioperative
work. This research indicates that economic understanding is not guiding decision-­
making, and there is a lack of knowledge about the benefits of ecological procedures.
Social and cultural sustainability are not connected in perioperative work, although

This is an open access article under the terms of the Creative Commons Attribution License, which permits use, distribution and reproduction in any medium,
provided the original work is properly cited.
© 2021 The Authors. Journal of Clinical Nursing published by John Wiley & Sons Ltd.

J Clin Nurs. 2022;31:1061–1072.  wileyonlinelibrary.com/journal/jocn | 1061

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1062
there is collaboration between the surgical team and the patient is essential. This
study helps to organise operating room management effectively and diversely.
KEYWORDS
cultural, ecological, economic, manager, nurse, perioperative, social, sustainable development
1 | I NTRO D U C TI O N
The United Nations adopted the second set of global goals, the
Sustainable Development Goals (SDGs), in 2015. This set of 17 goals
will drive sustainable development globally through 2030 and will
also influence nursing practice (Rosa & Iro, 2019). The United Nations
(2020) defines sustainable development as ‘development that meets
the needs of the present without compromising the ability of future
generations to meet their own needs’ (United Nations (UN), 2020).
Sustainable development is observed through four dimensions: eco-
nomic, societal, cultural, and ecological (Unesco, 2019). There are
applications for sustainable development in healthcare systems, and
surgical care can be examined in a sustainable development context.
For example, Great Britain's National Health Services (NHS) estab-
lished the Sustainable Development Unit in 2008. A target was set
to make NHS organisational practices more sustainable. There were
set targets in each NHS organisation that involved different depart-
ments (Dossey et al., 2019; Pencheon, 2015). A sustainable develop-
ment lens can also influence the Finnish health system.
The costs of acute health care are rising globally, and health
care spending has grown 3.9% annually, although the global econ-
omy only grew 3.0% in the years 2000–­2017. There are economic
benefits of development practices within health care (CC, 2019).
Ecological and social well-­being can be increased by applying eco-
nomic values to the choices that are made for long-­term and stable
economic growth (Harangozo et al., 2017). Societies that have high
standards of equality and justice are socially sustainable. Inequality
between genders is a global challenge regarding social sustainability
and influences health outcomes (Rosa & Iro, 2019). Cultural sustain-
ability means respecting, transferring, and preserving a group's val-
ues, values such as language, traditions, and practices for the next
generation (UN, 2020). Ecological sustainability means sustaining
nature's ecosystem and diversity (UN, 2020).
Despite the reduction in the number of days that patients
spend in the hospital and the increase in outpatient care, publicly
funded healthcare costs are increasing worldwide. A growing, age-
ing global population requires careful reorganisation of healthcare
system funding (Pot et al., 2018). Healthcare systems should also
work effectively with measurable impact value (Kruk et al., 2018).
This means that the health systems provide effective health care
and increase health outcomes, considering limited societal eco-
nomic resources. Economic sustainability is an important aspect
when the impact value of surgical care effectiveness is assessed. It
is important that surgical departments are delivering quality care
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LEPPÄNEN et al.
What does this paper contribute to the wider
global clinical community?
• The perspective of the study brings out a new vision for
the framework of sustainable development in operat-
ing theatres and, more broadly, for the management of
health care.
• The study will support nurses and nurse managers to
understand their work through the dimensions of sus-
tainable development.
• The research can be used to organise the management
of operating theatres efficiently and to increase their
understanding of sustainable development within the
organisation.
while balancing cost and equal access to care (Chasseigne et al.,
2018). However, healthcare managers seem to have limited knowl-
edge about economics, lack budgeting information and input within
their own organisations (Al-­Rundio, 2019, Bai et al., 2017, Waxman
& Massarweh, 2018). Only a few studies exist about sustainability
in operating rooms (Anåker et al., 2015; Nichols & Mukonoweshuro,
2017). According to these studies, teamwork, high-­volume usage of
disposable products, and expensive equipment add to the need to
address an economical perspective within surgical suites. The equip-
ment, used in perioperative operations, may also have a relatively
short utilisation rate, which makes it inefficient to use (Anåker et al.,
2015; Nichols & Mukonoweshuro, 2017).
Surgical care needs to be accessible, effective, and patient
centred (Pot et al., 2018). Patients´ needs should be considered in
the hospital environment at all levels of the organisation to make
care socially sustainable (Capolongo et al., 2016). More specifically,
equality and patient safety could be seen as a socially sustainable
way to act in operating rooms. Effective operating room manage-
ment is important for timely surgical scheduling and to ensure short
enough waiting times for the patients for their procedures. One
challenge is to create a trusting relationship with the patient in a very
short moment before beginning the surgery. Social sustainability
can be considered from different perspectives. Social sustainability
is operationalised by collaborative teamwork in the operating room
and by the surgical team guiding and accepting the junior team mem-
bers. Additionally, effective communication and collegiality between
team members increases patient safety. Collaboration between the

LEPPÄNEN et al.
surgeon and staff nurses has been found to reduces waste gener-
ated from surgical procedures (Chasseigne et al., 2018). Equal and
respectful treatment between different disciplines, colleagues, and
patients increases social well-­being.
Cultural sustainability supports both individual and group val-
ues that are found in language, traditions, and practices. Cultural
sustainability aims to sustain cultures and heritages to advance
them to the next generation. (UN, 2020) In the operating room en-
vironment, that could mean not only introducing the department´s
working culture and best practices to the new employees but also
respecting and understanding the patients’ cultures. It is important
to understand and observe cultural differences and discuss them in
a way that the quality of cultural sustainability improves in operative
teamwork. No published research currently exists from the social
or cultural sustainability literature related to the operating room
environment.
Ecological aspects in the operating room are emphasised when
compared to the other departments within the hospital. A great
number of disposable products are consumed during surgical proce-
dures (Kallio et al., 2020). Water usage and energy consumption are
also high within surgical departments due to instrument sterilisation
and aseptic procedures (Cheng et al., 2011; Kampf & Gray, 2017).
Chasseigne et al., (2018) found that about twenty per cent of dispos-
able products received for a surgical procedure are left over without
using them. The reasons were over preparing of the supplies needed,
usage of disposable products that are inadvertently opened for the
surgical procedure and mistakes in aseptic procedures (Chasseigne
et al., 2018; Rigante et al., 2017). For example, surgical procedures
in the United States generate over 2000 tons of waste from single-­
use products daily (Zygourakis et al., 2017). Surgical waste contains
biohazardous items, such as bloody swabs and human tissues; thus,
handling and disposal is more complex and expensive than normal
waste (Weiss et al., 2016). Furthermore, sharp items and liquid waste
with medications require their own disposal procedures, which in-
creases the handling costs (Rafiee et al., 2016) and influences eco-
nomic sustainability.
The benefit of a sustainable development lens in the operating
room is that opportunities exist for economic, social, cultural, and
ecological improvements in nursing practice and leadership. It is
possible to set quantitative targets and measure the results in each
dimension. A sustainable development setting effectively guides
staff engagement to understand and improve the nursing practices
in their own working environment. It can help the staff see their
own potential to influence to sustainable development items and via
them to affect to the global challenges such as climate change.
1.1 | Purpose
This study's aim was to describe how perioperative nurses and
nurse managers consider principles of sustainable development in
their daily work; how they recognise the principles of sustainable
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1063
development; and if these principles are considered in decision-­
making in perioperative work. The research questions were:
1. How are the principles of sustainable development demonstrated
in perioperative nurses´ and nurse managers´ daily work?
2. What kind of barriers do perioperative nurses and nurse manag-
ers face when using principles of sustainable development in their
daily work?
3. How can perioperative nurses and nurse managers promote the
implementation of sustainable development principles in their
daily work and what kind of opportunities do they have to opera-
tionalise these principles in their work?
The findings can be used to describe sustainable development
principles in surgical care decision-­making and to make ecological,
social, cultural, and economic improvements in perioperative nurs-
ing practice and leadership.
2 | M E TH O D S
2.1 | Design
A qualitative descriptive design with naturalistic orientation was
used in the study. It is used to understand participant's context and
these perspectives can initiate a research programme to develop
measurable concepts (Colorafi & Evans, 2016). This approach was
selected because the research aim was to describe nurses´ and nurse
managers´ experiences with sustainable development dimensions in
their work. The first author was familiar with the specialised termi-
nology and operating room environment as a nurse manager, so the
terminology did not need interpretation. The literature review was
made separately four dimensions on sustainable development. The
literature review was used as support material during the develop-
ment of interview questions. The consolidated criteria for reporting
qualitative research (COREQ) were used to report the study (Tong
et al., 2007. (Supplementary File 1)).
2.2 | Data collection
Data were collected from five different surgical departments in
Finland during the spring of 2019. One of the departments offered
only day surgery while the other four departments provided sur-
geries 24 h a day and seven days a week. The researchers´ inter-
est was in collecting data to describe sustainable development in
perioperative work as broadly as possible and taking into account
the different surgical staff positions involved in perioperative
work, such as anaesthesia and scrub nurse, nurse manager, and
recovery nurse.
Participants received a written information sheet about the
research and its background. After giving a time to study the
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1064 LEPPÄNEN et al.

information sheet, an oral explanation of research plan was given

development do you find most

to each participant. Participants signed a written approval for par-

What dimension of sustainable

important in your work?

ticipation of the study. Interview materials were handled according
GDPR demands (GDPR, 2016, Data protection Act 1050, 2018).
The participants were given a possibility to ask questions about the
research and they were informed about the option to abort their

Importance?
participation at any time. All participants completed the study. The
hospital research committee was able to approve this research be-
cause it focused to employees only. According to Finnish ethical
guidelines, separate ethical approval was not needed because no

How do you pay attention to ecological

vulnerable groups were included among the participants (Tong et al.,

In what way would you save on energy

recycling in the operating room?
2007, TENK, 2019.)

What ways are there to reduce the

consumption in the operating

issues in perioperative work?

waste in perioperative work?

How would you develop waste

Ecological sustainability in
2.3 | Sample size and implementation

perioperative work
The semi-­structured interviews were based on the four dimen-
sions of the sustainable development definition: economic, social,

room?
cultural, and ecological sustainability (UN, 2020, Hopwood et al.,
2005). A pilot interview was made prior to the actual interviews.
Based on the pilot, some questions were eliminated because they

different backgrounds considered

were too detailed. Table 1 presents the semi-­structured interview

different cultures have you had in

in your introduction programme?
cultures affect the perioperative

How are different cultures visible in

What kind of experiences regarding

In what way do patients´ different
questions. Audio-­recorded face-­to-­face interviews were conducted.

In what way are new employees´

The first author conducted all interviews in the Finnish language.
The interviewees did not know the researcher in advance. The first
Cultural sustainability in

perioperative work?
author contacted the nurse managers in each surgical department

your workplace?
perioperative work

and provided information about the research. The nurse managers

inquired volunteering to participate to the research from staff. The
nurse manager of each surgical department's operating room se-
work?

lected the voluntary participants based on their availability related

to the surgical schedule within the department. The interviews were
conducted in a private room in a hospital. Only the interviewer and
Social sustainability in perioperative

between colleagues actualised in

between patients have you seen

How are equality and fair treatment

each single participant were present during the individual inter-

possible to increase equality in
shown in perioperative work?

What kind of unequal treatment

views. The same interview script was used in each interview, but
In what way is patient equality

How do you think it would be

the order of questions varied according to the discussion with the perioperative work?
interviewee. The interview durations ranged from 35 to 95 min. A
in your daily work?

your workplace?

total of n = 26 interviews were conducted. Participants were oper-

ating room nurses (n = 20) and nurse managers (n = 6) who worked
in different hospital surgical departments (n = 5). In the five surgical
departments were working at total of 400 perioperative nurses and
TA B L E 1 Semi-­structured interview questions

work

19 nurse managers.
The researchers used a background form to collect informa-
tion about participants’ attitudes and knowledge about sustainable
aspects in your perioperative work?
in your daily work and how are you

What kind of issues prevent you from

What kind of economic issues do you

Are you considering economic issues

development. The purpose of the background form was to deter-

taking account of the economic
budget affect your daily work?
In what way does your employers’

What kind of issues increase your

opportunities to consider the

mine if the participants were familiar with sustainable development

economic aspects in your

principles so they could also use this information in their work. The
Economic sustainability in

identify in your work?

background form asked the interviewees’ views on how an individ-

perioperative work?
processing them?

ual could improve the realisation of sustainable development in their

perioperative work

personal and professional lives, and whether they followed national

policy decision-­making on sustainable development. The findings of
the background form are reported in the results section. The partic-
ipants were told about four dimensions of sustainable development
after they completed the background form.

LEPPÄNEN et al.
2.4 | Data analysis
Data analysis was conducted with deductive and inductive content
analysis (Bowling, 2002, Burns and Grove, 2009). Inductive analysis
was used because of limited research about the four dimensions of
sustainable development in the operating room environment. More
specifically, the social and cultural aspects of sustainable develop-
ment have not been studied. Deductive analysis was based on the
UN’s definition of sustainable development. Verbatim transcripts
were generated from the interviews. The first author performed
the main analysis in collaboration with two authors. The transcripts
were read repeatedly to identify key themes in the context of sus-
tainable development in operating room work.
Inductive analysis was used to identify similar participant quo-
tations as exemplars and combine them with different categories.
Matrices were used at the beginning for each sustainable develop-
ment dimension and to address the research question. Each matrix
included data s from perioperative nurses that addressed each di-
mension of sustainable development: For example, a quotation ex-
emplar of the economic sustainability matrix was ‘all the disposable
items in surgery’ or ‘sterilization process is expensive’. Exemplars of so-
cial sustainability were ‘men and women should be treated as equal’ or
F I G U R E 1 Analysis process
|
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1065
‘surgeons´ attitudes towards nurses are not equal’ or ‘teamwork could
be better’. Cultural and ecological matrices were also made and used
in similar manner. Additional matrices were created for every sus-
tainable development dimension regarding nurse managers. Similar
exemplar from nurses and nurse managers were combined within
the subcategories in each sustainable development dimension.
Next, subcategories were combined with similar subcategories from
nurses and nurse managers. Finally, analysing of these categories,
the main categories from each sustainable development dimension
emerged. The analysis process is described in Figure 1.
2.5 | Rigour
The semi-­structured interview questions were asked in all interviews,
and the interview guide was followed systematically in order to en-
sure rigour during the data collection process and to maintain stability
(Table 1). Stability is related to reliability criteria in qualitative studies.
(Long & Johnson, 2000). The first author conducting the interview
has been working as a perioperative nurse and the nurse manager
in an operating room. The author's background as a nurse caused
some bias, although the operating theatres were of different sizes
 |
1066
and surgical specialties were different from those in the author's own
ward. This bias was reflected with the other researchers. The first au-
thor bracketed bias by using the semi-­structured interview questions
and letting the interviewee lead the conversation. Researcher's bias
was also attended to by a detailed report and the original quotation
exemplars from the interviews (GDPR, 2016, Gray et al., 2017, Data
Protection Act, 2018) Consistency emerged with the data saturation
during the interview process (Long & Johnson, 2000). The data analy-
sis was done with the other researchers, and all researchers accepted
the assumptions. Verbatim quotations were used to support the as-
sumptions. Verbatim quotations in a research report increase the vali-
dation of qualitative research (Long & Johnson, 2000). The research
was performed with high ethical standards. The importance of the
research was evaluated within a social and nursing science context.
3 | R E S U LT S
Ten anaesthesia nurses, 12 scrub nurses, and six nurse managers par-
ticipated in this research. The participants’ mean age was 47 years;
the age range was 25 to 63 years. The participants’ working experi-
ences varied from one to 30 years, and the median experience of
perioperative nursing was eight years. None of the participants had
heard about the Sustainable Development Agenda 2030 or about
the UN’s Sustainable Development Goals. Eight participants re-
ported that they did not follow any environmental or political news
from television or newspapers. Nine of the participants thought that
sustainability meant just waste recycling.
This research found that the principles of sustainable develop-
ment were not familiar to the nurses or nurse managers. The eco-
nomic aspects of care were not a top priority in the nurses´ work.
Nurses felt that financial considerations did not matter to patient care
in the operating room. Their opinion was that the economic aspects
of care should be considered elsewhere within the health system, but
not in the operating room. The social and cultural aspects related to
the sustainability principles were not recognised in the perioperative
work. The nurses knew better for the principles of ecological sustain-
ability, but they experienced obstacles to the use of these principles
in their daily work. The obstacles were related to difficulties in ar-
ranging recycling in the operating room. Nurses thought that ecologi-
cal behaviour was unnecessary in the hospital environment, although
some of them followed an ecological lifestyle in their own lives.
The inductive analysis process led to six subcategories in the
economic and social dimensions, five subcategories in the cul-
tural dimension and seven subcategories in the ecological dimen-
sion. From these subcategories the main categories were created.
Table 2 shows the main categories of this analysis.
3.1 | Economic sustainability in perioperative work
Overall, economic sustainability was not identified as an impor-
tant part of the work in the operating room. Only two nurses out
of 20 reported that they considered the economic aspects are an
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LEPPÄNEN et al.
important part of their work. There was a contradiction between
nursing and economic thinking, which was an obstacle to identify-
ing the economic dimension as a part of the operating room work.
Assortment of disposable products and devices was described the
most important economic aspect in daily work. Perioperative nurses
considered that they have limited opportunities to influence to the
usage of disposable products in surgeries. ‘In my position as a nurse…
If the surgeon wants something, I can´t do anything about it’. (Nurse 6).
Most of the perioperative nurses did not recognise the connection of
economic aspects at their daily work. They understood that there are
areas like wound infections that may increase healthcare costs, but
they did not consider it as an important issue in their own work. ‘Well,
I don´t consider any economic aspects in my work, I concentrate more on,
how everything is functioning. That is my only priority’. (Nurse 6). Nurse
8 expressed it similarly. ‘I have to say, all I can do is to decide, which dis-
posable items I´m opening to the sterile field in advance, but to be honest,
I don´t think it matters in the bigger picture. And sometimes when we tell
the surgeon the price of a disposable product, he doesn´t care’.
Nurse managers considered the financial affairs of the operating
room as ‘a grey area’, that was regulated elsewhere within the organi-
sation. Most nurse managers considered in their work they implement
the financial decisions made by someone else. The nurse managers
did not have knowledge about the surgical department's budget, how
they could influence the budget, or how the budgeted money will be
used. Some of the nurse managers felt that the economic aspects did
not affect their work at all. ‘I´m not responsible for budget nor think
about budget matters daily. There are some financial purchases that I
have to negotiate with the financial department, but again, in the end, I
do not decide about these purchases. Sometimes, when I disagree with a
surgeon about purchasing certain equipment, it is always the surgeon who
rules. I don´t think I have a great impact on the economic aspects’. (Nurse
manager 3). The assortment of daily disposable products and purchas-
ing of devices were mentioned to be outside of the nurse managers’
decision-­making. ‘I think it is not my job to consider economical aspects.
And they don't give me any information about financial matters. Maybe,
if I would have some information, I could influence better. But we don´t
get any information from organization management’. (Nurse manager 2).
Nurse managers mentioned that they were having a dialogue
with surgeons about the purchase of surgical devices, but they felt
their opinions were overlooked. Nurse managers supported stan-
dardisation regarding similar surgical procedures. The most import-
ant financial aspects that nurse managers felt they could influence
were shift planning, recruitment, and impact on the organisation´s
operating schedule planning. They felt they were using resources
effectively in this way. According to the nurse managers, economic
social impact is not part of their work, even though they worked in
healthcare paid for with public tax revenue.
3.2 | Social sustainability in perioperative work
Social sustainability in the operating room was described as equality
between patients, staff, and surgical groups. According to operat-
ing room nurses it was easy for them to treat patients with respect
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LEPPÄNEN et al. 1067

because the surgeons were responsible for the medical decisions in

Improvement methods for implementation

patient care. Nursing actions related to equality towards patients

of sustainable development principles

include protecting privacy, friendliness, and paying attention to all

Introduce ecological values in work

patients´ needs. Nurse managers considered equal treatment self-­

Improve economic know-­how

evident. They trusted their staff to give the very best care for every
patient.

Enhance professionalism
Perioperative nurses thought that inequality between patients

Build collaboration
was observed mainly when patients were unable to access med-
ical services on an adequate timeframe. According to nurses, the
treatment of patients varying depending on surgical specialty area
and possible earlier surgery received. Different surgical specialties
influenced the nurses´ attitudes towards patients and the nurses´
interest in their work. Nurse 16 described attitudes towards differ-
Maintenance of old-­fashioned structures
principles in operating room work daily

ent patient groups like this. ‘And of course, there are inequal patient
Barriers to implementing sustainable

Contradiction between nursing and

groups, I mean that some surgical specialties are more unique than the
others. For example, the same specialties that are always cancelled
Lack of ecological structures

when there is shortage of staff. Some surgeons never cancel their oper-
ations although it would be their turn. Then some speciality patients are
economic mindsets

Conflict of knowledge

withdrawn, and I think that is unethical for these patients. As is rarely

development

the case with heart surgery, cardiac operations are rarely cancelled, but
some other major operations can be cancelled. And, of course, nurses
think that it is better to cancel some basic operations than a long and
complex surgery’.
Perioperative nurses felt that it is unpleasant task to treat pa-
tients, who require isolation. To protect themselves from diseases
Heterogeneity in working community

such as diarrhoea which require isolation protocols, nurses found

nurse managers’ work in operating
Sustainable principles identified in

particularly unpleasant. Treating of burn injuries in the operating

Awareness ecological activity

room was also considered an unpleasant task, as the use of an

Attitude and relationships

isolation gown and the heat in the operating room can make the
Limited opportunities

operating room an uncomfortable environment. ‘I mean, it´s not a

pleasant to be forced into isolation for many hours. The gowns are hot
TA B L E 2 Sustainability in perioperative work through sustainable dimensions

and unpleasant. I don't want to work in isolation. Sometimes my col-

leagues show their disgust to the patient, and I have to say, foreigners
rooms

are quite often patients that needs isolation. Well, of course it is not
right that patients will be treated as a burden, but what can we do
about it. (Nurse 12.)’.
Paying attention to cultural differences

Rush and fatigue cause unprofessional behaviour towards pa-

Making ecological choices in materials
Sustainable principles identified in

tients. It was expressed as impatient behaviour or patients’ needs

Valuing individuality and equality

were poorly met. Nurses working in the operating room found

Using resources deliberatively
perioperative nursing work

that it is especially difficult to treat foreign patients equally be-

and disposable items

cause of language barrier. Nurses had difficulty assessing the pa-

tient's cultural care needs due to lack of cultural knowledge. The
operating room environment and aseptic conditions prevented
addressing culturally important aspects from being addressed
during patient care. For example, sometimes only male nurses
were available to a patient who wanted a female nurse for cultural
reason. Nurse 9: ‘Language is a problem. If we don´t have a mutual
language, it is hard to explain why we can´t change a male nurse to
Social sustainability
sustainability

sustainability

sustainability

a female nurse because of the wishes of female patient. Sometimes I

Main categories

have noticed that some of my colleagues are more impatient towards

Ecological
Economic

foreigners. And I understand it. It is frustrating when everything pro-

Cultural

ceeds slowly because the patient does not understand what we are
expecting him/her to do’.
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1068
Nurses and nurse managers considered that there were some
old-­fashioned structures that were barriers to implementing social
sustainability in operating rooms.
There was variation in how different occupational groups in the
hospital environment were valued. There was hierarchy in decision-­
making and interaction between different occupational groups in
the operating room environment. ‘I think the anesthesiologist is a col-
league, and surgeons… well, we are their servants’, said nurse 3. The
hierarchy was also revealed to exist between nurses, housekeeping
staff, and healthcare assistants. The nurses pointed out that sur-
geons were allowed different aseptic activities compared to nurses.
Anaesthetists interacted as colleagues with the nurses, but the
nurses found that they were treated as inferiors by the surgeons,
not as colleagues.
Men and women were seen as equals in the operating room
work, although men were considered to be able to get things done
more easily than women. This was reflected in the fact that female
nurses received more comment on the quality of their work from
colleagues and doctors than male nurses. Some of female nurses
thought that male nurses could help nurses receive better benefits,
like a better salary.
The length of time and experience working in the operating
room was a barrier to workplace equality between nurse colleagues.
Nurses who had less working experience thought that they were
expected to behave with humility and respect towards their elder
colleagues, but they felt that they were not treated in an equal and
individual manner in the workplace. Nurse managers had also no-
ticed that elder colleagues did not want to support younger col-
leagues to move forward in their careers. This was a deeper problem
in some work communities than others.
3.3 | Cultural sustainability in perioperative work
The nurses did not consider cultural sustainability to be related to
or a part of operating room work. The most mentioned cultural as-
pect was language skills of nurses and foreign patients. Some nurses
did not consider the patient´s cultural background relevant when
the patient was coming for a surgical procedure. Some nurses men-
tioned that they have heard disrespectful talk about foreign patients
from colleagues after the operation, but in their opinion that did not
affect the care provided for the patient.
The barrier to implementing cultural sustainability in the oper-
ating room was limited knowledge about different cultural back-
grounds. Work colleagues’ different cultural backgrounds were
considered a greater challenge than foreign patients. The partic-
ipants stated that different kinds of working habits and language
skills were especially problematic. Nurse managers found that an
employee coming from another country was a challenge in the work
community. Nurse 5’s opinion about different cultural backgrounds
was: ‘I think that we should value our culture and others should do the
way we are doing. That other culture is coming from outside. It should
not dominate our culture’. The challenges described related to the
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LEPPÄNEN et al.
attitudes of native employees towards foreign employees’ working
skills. ‘I don´t see we take cultural background into consideration. I mean
that in what way would it be possible, anyway’. (Nurse manager 1).
However, nurse managers found that it is important that there are
nurses from different backgrounds in the work community. Nurse
managers thought that there should be a regular discussion about
values in the work community and that attention be paid to cultural
differences between staff.
Nurse managers found individuality and different views in the
operating room department to be a good thing; conversely, nurses
felt that individuality was a problem in the workplace. Some nurses
were less receptive to foreign employees and commented that the
induction of foreign employees should be carried out in the same
way and on the same schedule as native workers. ‘Sometimes, has to
fit in to the same mold and can´t be themselves. I mean, one has to move
ahead with their orientation program on the same schedule as everyone
else, regardless of one´s background. No matter if you have already a lot
of experience. You must do everything exactly the same way that your
mentor does. Sometimes there are many ways to find Rome, you know’.
(Nurse 2).Ecological sustainability in perioperative work.
Nurses and nurse managers understood well that surgical pro-
cedures produce a lot of waste. Concerns about the amount of
waste varied from being very anxious to completely indifferent at-
titudes. Many of the nurses and their managers thought that there
was nothing that they could do to decrease the amount of waste in
the operating room. Nurse 3 reflected on whether there was a way
to do better. ‘I´m not actively for recycling…maybe, if there would be
better rubbish bins…But, I don´t know if that would make any differ-
ence either…’ Some nurses had thought a lot about whether it would
be possible to sort different kinds of waste in the operating room
environment. They implemented these ideas in their daily work by
considering carefully if they needed the products during surgeries
and suggesting alternative choices to the surgeons. They shared that
they have faced a lot of resistance in their work to reduce the waste
and felt that they had not received enough support from managers.
The nurses felt that ecological activity was not allowed. Nurse man-
agers thought that reducing waste in the operating room was not
part of their responsibilities.
Reducing energy consumption was found to be the most diffi-
cult thing in the operating room environment. However, there were
some nurses who considered ecological sustainability in the instru-
ment sterilisation process as well as in the energy use and water
consumption in their daily work. Reducing water consumption is
possible, but the perioperative nurses did not actively think about
it. Nurses felt that the most important ecological aspect of surgical
work was how much disposable products nurses reserve for surgical
procedure. Garbage sorting was not felt to be part of their job de-
scription. The nurses felt that they had no chance of affecting the
amount of waste generated at their work, as many items are packed
in multi-­layered. Nurse managers did not know how ecological as-
pects have been considered in their ward.
Operating room nurses felt that they were not responsible for
environmental issues in their workplace. Overall, there was a lack

LEPPÄNEN et al.
of development of ecological structures in the operating room envi-
ronment, and the surgical departments had either solved ecological
aspects in their own ways or not at all. Only one perioperative nurse
mentioned anaesthetic gas as a greenhouse gas, and she recognised
it as a problem to be solved. The nurse felt that reducing the an-
aesthetic gas consumption depended on the anaesthetist´s attitude.
Although, perioperative nurses were generally concerned about cli-
mate change, they did not see it as something they could influence
at work.
4 | DISCUSSION
The study offers insight into how and if sustainable development
principles are used by nurses in the operating room context. It is
notable that the sustainable development principles were poorly
known by perioperative nurses and nurse managers. According to
the perioperative nurses, the high-­quality standards of patient care
did not include elements of sustainable development. The social
and cultural dimensions were unfamiliar to them, and periopera-
tive nurses had difficulties to understand how these dimensions are
related to their work. Similar results were found by Ånaker et al.
(2015): The nurses thought that their work supported climate ac-
tion because they are taking care of people who can participate in
climate actions after they have recovered.
Nurse managers had a better perception about the issues that
are involved with social and cultural dimensions of sustainability
in perioperative work than did the perioperative nurses. There are
several explanations for these findings. The Finnish Law of Health
Care Act (1326/2010, §10) has stated that services must be available
and universally accessible for all people who require help. Patients
are given priority based on their diagnosis related to the acuteness
of their illness, but everyone has access to treatment. The law also
determines that patients must have access within a six-­month period
for non-­urgent surgical treatment (The Finnish law of Health Care
Act 1326/2010, §52). The nurse managers must take this timeframe
into account in their organisations’ surgical schedule planning.
Nurse managers identified their employees’ foreign backgrounds
as a challenge. It would be beneficial to increase the nurses’ cultural
knowledge. Additionally, nurse managers had to solve conflicts
between employees who had different cultural backgrounds. The
managers also faced conflicts between employees of different age
groups. Nurse managers thought that they did not have enough
skills to solve these conflicts. Failure to acknowledge cultures was a
barrier to increasing cultural diversity in perioperative departments.
Staff development programmes regarding cultural humility among
workers could support cultural sustainability within the workplace.
Perioperative nurses do not identify social or cultural topics as
a part of their work because they do not identify these dimensions
as being related to their professional collaboration or how they treat
patients. Perioperative nurses described that they are treating for-
eign patients in an equal manner, but they do not identify equality
between colleagues as a part of social and cultural sustainability. It is
|
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1069
notable that the Finnish population is relatively homogeneous with
few foreign residents. Therefore, foreign work colleagues are gen-
erally quite rare in Finnish acute health care. Nurse managers men-
tioned this aspect as a major cultural and social problem in Finnish
work communities because Finnish nurses are not used to working
with colleagues from different cultures. The perioperative nurses
do not actively identify social and cultural aspects of their practi-
cal work. Hence, they felt the social and cultural aspects are a self-­
evident part of their nursing practices. Research question number
three was answered only partly; however, this was a major finding
and needs some more research so that nursing practices on these
aspects can be developed in perioperative work.
The economic dimension of sustainability was better understood
by the perioperative nurses and their managers than were the social
or cultural dimensions of sustainability. However, nurses and nurse
managers felt that they have no ability to influence the economic
aspects in their work. Only a few perioperative nurses and nurse
managers recognised that they have an opportunity to influence the
economic aspects in their work. The most common economic issue
that the nurses identified was the disposable items that are opened
within operating rooms. Nurses did not know the prices of dispos-
able items in most cases, so price was not an obstacle to opening the
sterile packages. Some nurses thought that if the price of the item
was visible, it might prevent unnecessary openings of the packages.
Nichols and Mukonoweshuro (2017) found that an awareness of
items’ prices motivated the nurses to consider what kind of dispos-
able items they are using.
The need to increase economic knowledge in operating room
decision-­making and for more cost-­effective patient care have been
indicated in another research. Waxman and Massarweh (2018) found
that business knowledge was one of the key imperatives of nurse
managers’ competencies. Addressing the lack of budgetary knowl-
edge among managers in the surgical department has been a focus
of the American Organization of Nurse Executives (AONE), which
develops nursing knowledge and cost awareness for surgical depart-
ments. Nurse managers must have better visibility, understanding,
and voice in addressing unit budgets, including the way funds are
allocated. It would be useful for surgical departments within publicly
funded healthcare systems to be managed in an economically sus-
tainable manner (Golden, 2008; Madigan & Harden, 2012; Waxman
& Massarweh, 2018). An economically sustainable perspective in
care requires an interdisciplinary approach with measurable impact
value that includes collaboration between hospital management,
surgeons, nurse managers, and nurses.
It is noted in this research that cooperation between sur-
geons and nurses regarding economical decisions in the operating
room requires greater collaboration. The greatest obstacles that
perioperative nurses identified related to economic and ecologi-
cal decision-­making was the surgeons’ lack of commitment to the
agreed principles. Interprofessional collaboration entails trust and
respect by both professions. The stewardship of resources and the
careful selection of disposable items promotes economic and envi-
ronmental sustainability (Kruk et al., 2018; Rigante, 2017; Zygourkis
 |
1070
et al., 2017). Nurse managers found that securing the functioning of
the operating rooms daily was an important economical task (Siirala
et al., 2016). Cancelled surgeries are extremely expensive in patient-
care and can lead to a bad reputation for hospital. Interprofessional
collaboration helps to find solutions to ensure that the surgeries can
be performed. The hierarchy between healthcare disciplines is an
obstacle to good communication in operating rooms and to effective
patient treatment. The management of human resources and the ca-
pacity management of the operating department should be effective
so that they are beneficial to patient care and society.
Developing ecological procedures in the operating room requires
shared operational models between different surgical departments.
Nurse managers seemed to be aware of the ecological procedures,
but those goals were not shared with the staff. According to this
research, ecological sustainability is not universally integrated into
surgical work and is not a part of decision-­making in the operating
room. Ecologically sustainable practices must be identified, and
the assortment of disposable items should be carefully selected.
Perioperative nurses and nurse managers hope that the manage-
ment of various wastes in functional garbage cans will be directed
at the organisational level so that it is easy as possible to sort waste.
Standardisation within the health system has been observed to de-
crease not just the economic but also the ecological burden. The
ecological dimension of sustainable development should be a part
of operating room nurses’ decision-­making. It would be beneficial
to consider the ecological values in operating rooms and how these
values are implemented in practice in perioperative work. The eco-
logical burden is part of a bigger problem in surgical work. It involves
device manufacturers, producers of disposable products and anaes-
thetic gases, and hospital buyers.
4.1 | Strengths and limitations
The topic of this research is a novel one, and it is a basis for a new
framework of sustainability in operating rooms and in health care.
The strength of this research was the use of the sustainable devel-
opment framework in the data gathering and analysis processes. The
research is based on the four sustainability dimensions, so it consid-
ered sustainability extensively. Another strength of the research is
that the interviews were conducted in five different surgical depart-
ments and were performed by one researcher in a similar way using
the semi-­structured interview themes.
A limitation of this study was the limited number of partici-
pants (n = 26), so the results of this qualitative study are not gen-
eralisable. The interviews were also conducted in one hospital in
Southern Finland. There may have been different findings related to
sustainable development if the interviews had included other areas
of Finland. Additionally, the findings of qualitative research are not
generalisable. Another limitation was no feedback was requested
from the participants when the transcript was made. The findings
were presented in the participants´ operating room departments
after the transcript was finished.
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LEPPÄNEN et al.
4.2 | Future research
The increasing costs of the public healthcare system and concern
for its environmental impact are forcing healthcare organisations to
develop their employees´ knowledge about sustainable practices.
Surgical departments comprise a large portion of hospitals’ budgets
and produce a lot of waste. A more comprehensive picture of the
economic and ecological decision-­making processes that nurses and
their managers make within surgical departments could be gained
and could help to reduce the cost of care. Furthermore, increased
knowledge of the topic could help develop cost-­effective ways to
deliver patient care while positively impacting ecological sustainabil-
ity. The social and cultural dimensions of sustainable development
have not been researched in the context of perioperative work.
Further research in this area would help to develop these nursing
practices in perioperative work.
5 | CO N C LU S I O N
The sustainability dimensions related to sustainable development
are poorly known, especially in health care and in operating room
work. Lack of knowledge of the phenomenon in operating room
work leads to decision-­making that is neither structured nor trans-
parent. Several structures are obstacles to conducting sustainable
patient care in surgical departments, such as hierarchy and lack of
cultural and economic knowledge. It would be beneficial to increase
knowledge about sustainable development and support sustainable
decision-­making within the operating room. Perioperative nurses
and nurse managers respect an increased understanding of sustain-
able development, but they do not connect it as a part of their work.
With the help of a sustainable development framework, it would be
easier to see perioperative work as a part of wider context.
Healthcare organisations would benefit not only from sustain-
able structures that increase nurse managers’ financial knowledge
for the operating room environment but also from increased col-
laboration between surgeons and nurse managers. Social and cul-
tural knowledge should be developed in operating rooms for better
quality of care. Coherent instructions for implementing ecological
sustainability in operating rooms would be desirable. Ecological
awareness should be part of the organisation's values to guide
decision-­making in the procurement process. These findings sup-
port four of the UN’s Sustainable Development Goals (SDGs): #3 by
supporting development of the processes for well-­being, #6 and #15
by performing ecological aspects in perioperative work, and #10 by
supporting equality through multiple perspectives within the surgi-
cal department.
6 | R E LE VA N C E TO C LI N I C A L PR AC TI C E
Sustainable development´s four dimensions cover the whole perio-
perative process. This research indicates that perioperative nurses

LEPPÄNEN et al.
and nurse managers are recognising the importance of economic
sustainability, but they have limited opportunities to influence it. A
need exists to develop collaboration with the surgical team and to
find ways to decrease costs effectively. There are many benefits to
managing operating rooms in a sustainable way. Economic knowl-
edge is an important task for nurse managers, but it also guides op-
erating room nurses to make cost-­effective decisions in their daily
work. Ecologic aspects are one of the greatest challenges in operat-
ing rooms because of various disposable items.
Social and cultural sustainability are not integrated into periop-
erative work although collaboration between the surgical team and
with the patient are an important aspect of the perioperative nursing
role. This study helps nurses and nurse managers understand their
work through the sustainable development dimensions and to or-
ganise operating room management effectively and to support sus-
tainability within the surgical department.
Organisations are expected to operate in a sustainable manner.
Well-­organised and effective surgical departments are produc-
ing value to the organisation at the meso level (Kruk et al., 2018).
Most European countries, towns, and corporations are currently en-
gaged with sustainable development principles at the macro level
(Raszkowski & Bartniczak, 2019; Ylönen & Salmivaara, 2021). It is
possible for hospitals to use sustainable principles, as well.
C O N FL I C T O F I N T E R E S T
The author(s) declared no potential conflicts of interest with respect
to the research, authorship and/or publication of this article.
AU T H O R C O N T R I B U T I O N S
TL, TK and PK made substantial contributions to conception and de-
sign, or acquisition of data, or analysis and interpretation of data. TL,
TK, RM-­L and PK involved in drafting the manuscript or revising it
critically for important intellectual content, given final approval of
the version to be published, each author should have participated
sufficiently in the work to take public responsibility for appropriate
portions of the content, and agreed to be accountable for all aspects
of the work in ensuring that questions related to the accuracy or
integrity of any part of the work are appropriately investigated and
resolved.
DATA AVA I L A B I L I T Y S TAT E M E N T
Data available on request due to privacy/ethical restrictions.
ORCID
Taava Leppänen https://orcid.org/0000-0001-7951-9953
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Supporting Information section.
How to cite this article: Leppänen, T., Kvist, T., McDermott-­
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