Abstract
Introduction
The National Health Service in England has a large carbon footprint. Waste production and disposal contributes to this carbon footprint and costs the National Health Service England over £82 million per annum. This study builds on existing work regarding health care waste management in the United Kingdom where the potential for recycling has begun to be studied. The study focuses on a private hospital and social care organizations, and provides a more detailed study of the behaviour of individuals across a variety of waste management systems.
Methods
The study was an overt observational study at four health and social care sites in the South West of England. Systematic observations were made of the waste disposed of by employees in which the observer recorded: a description of the waste item; the bin into which the waste was placed; the type of employee who disposed of the waste; the material the waste comprised and the appropriateness of the disposal behaviour.
Results
The domestic waste bin was found to be most commonly used by employees to dispose of waste (51%), and the materials observed being disposed of most often were paper (26%), organic wastes (19%) and plastic (19%). There were significant differences between the four sites indicating that the activities performed at each site may have been influencing the waste being disposed of.
Conclusion
It was concluded that the transfer of waste from the domestic waste stream to the recycling waste stream should be a central focus for the design of new health and social care waste management systems. Employees will require guidance and training in identifying and classifying waste materials for recycling.
Introduction
Effective waste management has been highlighted in the literature as a way of reducing the environmental impact of society. 1 The National Health Service (NHS) in England, being the largest health care organization in the country, was reported as having a carbon footprint of around 20 million tonnes CO2e in 2011/2012. 2 Waste contributes to this figure with the NHS producing over 286,221 tonnes of waste in 2010/2011. 3 These figures, while large, do not include the private health care organizations or social care sector operations in the UK, and there is an absence of information regarding waste in these areas.
Improving health and social care waste management is an appealing target for organizations seeking to reduce costs and emissions. This is due to the immediacy of the change that can potentially be achieved and the low risk of interfering directly with patient care.4–6 One barrier to achieving such improvements is that changing systems and behaviour can be complex. There is little information for service managers to base effective strategies and interventions on in order to improve waste management in health and social care. 7
Much of the previous literature has focused on assessing the composition of the various waste streams in health care which has been instrumental in demonstrating the potential for improvements to waste management.8–11 Daschner and Dettenkofer 12 highlighted that only approximately 3% of clinical waste is contaminated with infectious materials. By providing insight into the material composition of the waste streams, Tudor et al. 13 were able to show that there are large quantities of waste in health care that are disposed of by incineration and landfill that could potentially be recycled.
This study, therefore, seeks to investigate the waste management behaviours of health and social care employees through direct non-participant observation. The interaction of the individual with the waste management system is the focus looking specifically at the bins in which the waste is placed, which employees are disposing of the waste, the material composition of the waste and the appropriateness of the waste disposal behaviour. This study seeks to complement the existing literature by carrying out further investigation of health care waste composition while also studying social care waste composition about which there are few data. Furthermore, it compares and contrasts the waste disposal behaviours at each site across a range of variables.
Methods
Sample
Four health and social care sites in the South West of England, selected through purposive sampling, participated in this study. One was a private hospital, the second was a residential care home, the third a nursing care home and the fourth was a residential care home that was transferring to nursing care. These four sites were operated by two health/social care providers and represented a cross section of their operations in the South West of England.
Each of the four sites was sampled five times over a three-month period from 1 May to 31 July 2012 resulting in 20 data collection sessions. The data collection schedule was predetermined using a partially stratified sampling method to ensure that each site would be sampled once on each day of the week (Monday to Friday) during the three-month study period with no repeats.
Data collection
Ethics approval for this study was granted by the Plymouth University faculty of health and human sciences ethics committee and informed consent was gained from the organizations and employees who participated in the study.
Overt observations of the waste disposal behaviours were conducted at each of the four sites. Two locations were selected at each site with the aid of the management team and lead housekeeper. The observation locations were where the majority of waste disposal was thought to take place and included outpatients sluice, general ward sluice, dining/lounge areas and sluice/bathing facilities.
The observations were undertaken systematically. The observations began at 09:30 and finished at 15:30. The observer spent 40 min at the first location, took a 20-min break, then moved to the second location and made observations there for a further 40 min. This process was repeated so that observations were made at each location three times, resulting in a total of six observation periods during any given session. This allowed each site and each location at any site to be fairly represented in the final dataset.
During each observation period the observer used event-based sampling to collect data on employee waste disposal behaviour. Every time a piece of waste was disposed of by an employee, the observer recorded the following information on an activity log: the date; the site; the observation location and the time of the event. The observer then recorded five more pieces of data regarding the disposal events according to a predetermined protocol:
a brief description of the waste providing sufficient information to identify the specific item bin type – the bin types common to each site were clinical, domestic (municipal) and recycling bins. Any bin used to dispose of waste other than these three were included in an ‘other’ category employee type – this could not be predetermined and so was kept simple using information provided by staff material type – these could not be predetermined and so were kept simple disposal behaviour appropriateness – categorized as appropriate, inappropriate or uncertain. ‘Uncertain’ was used when the observer was unable to ascertain whether the disposal behaviour was correct or incorrect. Appropriateness was judged based on the availability of bins at a site and the contamination status of the waste within the context of national legislation and local site policy.
The categories described above had to allow for easy visual identification due to the speed with which the disposal events took place. The use of simple categories minimized the possibility of the observer making a mistake. When two or more disposal events occurred at the same or in similar time frames, the observer recorded the data in chronological order dealing with one disposal event before moving to the next.
Results
Bin use
Percentage bin type used to dispose of waste within each site and overall (%).
Employee type
Percentage employee type that disposed of waste within each site and overall (%).
Material type
Percentage of materials disposed of within each site and overall (%).
Appropriateness
Percentage appropriateness of the waste disposal behaviours within each site and overall (%).
Bin use by employee type
Overall there was a significant relationship between the bin in which waste was disposed of and the employee type disposing of the waste (χ2, p < 0.001; Cramer’s V, 0.37). Nursing staff were more likely to dispose of waste in the clinical and recycling bins. Care staff disposed of more waste in the domestic waste bins and less in the recycling bins.
Bin use by material type
There was a significant relationship between the bin in which the waste was disposed of and the material it was made from (χ2, p < 0.001; Cramer’s V, 0.52). Latex, nitrile, mixed material and detergent wipes were more commonly disposed of in the clinical waste bin than the other bin types. More paper was disposed of in the domestic waste bin than expected while cardboard and glass were more often disposed of in the recycling bins.
Bin use by appropriateness
There was a significant relationship between the bin type and the appropriateness of the disposal behaviour (χ2, p < 0.001; Cramer’s V, 0.47). Larger proportions of appropriate waste disposal behaviours were performed at the clinical, recycling and ‘other’ waste bins, while larger proportions of inappropriate waste disposal behaviours were performed at the domestic waste bins.
Material by employee type
The relationship between the material being disposed of and the employee type disposing of the waste was significant (χ2, p < 0.001; Cramer’s V, 0.31). Nursing staff were observed disposing of more cardboard and glass than the other staff types and less organic waste. Care staff disposed of more organic waste and less cardboard waste while housekeeping staff disposed of more organic and latex waste along with less mixed, metal and nitrile waste.
Appropriateness by employee type
The appropriateness of the disposal behaviour was significantly related to the employee type disposing of the waste (χ2, p < 0.001; Cramer’s V, 0.22). Nursing staff performed more appropriate than inappropriate disposal behaviours while the other staff types all performed similar proportions of appropriate and inappropriate behaviours.
Appropriateness by material
The appropriateness of the disposal behaviours and the materials being disposed of were significantly related to one another (χ2, p < 0.001; Cramer’s V, 0.55). Plastic and paper wastes were more commonly disposed of inappropriately than appropriately. The materials that were more often disposed of appropriately were cardboard, organic, mixed, latex and nitrile wastes. Glass waste was the material type that was most often classified as uncertain.
Discussion
The researcher observed a wide range of different wastes being disposed of during this study. Clinical waste appeared to be most diverse at the health care site. A range of intravenous bags, lines and minor operation equipment was disposed of, alongside packaging and consumables. Most of the clinical waste at the social care sites appeared to comprise four items: incontinence pads, wet wipes, plastic aprons and paper hand towels.
The bin type that was most commonly used to dispose of waste varied between the sites, but was similar at three of the sites. Particular employee types disposed of different proportions of waste, particular employees used different bin types and distinct materials were disposed of in different bins. This may be indicative of the disparate tasks carried out by particular employees. It is also possible that particular employee types were using distinct locations to dispose of the waste that they produced. These findings support previous research which found that waste type varied by site and department (location).12,13
One limitation to be considered when conducting overt observations is the Hawthorne effect, where the participant under observation alters their behaviour due to a change in the environment. The participants in this study performed a large number of inappropriate waste disposal behaviours. This indicates that if the participants did change their behaviour, attempting to always perform appropriate waste disposal behaviours, they were unsuccessful. The highest proportion of inappropriate waste disposal was performed at the domestic waste bins. Waste that could have been recycled was disposed of in the domestic waste bins, especially the three most commonly disposed of materials: paper, plastics and organic wastes. Such behaviour could be the result of a lack of awareness and knowledge on the part of both the employee and the organization regarding effective practice. There is a particular need for organizations to provide effective guidance to their employees. 1 In order to improve recycling rates, this might focus on material classification and segregation allowing for the transfer of waste from the more expensive clinical and domestic waste streams to recycling.
The possible impact of any regional differences in the availability of recycling services or attitudes towards waste disposal and recycling was controlled for. Each of the participating organizations adhered to a local waste management policy based on legislation and guidance set by the Department of Health, the Care Quality Commission and the Royal College of Nurses. The observer was familiar with the local waste management policies at each site and was able to judge the appropriateness of the waste disposal behaviours in relation to the relevant policy.
Calculation of the financial and carbon emission savings that could result from improvements to health and social care waste management is one line of research that could follow this current study. This study was designed to identify the general patterns of employee waste disposal behaviour, not to produce an accurate estimate of the cost of disposal and carbon emissions resulting from disposal. Future research will need to capture data about the weight of every item disposed of by the employees to produce emission figures which could be used to inform behaviour changes interventions. A second potential line of future research is the investigation of the most effective contents of, and means by which, to disseminate waste management information.
This paper contributes to literature on the composition of healthcare waste confirming the work of Tudor et al. 13 and Daschner and Dettenkofer. 12 It goes further in beginning to assess the composition of social care waste and explores the potential for recycling while making comparisons with the healthcare setting. The direct observational design and combination of variables used in this study provide a novel method for investigating health and social care waste disposal behaviour. Furthermore, the study explores relationships between waste disposal behaviour and other variables that through further research have the potential to lead to more effective waste management strategies.
Footnotes
Declaration of conflicting interests
The authors declare that there is no conflict of interest.
Funding
This research received no specific grant from any funding agency in the public, commercial, or not-for-profit sectors.