Who did it work for & why?
We were able to identify four distinct educational outcomes for students, illustrated in the impacts column of Fig. 1:
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the activated practitioner who fully assimilated their classroom-based learning to develop a ‘SusQI gaze’;
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the willing but cautious practitioner who needed permission and support;
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the frustrated practitioner who felt overwhelmed by barriers to action;
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the disinterested (or pre-contemplative) practitioner who saw sustainability as beyond their future professional role.
We present these four outcomes in the above order, and explore them in relation to preceding factors, motivations and other modulating factors. Quotes are identified according to focus group letter (A-E) and participant number. Square brackets and ellipses indicate where the verbatim quote has been clarified or condensed.
Outcome 1: The activated SusQI practitioner
The SusQI teaching session was most successful in activating students who already prioritised sustainability. These participants recognised a spectrum of sustainability and identified themselves as more sustainably minded than most. They already valued and were familiar with concepts of sustainability, however the session reframed their thinking about healthcare as a contributor to the global health emergency and ecological degradation.
External motivators such as career benefits, mitigating future threats, avoiding guilt, and associated prestige were common activating factors across all student groups, however these sustainably-minded students were additionally motivated by internal values such as curiosity, altruism and self-determination. We found no comments explained by goal-orientation, perhaps because the completion of SusQI projects did not contribute to summative assessments. Activated practitioners expressed a set of core beliefs: sustainability action as necessary, the healthcare system as running unsustainably, SusQI as a helpful tool, change as possible, the workplace as welcoming of improvement, and action as a professional duty.
Workshop content demonstrating the scale of unsustainable practices in healthcare troubled these students who felt alarmed that their involvement with the health service was out of step with their sustainable lifestyles and values.
I think it just really took me aback, like ‘wow, [the health service plays] such a big role in [environmental destruction.]’ I always think that I'm quite a sustainable person generally, but I think I realise my involvement with the NHS [counteracts that], and that... I need to do something to balance [my footprint] out. D2
They were also shaken by the impacts of environmental degradation on patients and healthcare: “It made me realise that it's going to directly impact my future career. And that was quite scary” A1.
Near-peer examples of successful projects enabled these students to reframe sustainability as within their control and influence, helping to mitigate those concerns. SusQI then became powerful tool for change through relatable examples of the SusQI framework which “put [QI] in a context that made us *want* to do it” E1.
I think it kind of made me more curious because it made me feel like I could make a change… if you've got the right research and you go about it the right way with the right process, you can make small changes that can make a difference. So, I think that was quite empowering and it kind of changed my impression of QI. C2
Interactive discussions during the workshop were valued, empowering students to identify and reflect on unsustainable workplace practices with peers. They expressed frustration that solutions were not yet in place but felt reassured by a like-minded peer community and the potential for change “that actually felt like we could make a difference if we actually put some effort into this.” C3
Participants were inspired by role models who framed SusQI as “part of the bubble of patient care” A2, whilst depicting the NHS as “an ever-evolving system” A3, which would ultimately embrace sustainability.
[This teaching showed me] that people are willing to change like, I never really realised that the NHS is supportive of these changes, like they want to help decrease their environmental emissions and things because there are so many benefits… actually, it's been quite optimistic. A1
Activated students worked to overcome barriers, for example, leveraging workshop resources to mitigate hierarchy and broach conversations about change.
Almost like a slip of paper to wave at your colleagues saying "Look, this is why we have to [make sustainable change] It's not just my own personal, you know, want" or anything. Sorry! B4
They conceptualised sustainability as an integral part of their future clinical practice rather than a separate siloed concept:
It's made me more aware in my understanding that everything's interlinked… "patient care, my own health," you know, "education, treatment," it's all interlinked with sustainability rather than sustainability being this separate thing. C1
The session transformed the way these students saw previously accepted practices, developing a new critical sustainability lens or ‘SusQI gaze’ which prompted them to start up conversations with clinicians.
… rather than just following things for no reason, kind of looking for improvements and going in with that kind of "QI head on your shoulders" C2
When I do go back to the hospital, it will be [a case of] trying to start up conversations with people more. So, if you notice, like, "oh, like, that's a lot of waste." A1
The session had a strongly positive impact on their professional identity creating “a sense of meaning within your job, even greater than just [the job] itself” D1. The session was also successful in creating a sense of leadership and agency “that actually, we have the capability to make a massive difference... quite inspiring... you wanted to go out and help”" A1. Another noted “it was something that I anecdotally told other people about because it impacted on me so much” E1.
We identified a triad of positive reframing in this group, illustrated in Fig. 2. Activated students newly identified themselves as agents for positive change, their profession as potentially ethical and sustainable, and quality improvement as a worthwhile practice.
Outcome 2: The willing but cautious SusQI practitioner
Willing but cautious participants described expectations to conform when shadowing on placement, which included adopting seniors’ unsustainable practices. Tacit professional boundaries prevented these students suggesting new or improved practices.
I don't know how the wards run… Managerial staff will know more than I do… And so yeah… Going onto the ward and trying to bring about changes is terrifying. A2
They explained that students “don’t feel comfortable enough to be able to broach that conversation to a consultant or anyone else” C4. They felt it would be inappropriate to educate their busy seniors. These students identified themselves at “the bottom of the food chain” A2 in a hierarchical organisation, lacking the social capital or knowledge to push for sustainability. Constantly rotating between specialties and hospitals left them without insights into local expertise, systems or processes.
To suddenly come up and say, "Can we look at [sustainability as well]", it might seem slightly [brash, over-confident]... I don't feel in the place [of authority] where I can do that right now. C3
In contrast, they perceived their mentors as possessing the influence to drive SusQI projects but unapproachable and lacking awareness or time, undermining the achievability of SusQI.
I think educating more senior doctors [is needed]. Once more senior positions start doing something you think “I could do that” and make it more likely for people to listen and do something about it. C1
Their perceptions of how the clinical hierarchy impacted on their ability to enact SusQI are illustrated in Fig. 3.
Students suggested appointing established team members as sustainability champions to collate and advocate for SusQI ideas, and to act as role models.
If they'd previously put their name out there as someone who would be interested in something like this… then yeah, I would be more inclined to go forward [and approach them]. C3
I feel quite daunted by the idea of having to go and speak to doctors myself and bring about a change myself. Doesn't necessarily have to be doctors, it could be nurses, it could be HCA's, could be anyone [in the healthcare team] really, couldn't it? A2
Outcome 3: The frustrated SusQI practitioner
Students in this outcome group valued and were motivated by the SusQI teaching session, however barriers due to their junior status were compounded by perceptions of structural barriers in the clinical workplace. These combined to undermine their belief in the achievability of SusQI, leading to disengagement and frustration.
I've sent numerous emails… It's like [I get] blocked, people don’t… have anything for me to do… I feel quite disheartened that [QI] was this big, like, exciting thing you can get involved in and it's actually, in reality, It's not… The actual getting [a project] is really difficult. E1
They also described a disconnect between senior and junior engagement and criticised the absence of sustainability guidance from the NHS or University “if everyone's been told the same thing, you're working together to do it” B2.
Clinical administration was described as over-regulated, complex and mysterious; clinical teams as busy and resistant to change. The busy, hectic and often stressful healthcare workplace was described as lacking the psychological space to engage clinical staff in SusQI planning.
Trying to find the time and headspace to stand and, just thinking ‘how [we] could change practice for sustainable benefit?’ That's quite difficult. E1.
Where sustainability guidelines were in place, contradictory actions within a local NHS trust epitomised the greenwashing perceived by students, who expressed disillusionment that they were not being followed. They felt that large-scale sustainability appeared unrealistic "until cultural change happens at the lower levels” B1.
Conformity to clinical guidelines was described as part of patient safety but also a safety blanket for clinical staff, with change perceived as disruptive. Systems were too complex to adapt and fear of blame stifled innovation. Frustrated participants expressed a dilemma: whether to persevere with action, or to stick with current practices and accept the associated moral injury: “the ethical implications of not doing things sustainably are quite high for future generations... It’s a big ethical problem” D2.
Like, putting yourself in the firing line [if you question it]. But it would be so much easier just to keep on going, and using all this PPE, and throwing it in the bin, and going home and [getting praised] "you've done such a great job [on the COVID front-line]." But in reality, you're acting incredibly unsustainably. E4
Outcome 4: The pre-contemplative SusQI practitioner
Students in this outcome group were not ready to engage with the learning. They described sustainable healthcare concepts as unfamiliar: “[It was] the first time.... that we've talked [in medicine] about environmental issues… [we] would obviously really love to integrate it, but... [we] need more information and about how to do that” E3. These students suggested that sustainable healthcare needed to be an integral theme, rather than confined to quality improvement teaching.
But I feel like one lecture will not just change how I act and how I - sort of - work. I feel like it needs to be a continuous thing of building upon what we've learnt already… you're not going to learn one thing from one lecture and change the entire way you act, you need to keep on sort of building up on that, I think.” A2
Unsustainable healthcare and ecological breakdown were perceived as an insurmountable far away problem that someone else would sort out: “... I think a lot of people feel like it's not actually helping themselves. So, it's easier... to leave it to other people to deal with it” B2. They prioritised the health of patients today over the health of wider populations tomorrow, despite acknowledging the exponential consequences for future generations.
What you do now doesn't have any immediate ramifications for you but has… everlasting ramifications for ‘this many’ people. But since it doesn't affect you, you don't pay attention to it. B3
Quality improvement projects had a prior reputation as “boring... something that you had to do” D2, and preventative health was described as too abstract and less exciting than patient-facing acute medicine.
If you're [undertaking QI] there's not that immediate kind of satisfaction of "I can do this"… it's the cliche thing to say, I've gone into medicine because I want to help people... There's more immediate satisfaction [in helping patients] than there would be with QI projects, I think. C1
I'm not gonna lie: I think when I hear quality improvement, it just … kind of just, like makes me start snoring a little bit. B1
Pushing for change was seen as exhausting and beyond their professional scope.
Yeah, it gets a bit exhausting if you're thinking about how to improve every aspect of your job at all times. B1.
Motivation to persevere was related to expected success rate, with students dissuaded by rumours that “QI failing is brutal” C1. For these students, altruistic motivations did not appear to justify the perceived effort and risks of engagement.