Abstract
Background: The cultural-cognitive, normative and regulative pillars of institutions influence the ability of hospitals to change how they function at an organizational and operational level. As more hospitals and their foodservices instigate changes to address their environmental footprint and impact on food systems, they move through the “sustainability phase model” from no response through to high level action and leadership. The aim of this study was to describe and compare the pillars of institutions between hospitals in different stages of achieving environmentally sustainable foodservices (business-as-usual vs. exemplar hospitals). Methods: For this qualitative inquiry study, interviews were conducted with 33 hospital staff from 3 business-as-usual hospitals in Melbourne, Australia and 21 hospital staff from 14 exemplar hospitals across 9 countries. Participants were asked questions about their perspectives on environmental sustainability in foodservices and the barriers, enablers and drivers they experienced. Each data set was analyzed thematically and then compared. Findings: There was a clear and distinct difference in responses and behaviors within each pillar between the exemplar and business-as-usual hospitals. The cultural-cognitive pillar identified a similarity in personal belief in the importance of addressing environmental impacts of foodservices, but difference in how staff saw and acted on their responsibility to drive change. The normative pillar uncovered a supportive culture that encouraged change in exemplar hospitals whilst business-as-usual hospital staff felt disheartened by the difficult processes and lack of support. The regulative pillar reflected business-as-usual hospital staff feeling restricted by government policy vs. exemplar hospital participants who were motivated to internalize government policy in different ways and work with other hospitals to advocate for better policy. Interpretation: These findings highlight strategies related to each of the three pillars of institutions that can be used to drive effective, sustainable long term change within hospitals. This includes staff education and training, revisiting hospital culture and values around environmental sustainability, embedding
Generated Summary
This qualitative inquiry study aimed to describe and compare the institutional pillars that drive environmentally sustainable foodservices in hospitals. The study involved interviews with 33 hospital staff from three business-as-usual hospitals in Melbourne, Australia, and 21 hospital staff from 14 exemplar hospitals across nine countries. Participants were asked questions about their perspectives on environmental sustainability in foodservices, and the barriers, enablers, and drivers they experienced. Each data set was analyzed thematically and then compared. The research utilized the “sustainability phase model” to assess and compare organizations’ commitment to environmental sustainability. The model describes six phases organizations may move through on their improvement trajectory. In the early stages of the model, the organization begins with a disregard for their negative environmental impacts. The functioning of institutions (including hospitals) has been described as being dependent on three pillars: regulative, cultural-cognitive, and normative. These pillars were used as an analytical tool for sustainable activities in institutions. Data collection procedures for both data sets have been previously published. Semi-structured individual or small group interviews were conducted in person in July to November 2019. For the business-as-usual hospitals, and for the exemplar hospitals, semi structured individual or small group interviews were conducted via Zoom in October 2020 to January 2021. The number of hospitals recruited was also guided by “information power” whereby this concept was considered throughout recruitment and was complete when study aims had been fulfilled and the sample included hospitals from a variety of contexts. For both data sets, the aim of recruitment was not necessarily a thoroughly representative sample, but to capture a diverse range of perspectives to be able to sufficiently answer the original research question. For both data sets, all interviews were conducted, recorded and transcribed by the same researcher.
Key Findings & Statistics
- Interviews were conducted with 33 hospital staff from 3 business-as-usual hospitals in Melbourne, Australia, and 21 hospital staff from 14 exemplar hospitals across 9 countries.
- The mean interview duration was 22 min for business-as-usual hospitals.
- The mean interview duration was 70 min for exemplar hospitals.
- From three business-as-usual hospitals a total of 33 participants were interviewed across 11 individual and 7 small group interviews of 2 to 5 participants.
- There were 14 exemplar hospitals across 9 countries, with a total of 21 participants interviewed.
Other Important Findings
- The cultural-cognitive pillar revealed a similarity in personal belief in the importance of addressing environmental impacts of foodservices, but a difference in how staff saw and acted on their responsibility to drive change.
- The normative pillar uncovered a supportive culture that encouraged change in exemplar hospitals whilst business-as-usual hospital staff felt disheartened by the difficult processes and lack of support.
- The regulative pillar reflected business-as-usual hospital staff feeling restricted by government policy vs. exemplar hospital participants who were motivated to internalize government policy in different ways and work with other hospitals to advocate for better policy.
- Participants from exemplar hospitals believed that they have a personal responsibility to act, even if not defined or expected in their role.
- Participants from business-as-usual hospitals tended to focus on food waste during the narrative on sustainability issues. In comparison participants from exemplar hospitals had a more holistic view of sustainability.
Limitations Noted in the Document
- The study’s generalizability is limited due to the qualitative nature of the research and the specific contexts of the hospitals involved.
- The study does not include a thoroughly representative sample.
- Differences in the timing of interviews could have influenced the results.
- The research was conducted during the coronavirus pandemic, which may have impacted the perspectives of participants.
- The reliance on pre-existing datasets may have limited the ability to explore specific questions or follow up on emerging themes.
Conclusion
The study identifies key differences in the pillars of institutions between hospitals in earlier and later stages of the sustainability phase model for achieving environmentally sustainable foodservices. The findings suggest that a multi-level and multi-strategy approach addressing cultural-cognitive (staff factors), normative (hospital factors) and regulative (external influences) pillars may be helpful to move healthcare organizations along the sustainability phase model, toward exemplar institutions. The cultural-cognitive pillar emphasized the importance of education and training, both in tertiary settings and professional development, to foster a sense of responsibility and drive change, as this was more evident in the exemplar hospitals. The normative pillar highlighted the need to revisit traditional healthcare values and realign them with planetary health. The exemplar hospitals demonstrated this by embedding sustainability into their mission and vision. The regulative pillar showed a contrast in how staff from exemplar and business-as-usual hospitals perceived external influences, such as policy and member organizations. Exemplar organizations advocated for what they wanted, or filled the gap with internal organizational policies. This signifies the need for a uniform and coherent public policy approach for sustainable foodservice. Hospitals can be stewards of change for advancing planetary and human health, both within their hospital and beyond. Future policy initiatives and government approaches could leverage member organizations and work with them to promote their membership and resources to health services. The study suggests that a multi-level and multi-strategy approach addressing cultural-cognitive (staff factors), normative (hospital factors) and regulative (external influences) pillars may be helpful to move healthcare organizations along the sustainability phase model, toward exemplar institutions. Reconsidering and optimizing the pillars of institutions, including the knowledge and beliefs of staff, the culture and values of the hospital, and the policies, rules and regulations can build momentum for change.