Beyond Awareness: Moving from Knowledge to Action in Operating Room Sustainability

Commentary In their article, Bellaire and Freiling address a critical and timely challenge in orthopaedic surgery: the excessive waste generated in operating rooms (ORs) and the communication strategies needed to drive meaningful change1,2. As health care's environmental footprint continues to grow, and with orthopaedic surgery generating disproportionate amounts of waste, this work provides valuable insights into how we can move beyond simply presenting facts to changing behavior. The authors' most important contribution lies in their rejection of the "knowledge-deficit model" that has dominated medical education and quality improvement efforts for decades. This model assumes that providing information alone will drive behavioral change, a premise that social science research has debunked. By introducing evidence-based communication strategies from social psychology, including framing, priming, and deliberation, the authors offer a sophisticated alternative to traditional educational approaches. The clinical scenario opening the article effectively illustrates the disconnect between awareness and action that many surgeons experience. Standing among bags of unnecessary waste, "Dr. A" recognizes the problem but lacks the tools to address it systematically. This resonates with the lived experience of many of us who understand sustainability concerns intellectually but struggle to implement change within complex organizational systems. The disconnect highlighted is also emblematic of the quality, safety, efficiency, and utilization aspects of our practices that we feel powerless to address. Particularly valuable is the authors' emphasis on loss framing over gain framing, supported by orthopaedic-specific research showing preference for avoiding loss rather than achieving gains. The systematic literature review cited demonstrates that loss framing more effectively promotes environmental behaviors, providing actionable guidance for sustainability advocates in orthopaedic surgery. Although the communication strategies presented are evidence-based, a more robust discussion of implementation barriers is required. The authors acknowledge that communication alone cannot drive sustainable change, but they provide limited guidance on how communication strategies integrate with broader systemic requirements. Successful sustainability initiatives require attention to individual, institutional, geographical and infrastructural, and political levels, with leadership support, funding, and stakeholder engagement being consistently identified barriers and facilitators. Although they are a start, the communication strategies outlined operate primarily at the individual and interpersonal levels, potentially having limited impact without corresponding institutional, industry, and governmental policy changes. This work arrives at a critical juncture when health-care organizations face increasing pressure to address their environmental impact. Recent waste audits demonstrating 5 to 10 kg of landfill waste per orthopaedic case underscore the urgency of the problem. The authors identify orthopaedic surgery as an ideal target for intervention because we generate more waste than other specialties. However, there is a need for greater discussion of competing priorities in the OR environment. Patient safety, efficiency, and throughput remain paramount concerns, and sustainability advocates must demonstrate how their proposed changes will align with and add to, rather than compete against, these established and entrenched priorities. The authors touch on this with their priming strategy of emphasizing patient health, but a more detailed exploration of these tensions is required. The communication strategies presented offer a foundation for broader scientific research on its implementation in health care. Future studies should examine how these approaches perform when integrated with structural interventions such as revised supply-chain policies, waste measurement systems, and incentive alignment. Additionally, longitudinal research examining the sustainability of communication-driven behavior change would provide valuable insights into the durability of these approaches. The deliberation strategy deserves further development. Although the authors emphasize the importance of including all stakeholders, greater guidance is needed on how to navigate the complex power dynamics inherent in OR hierarchies when implementing collaborative decision-making processes. Bellaire and Freiling have made an important contribution by shifting the sustainability conversation beyond awareness toward evidence-based behavior change. Their rejection of knowledge-deficit thinking and their emphasis on sophisticated communication strategies represent a meaningful advance. However, the ultimate success of these approaches will depend on their integration within broader organizational change management frameworks that address the structural, financial, and policy barriers that perpetuate wasteful practices. The field now needs implementation research that tests these communication strategies within real-world, pragmatic, organizational contexts to determine their effectiveness at scale.