Emergent climate protection strategies in German hospitals: A cluster analysis

PLOS One | https://doi.org/10.1371/journal.pone.0312661 May 16, 2025 13 / 18 Communication. The findings indicate the relevance of employees´ engagement through communication. Communication about climate protection is often associated with greater employee initiatives (Cluster 4), which is why this can be understood as a critical factor for the long-term success and legitimacy of further actions. Hospital stakeholders´ awareness of GHG emissions and their sources is imperative for developing and implementing effective strategies for climate protection [85]. Thus, involving and addressing hospital employees´ expectations regarding climate issues is paramount [81,82]. In contrast to earlier research, suggesting a lack of employees´ influence on climate actions [85], this study indicates that employees across all hospitals can contribute ideas for implementing climate protection initiatives. However, effective climate actions require not only the engagement of hospital stakeholders but also collaboration and supportive actions from other organizations within the healthcare system, such as the pharmaceutical and medical device industries to provide more climate friendly options [95,96]. In summary, the significant disparities among the clusters underscore that climate protection remains an emerging issue in the German hospital sector, with many institutions yet to prioritize it. While some hospitals advance efforts, others face barriers to adopting effective climate strategies. Only hospitals in Cluster 4 exemplify adherence to Stakeholder

Theory principles [97,98], demonstrating a commitment to strategic planning, employee involvement in decision-making processes, assignment of clear responsibilities, and transparent communication regarding climate protection efforts and emissions data. These findings emphasize the interconnectedness of hospital administrative leadership´s influence and employees´ engagement, advocating for continued administrative leadership support of climate protection initiatives [99]. It is crucial that hospital administrative leadership maintains its commitment to climate protection, as changing administra- tive leadership strategies can cultivate employee awareness, dedication, and actions toward climate protection [100]. Limitations This study is the first to analyze the contribution of German hospitals to climate protection from the perspective of their administrative leadership. While extensive in its multifaceted analysis, this study acknowledges certain limitations that open avenues for future research. Due to the current challenges facing German hospitals, such as skill shortages, climate protec- tion is not a top issue for hospital administrative leaders, complicating recruitment efforts for this group. General challenges in recruiting administrative leaders for an online survey can also be observed in other studies among leaders [101,102]. The usual limitations of an online survey apply [103,104]. Although the questionnaire was sent exclusively to hospital adminis-

trative leaders, its anonymous nature means prevents guaranteeing that it was completed solely by the target group. Addi- tionally, comprehension problems on the part of the respondents cannot be recognized and rectified when using an online survey. However, this research approach was best suited to the aim of the study and the chosen target group. While day hospitals and psychiatric facilities were excluded, the results show emergent strategies that are applicable to all hospitals and relevant to all healthcare organizations providing medical care. Although the sample comprised hospital administrative leaders from various hospital sizes, ownership, and hospital structures, its representativeness for all hospitals in Germany remains limited. Consequently, the generalizability of the findings is restricted, a challenge that has also been noted in previous research within the hospital sector [105,106]. Perspectives of other stakeholders could not be incorporated, as the focus was on assessing the hospital’s administrative leadership. Exploring the perceptions of other hospital stakehold- ers could be a promising avenue for further research. The results may only partially reflect the diverse perspectives of the hospital administrative leaders, as interest and awareness of environmental issues beyond legal requirements vary. Those predisposed to climate protection might have been more likely to participate in this study than those less engaged with envi- ronmental issues. Additionally, the possibility of social desirability bias cannot be dismissed. Conclusion

The urgency of climate change continues to require strategies within the healthcare sector. However, research on corpo- rate strategies and the practical approaches of hospital administrative leadership regarding climate protection remains