critical thinking in operating room nursing

Developing critical thinking in the perioperative environment

Affiliation.

• 1 Wellstar School of Nursing, Kennesaw State University, Kennesaw, GA, USA.
• PMID: 20152198
• DOI: 10.1016/j.aorn.2009.09.025

Critical thinking is considered an essential skill for nurses by many, including major accrediting agencies, health care administrators, and AORN. This is in part because of the environment in which nurses function. Health care, medicine, technology, and nursing are dynamic and constantly changing. The perioperative environment is complex, fast paced, unique, and oftentimes unpredictable. Critical thinking skills enable perioperative nurses to function effectively and evolve in this ever-changing environment. Nursing education programs are mandated to teach critical thinking skills. It is the practice arena, however, that refines, hones, and grows these skills. This article provides an overview of critical thinking in the context of nursing, as well as strategies and interventions designed to teach critical thinking skills.

Copyright 2010 AORN, Inc. Published by Elsevier Inc. All rights reserved.

Publication types

• Case Reports
• Attitude of Health Personnel
• Cholecystectomy, Laparoscopic / nursing
• Clinical Competence*
• Education, Nursing, Continuing
• Health Facility Environment / organization & administration
• Middle Aged
• Nurse's Role* / psychology
• Nursing Process / organization & administration
• Operating Room Nursing* / education
• Operating Room Nursing* / organization & administration
• Operating Rooms / organization & administration
• Preceptorship
• Problem-Based Learning

• Research article
• Open access
• Published: 19 May 2020

Managing complexity in the operating room: a group interview study

• Camilla Göras 1 , 2 , 3 ,
• Ulrica Nilsson 4 , 5 ,
• Mirjam Ekstedt 6 , 7 ,
• Maria Unbeck 4 , 8 &
• Anna Ehrenberg 1  

BMC Health Services Research volume  20 , Article number:  440 ( 2020 ) Cite this article

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Clinical work in the operating room (OR) is considered challenging as it is complex, dynamic, and often time- and resource-constrained. Important characteristics for successful management of complexity include adaptations and adaptive coordination when managing expected and unexpected events. However, there is a lack of explorative research addressing what makes things go well and how OR staff describe they do when responding to challenges and compensating for constraints. The aim of this study was therefore to explore how complexity is managed as expressed by operating room nurses, registered nurse anesthetists, and surgeons, and how these professionals adapt to create safe care in the OR.

Data for this qualitative explorative study were collected via group interviews with three professional groups of the OR-team, including operating room nurses, registered nurse anesthetists and operating and assisting surgeons in four group interview sessions, one for each profession except for ORNs for which two separate interviews were performed. The audio-taped transcripts were transcribed verbatim and analyzed by inductive qualitative content analysis.

The findings revealed three generic categories covering ways of creating safe care in the OR: preconditions and resources , planning and preparing for the expected and unexpected , and adapting to the unexpected . In each generic category, one sub-category emerged that was common to all three professions: coordinating and reaffirming information , creating a plan for the patient and undergoing mental preparation , and prioritizing and solving upcoming problems , respectively.

Creating safe care in the OR should be understood as a process of planning and preparing in order to manage challenging and complex work processes. OR staff need preconditions and resources such as having experience and coordinating and reaffirming information, to make sense of different situations. This requires a mental model, which is created through planning and preparing in different ways. Some situations are repetitive and easier to plan for but planning for the unexpected requires anticipation from experience. The main results strengthen that abilities described in the theory of resilience are used by OR staff as a strategy to manage complexity in the OR.

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Clinical work in the operating room (OR) is dynamic, and complex, and often time- and resource-constrained [ 1 ]. Performing surgical procedures requires, specific technical and cognitive skills from OR staff, such as anticipating patients’ needs, managing changes and handling unexpected events [ 1 , 2 ]. Increased co-morbidities of patients [ 3 ], and pressure for efficiency and productivity [ 4 , 5 ] are other challenges that may influence the work in the OR. Teams in the OR interact, communicate, adapt, learn and self-organize over time [ 6 , 7 ] which are common determinants of a complex adaptive system (CAS) [ 7 ]. From the perspective of complexity there are different strategies for improving patient safety, from attempting to control complexity to embracing it by encouraging flexible behaviors [ 8 ]. Complexity requires to wisely balance thoroughness and control with flexibility and adaptations [ 9 ]. The surgical safety checklist [ 10 ] is an example of a procedure that structures safe care processes in the OR that lay ground for patient safety which also can include flexibility in the face of unpredictable events. Complexity means that work processes may be disturbed or interrupted by unpredictable events that the OR staff has to adapt to and handle [ 11 ]. Adaptations contribute to keeping the system’s performance at an acceptably high level under both ordinary and extraordinary conditions, but can also create high-risk situations [ 12 ]. According to the coordination and mobilization of many interdependent processes, support and resources in a CAS are seldom optimal which may produce strain among staff and lead them to develop compensatory strategies [ 13 ].

In the attempts to understand and influence how complex systems such as OR works, traditional ways of thinking in forms of linear causality models are insufficient. A ‘system thinking’ approach that consider the flow of interactive activities (e.g. between people, equipment, procedures) and the continuous adjustments needed to cope with system variability can help to improve safety and performance in the daily practice in an OR [ 12 ]. Patient safety in the OR should be understood by studying “work-as-done”, which reflects the reality that professionals have to deal with in their everyday clinical work, rather than through the ideal picture of “work-as-imagined” which is often presented in policy documents or action plans [ 12 ]. However, a deeper knowledge is needed to understand how “the work is described as being done” in relation to safe care in the OR.

Strategies to cope with and adapt to complexity have been described from the perspective of Resilience engineering, RE [ 14 , 15 ]. Resilience is defined as the ability of the healthcare system to adjust its functioning prior to, during, or following changes or disturbances, so that required operations can be sustained under expected and unexpected conditions [ 16 ]. From a RE perspective, rather than controlling what professionals do, patient safety is strengthened by a systemic capacity which enables professionals to be reflexive, to adapt to changing conditions, and to understand the whole system [ 14 ]. Resilient organizations is often described through four abilities: the ability to respond to events, to monitor ongoing developments, to anticipate future threats and opportunities and to learn from past failures and successes [ 16 ]. Resilience research has shown that ways of managing complexity are also characterized by abilities such as anticipation, sensemaking, trade-offs, and adaptation [ 17 ]. Operationalization of resilience in inpatient healthcare is characterized by professionals anticipating and bridging gaps by proactively monitoring and acting on problems [ 18 ]. Adaptive coordination, the ability of a team to change its coordination activities in response to unexpected events and varying task characteristics [ 19 ], are other cornerstones of effective team performance in complex settings [ 20 ]. Preoperative huddles have shown to contribute to improvements in patient safety, communication, and teamwork. Postoperative debriefings after non-routine and routine cases are other strategies that stimulated learning, and improved work processes and teamwork [ 21 ]. Behaviors to manage non-routine events in the OR are also described to include task- and information management, teaching, and leadership [ 19 ].

To cope with complexity, that is managing expected and unexpected events, resilience has been described to be important. When managing unexpected events in the OR adaptive coordination was described an important skill. However, there is a lack of explorative research addressing what makes things go well and how the OR staff describe they do when responding to challenges and compensating for constraints. This can be understood by describing how health professionals describe that work is done in a clinical setting. Knowing how surgical teams manage complexity will be an important contribution to a deeper understanding of how patient safety is created in a collaborative way in the OR. The aim of this study was therefore to explore how complexity is managed as expressed by operating room nurses (ORNs), registered nurse anesthetists (RNAs), and surgeons, and how these professionals adapt to create safe care in the OR.

Setting and sample

This study employed a qualitative explorative design by using group interviews with OR staff. The interviews were conducted at two central OR departments at one county hospital and one local county hospital in mid-Sweden. Each hospital had one department for day surgery and one central OR department. The central OR department at the local county hospital served both acute and elective surgical and orthopedic patients, whereas the OR department at the county hospital in addition also served gynecological patients. Teams in Swedish ORs commonly comprise six different professionals: ORN, operating surgeon (surgeon), assisting surgeon, circulating nurse (commonly a licensed practical nurse) anesthesiologist and RNA. In Sweden, RNAs are allowed to maintain anaesthesia with direct or indirect supervision of the anesthesiologist [ 22 ]. The sample consisted of three professional groups of the OR-team, including ORNs, RNAs and operating and assisting surgeons in four group interview sessions, one for each profession except for ORNs for which two separate interviews were performed. Two ORNs at the county hospital, who participated in the pilot interview, were included, to achieve large enough group sizes. The four groups comprised a convenience sample of professionals who were available to be released from clinical work and who had been employed at the OR for least 6 months. The interviews were conducted at separate occasions divided in groups by professional specialization. The informants’ characteristics are given in Table  1 .

Data collection

Open questions were asked based on an interview guide which had been developed by the researchers. The interview guide was pilot tested and resulted in a minor rearranging of the themes, but no revisions or changes in content were needed. The interview guide consisted of five questions including “Can you tell me how you plan your day at work?”, “Could you tell me about situations when the work proceeded according to plan?”, “Could you tell me about situations when work did not proceed according to plan?”, “What enables and what hinders you from being able to do the work as planned?”, and "Do you ever have to abandon routines. To get permission to conduct the study, information was provided both verbally and in writing to the medical director of the surgical department and nurse managers at the OR department who invited their staff to participate. Those who volunteered gave their written informed consent after receiving verbal and written information including the voluntary nature of participation and the ability to withdraw at any time without further explanation, and confidential treatment of data.

The data were collected during February and April 2018, via scheduled 1-h interviews in an undisturbed and quiet location at the workplace. At the beginning of each session, the moderator and the assistant (i.e., the first and last authors) gave a brief presentation of the study, including the aim of the study and why the participants were selected. The discussions were led by the same moderator (first author) throughout all four interviews. The interviews were audiotaped, and field notes were taken by the assistant. The interviews lasted between 50 and 59 min and were transcribed verbatim.

Data analysis

The interviews were analyzed by using inductive qualitative content analysis focused on the manifest content [ 23 ]. All the authors are registered nurses or RNAs with experience of healthcare and the OR, and all participated throughout the analytical process to identify codes, sub-categories, and generic categories. Transcripts were read thoroughly several times to obtain a sense of the whole. Content that related to the aim of the study was noted first in the margins of the text and then on a coding sheet. The codes were based on similarities and differences and were sorted into sub-categories which were then interpreted and aggregated into broader generic categories. The different steps were discussed within the research team. To maintain consistency, there was a movement back and forth between the transcripts, codes, sub-categories, and generic categories. To reach consensus, the research group independently categorized the codes and discussed the findings several times. The analysis generated three generic categories. An example of the analytical procedure is presented in Table  2 .

When analyzing the group interviews three generic categories emerged from the sub-categories of each professional group: preconditions and resources, planning and preparing for the expected and unexpected, and adapting to the unexpected. In each generic category, one sub-category was common and shared between the three professions: coordinating and reaffirming information, creating a plan for the patient and undergoing mental preparation, and prioritizing and solving upcoming problems as displayed in Table  3 . Subsequently the generic categories with specific sub-categories representative for each profession follows.

Descriptions of how safe care is created shared by three professional groups

Preconditions and resources, coordinating and reaffirming information.

Coordinating and reaffirming information was a sub-category that emerged as common to all three professions. If critical situations or changes in patient conditions occurred, communication was described as central to creating safe care. Having the same information was also considered essential for a well-functioning surgical teamwork. When a change of plans was called for, the ORNs often used communication with external support services such as coordinators at the OR department to convey information, get support, and obtain new equipment. When issues occurred regarding surgical instruments, the ORNs expressed communication with the surgeon to be important in order to allow prioritization and planning. The surgeons said that they interpreted communication depending on their understanding of the urgency of the situation, which helped them to prioritize. Safe communication was perceived by both ORNs and RNAs to be easier in a small workplace with shorter information paths. The ORNs said that when the team was less integrated, communication within the sub-team (e.g. ORNs and surgeons) was even more important for safe care:

“Communication is more important when the team is not well integrated. That applies to talking to each other, who does what, and what do you need help with, so you don’t get parts of the team taking it for granted that others are doing it.” (ORN)

For the RNAs, an essential precondition was the ability to get access to colleagues quickly by having a telephone nearby. From the surgeon’s perspective, communication was a prerequisite for conveying difficult moments during surgery that required an increased focus from the entire surgical team.

Planning for the expected and unexpected

Creating a plan for the patient and undergoing mental preparation.

An important sub-category common to all three professions emerged as creating a plan for the patient and undergoing mental preparation. In order to be mentally prepared, the professionals created a plan for the patient before the procedure. They read about the patient individually or together to create a mental model and a shared plan. From identified potential patient risks they planned what might be needed for that patient and procedure. The ORNs described how they planned and prepared for equipment adjustments prior and during a surgical procedure, based on the individual needs of both the surgeon and the patient:

“It’s based on what’s best for the patient — to ensure that the surgery will be as good as possible. Don’t hurt the patient. How does it look, what are the things you have to watch out for when you use leg support — we’re thinking about that all the time.” (ORN)

While much of the work was standardized, it was then supplemented after the ORNs had created their mental model or seen the patient. The RNAs anticipated what could happen and adjusted the plan for the patient. The plan was also communicated and structured together with the anesthesiologists, based on the anticipated scenarios. The surgeons said that in most cases they knew the patient, when this was not the case, they created a mental model of the patient and the procedure by consulting the patient record and talking to the patient:

“Often you’ll already know the patient, but if you don’t then you read the patient record and create a mental picture of them.” (Surgeon)

For the RNAs to be mentally and practically prepared clinical experience emerged as a crucial underlying prerequisite. The RNAs described a standardized routine and workflow in which information was obtained from different systems, including reported patient status by the ward nurse. Preoperatively, they also anticipated possible scenarios by inspecting and talking to the patient. Hence, possible scenarios could be identified and anticipated in advance:

“Yes, you’re prepared for it ... You might ‘read’ the patient and understand that this isn’t going to work. Like, I can see that 82-year-old Agda hasn’t had anything to drink since noon yesterday, so she’s already dehydrated…a large surgical intervention, and then when I’m positioning her I find candy under her pillow. I mean, then it’s a completely different scenario.” (RNA).

The RNAs argued, if they planned and prepared carefully in advance this was not a problem:

“Otherwise, once the process has started things just keep rolling. And you’ve, like, created this whole plan for the patient. That’s why we plan — so that won't happen.” (RNA)

Adapting to the unexpected

Prioritizing and solving upcoming problems.

Adapt to the unexpected, by prioritizing and solving upcoming problems was the third sub-category that emerged as common to all three professions. When unexpected issues occurred during a surgical procedure, both RNAs and ORNs said that they assessed the risks against the benefits and adapted to the situation. The ORNs expressed that prioritizing the saving of life over ensuring sterility was an important strategy for safe care:

“Sometimes you can’t scrub the patient — life is more important than ensuring sterility, and you can deal with that later. If an infection occurs, you have to treat it then. For example, we don’t scrub the urgent Cesarean sections, or the ruptured aortas when they arrive directly from the emergency room. Those aren’t the times to argue if someone comes in in white clothes, without a surgical cap and coat.” (ORN)

When problems and issues occurred during surgery, the surgeons and the RNAs expressed that problems had to be solved and it was not an option to allow things to go wrong. Surgeons described that consultation took place with more experienced colleagues or specialized hospital clinics. The problem had to be solved, and inaction was not an option.

The ORNs said that when unexpected equipment-related issues occurred, they checked the equipment, asked for a replacement or handed the problem over to a colleague and continued to focus on the surgery without being affected. The surgeons said they prioritized the interruptions that were perceived as urgent. For the RNAs, intraoperative changes in patient status were anticipated by monitoring trends in the patient’s vital signs, which allowed them to be prepared and hence respond quickly to changes. Being flexible and responsive was one of the RNAs professional skills and perceived as an inherent ability of an RNA. The RNAs explained that when facing changes or challenges they adapted to the new situation and asked for help from their colleagues. To adapt, they used previously created plans B and C, as a part of their mental model when preparing for the procedure:

“It’s the planning ahead, you plan the surgical procedure. As I said, experience from this or that can happen, but then you have a plan B. Perhaps you also have a plan C as well, as it’s like … it’s people, and it can’t go wrong, you have to handle it.” (RNA)

The surgeons perceived that working in the OR meant having to be prepared for changes and variations that sometimes contributed to a lack of focus. Unexpected urgent procedures were taken care of ad-hoc in the work process. Handling this required flexibility, adaptation, prioritization and the ability to relate to variation, interruptions and disturbances. Everyone in the care process, including staff on the wards as well as staff in the OR and recovery, had to be flexible because changes could affect everyone. Some considered variations challenging, but being able to handle a complex workday was also a positive experience which helped make the work enjoyable and stimulating:

“Or is it that they, like most of us, love their work, so it’s more a positive challenge to, like, hit the volley, I think.” (Surgeon)

Preconditions and resources from the perspective of each profession

Orns’ perspectives, team coordination.

The ORNs described team coordination as a precondition for safe care. Familiarity with the team was described as providing security. When assisting surgeons, interaction and detection of the situation ahead were perceived as important. Cooperating with and supporting less-experienced surgeons were described as a significant part of their responsibility.

“After all, there are constantly new surgeons from different specialties who also need support, to make them feel safe and that they are moving forward, which is actually something I would say that is part of our profession. If we just stand there and wait, are grumpy, and turn our backs, the operating time extends. But when you have the flow, “a dream team” as you say, then it's wonderful.” (ORN)

The preconditions were also described as focused on the closest team members (surgeons and circulating nurse), the patient, and the assignment, as well as interacting and having a common goal.

Having experience

The ORNs saw experience as a resource, crucial for maintaining safe care in the OR. Being aware of one’s limitations and increased experience was said to make it easier to get a sense of the whole surgical work process. Different levels of responsibility were given to the other members of the team based on their experience. The less experience the circulating nurse had, the more responsibility was perceived to be placed on the ORN. Decision making seemed, by the ORNs, dependent on experience by making it easier to make decisions, speak up, and follow the plan. The ORNs said that if issues arose, they could always use their experience to find a solution:

“We solve problems; we see them as a challenge. Problems are there to be solved. Do the best thing possible. We now have the advantage of having so much experience that we don’t get stressed about it — we always have a plan B.” (ORN)

The ORNs also described how they gained experience by discussing and reflecting on a situation retrospectively with the other team members and learning from prior situations and decisions.

RNAs’ perspectives

Maintaining focus.

The RNAs said that there were many disturbances during surgical procedures. Staying focused was perceived important. To stay focused, they did not let themselves be disturbed, by conveying when it was not appropriate to interrupt and continuing with the ongoing task:

“When it comes to induction of anesthesia and the awakening, those are the sensitive phases. We can’t have people running in and out of the OR, giving a lot of information, or asking for a change. That’s when there needs to be a little more focus. Those are the situations when we’re in an extra sensitive phase, I think.” (RNA)

Surgeons’ perspectives

Having respect for the team and shared goals.

Respect and cooperation were considered preconditions for a well-functioning team, and the most essential prerequisite for the work in the OR:

“The team is everything. You go there to help and not to counteract each other. It has to do with respect and cooperation and all that.” (Surgeon)

Surgeons considered familiarity within the team and helping each other as a precondition for a smooth surgical workflow. Having a common goal and focusing on the patient were perceived to create the conditions for getting the job done properly. The surgeons also described a small “team within the team” comprising the operating surgeon, the assisting surgeon, and the ORN. With a well-functioning small team, they perceived themselves to be less disturbed by what was happening around them. It was important to respect the function of the team. Understanding and showing respect for one’s colleagues and recognizing that everyone was as important for the team despite having different tasks were described as prerequisites for safe care.

Having experience and competence

The surgeons described how they were trained from day one to handle interruptions and disturbances, which were perceived as expected and normal. They were prepared for unexpected events to occur and knew that they would have to handle the changing situation. When they were interrupted or disturbed during surgery and then continued with the primary task, it took a while to get used to these changes. However, all these abilities were linked to professional experience and would come with time:

“For that reason, I think the longer you work, the less disturbed you get, or you find some strategy for dealing with it.” (Surgeon)

As well as experience, high competence in the organization was described as an important precondition for safe care . Professional competence and training were important preconditions that had to be ensured by the management.

Maintaining focus and creating space for mental rest

Maintaining focus was considered an important ability, and the surgeons described several strategies to achieve this. When there was a high level of disturbance and noise in the OR, they tried to ignore it by staying calm, resisting, and staying in the “bell jar”. If, in spite of this, they were disturbed to the point of losing focus, they would speak up. For them to lose their focus, the interruption had to be of high urgency:

“It’s easy to say, but you have to brace yourself and stay hyper-focused. You don’t leave that state of extreme focus unless it’s something very important and relevant.” (Surgeon)

In order to maintain focus while still being able to adapt to the unexpected events that can occur during surgery, the surgeons described that they took care of unexpected issues ad hoc along the way. The strategy was to avoid cognitive overload that would consume energy. To maintain focus, they took small mental breaks; experienced surgeons said that they could do this without anyone noticing.

Planning and preparing for the expected and the unexpected per profession

Checking and having control to be prepared.

The ORNs considered preoperative control crucial for safety and security. To be able to plan for the expected, they described several operational checks prior to surgery including functional tests and checking of settings, the amount of gas, and availability of other material and equipment. When applicable, the marked operating area on the patient was checked, and paired organs were double-checked with radiographs and verified with the patient . To maintain awareness of the patient’s condition intraoperatively, the ORNs continuously observed the activity within the anesthesia team, such as looking at monitors, or calling on a colleague for support, as this was an indication of the patient’s status. Much of the preoperative preparation was performed by other ORNs or circulating nurses. For responsible ORNs to be prepared they had to check that the instruments, materials, and supplies were adequate. Counting and checking the sterile instruments and surgical tissues continuously during the procedure was another strategy described by the ORNs. To retain control, the surgeons were not allowed to pick up their own sterile instruments from the medical instrument stand. Being prepared and knowing that everything was in order before the surgeon arrived and being one-step ahead of the intraoperative process was important strategies described by ORNs. When working with new employees, the ORNs were more vigilant and prepared, as they did not know what to expect from the new colleague. However, they recognized the person’s capacity and prepared themselves mentally to provide support when needed:

“Interaction — get a sense of who the person is and give them a chance. But don’t retract those sensitive antennae — extra preparedness.” (ORN)

Taking support from roles and routines

When planning for the expected and unexpected, the ORNs described that they used routines and tools when preparing instruments for the procedure that existed in the OR to support their work.

“We have a lot of tools, routines, index cards, positioning guidelines — everyone has their position and knows what to do.” (ORN)

Adhering to policies and procedures, was important to reduce unnecessary interruptions or disturbances. The ORNs also described the importance of the different responsibilities of the professions in the surgical team. For example, when problems with equipment occurred, they often asked the circulating nurse for assistance as they were more skilled in handling the medical technical equipment.

Creating a basic plan for work

The RNAs described that they checked which OR they were placed in and the team members of the day, and then created a tentative plan of what could happen during the day .

“I might start by checking out the daily OR schedule in paper form, the number of procedures at this moment and what kind of procedures. Which team members, which ORN, which circulating nurse and maybe which anesthesiologist I should contact.” (RNA)

By looking at the OR schedule for the day, they could also anticipate potential changes in the schedule.

Checking and restoring

Another way the RNAs planned for the expected and unexpected was to conduct several pre-surgery operational checks including functional tests and checking settings and intended anesthesia equipment.

“Yes, you go through the trolley with all anesthesia equipment, locate what you need, and bring it out so it’s ready — then you can quickly see.” (RNA)

The RNAs also described how the team preoperatively checked the patient’s skin quality to prevent surgical site infections. When restoring the room after surgery, and to be prepared for acute surgery it was important to check and refill all the supplies that had been used.

Creating and re-evaluating a basic plan for work

The surgeons also said they created a basic plan to be prepared and plan for the expected and unexpected.

“There’s also a basic plan, but you sort of figure out the day as it develops, and no day is like another, which is also nice — variable and revitalizing I think, compared to many boring industrial jobs.” (Surgeon)

The preparation phase started the day before, when the surgeons thought about what could be expected and how they would get things done. On the day of surgery, they checked the OR schedule again as it might have been changed. Making a rigid long-term plan was not feasible, as the plan would be verified and re-evaluated several times during the day. This was perceived as an appropriate strategy when working in an unpredictable context such as the OR.

Using guidelines and routines but with certain degrees of freedom

The surgeons explained that following routines and using guidelines was important for being prepared, creating a good workflow, and reducing unnecessary interruptions and disturbances during surgery. However, sometimes a deviation from routine could be necessary:

“Routines are built from standard flows. Then you also have urgent situations, but they also have routines, right? So you can know what’s coming — at a certain interval this or that will happen and we have routines for it. But in every situation, you also have to be able to improvise. It’s like those Russian ice dancers — the more they practice, the more they can improvise.” (Surgeon)

The main results show that to manage complexity and create safe care in the OR, the professionals shared experiences that certain preconditions and resources were crucial, including having work experience and coordinating and reaffirming information. More specifically, resilience was expressed in the professional’s capacity to prepare, respond and adapt to expected and unexpected situations. By creating a common mental model of the patient, the team established readiness to anticipate, prioritize and solve upcoming problem during the surgical procedure.

The challenges, fragility, and unpredictability of working in a CAS have been described as time- and resource constraints in the OR [ 13 ], and gaps in continuity of care, such as lack of information or communication between professionals in handover situations [ 24 ]. Why most things go right, has been proposed to be pertaining to professionals ability to accomplish their tasks by adaptations and work-arounds [ 6 ]. One common precondition for safe care was expressed by the three groups as coordinating and reaffirming information. A previous observational study, that studied how work was done, found that communication was the most common task involved in multitasking [ 25 ]. The results of the present study show that professionals described communication as an important for achieving a safe and smooth care process and may reflect the challenges that comes with working in a CAS. Speaking up may fuel resilience, from a safety culture perspective [ 26 ] members of a surgical team must have the right speak up about a perceived risk or transfer of patient information [ 27 ]. Communication has been described as comprising important transfer of information between professionals, contributing to a safe, seamless, and efficient care process in the OR. In other situations it may cause interruptions resulting in non-completion of tasks [ 28 ] or gaps in continuity of care [ 29 ] that in turn may have a negative impact on patient safety. Good outcomes have been proposed to be related to the systems adaptive capacity, the individuals, teams’ and the managements’ ability to adapt to unexpected events and changing situations, for example by using interaction and communication [ 30 ]. With a focus on how work was done in a context with variable complexity, an ethnographic study explored communication and relationship dynamics in surgical teams. Proactive and intuitive communication, silent and ordinary communication, inattentive and ambiguous communication and contradictory and high dynamic communication were identified. Different types of team collaboration were connected to the level of complexity of performed surgical procedures [ 31 ]. From the perspective of a CAS, communication is crucial for having the right preconditions to create safe care, adapt to unexpected events and creating effective team interactions and coordination. Teamwork and shared mental models are also considered crucial for patient safety in dynamic domains such as the OR [ 32 , 33 ]. Communication allows a greater understanding of potential risks to develop [ 6 ] within the team, as the different professionals share their mental models [ 32 ] of the situation and ways to anticipate and be prepared to respond to system failures. A flat hierarchy seems more likely to manifest a well-functioning team communication [ 34 ].

The professionals also expressed that clinical expertise [ 30 ], experience and competence, were important individual resources to be able to plan and to meet the unexpected. According to surgeons, experience as well as organizational competence was described as an important precondition for safe care. Experienced colleagues were perceived by ORNs, as being more aware of the other team members’ capacity, competence, and need for support which made it easier to make decisions, speak up, and follow the plan. In line with other studies in the OR [ 19 , 35 , 36 ] the RNAs’ work experience was perceived as important for having the cognitive ability to anticipate risks, planning for the expected and unexpected, and be prepared both mentally and practically for the surgical procedure. Participants in this study had quite high mean experience which may predispose for degrees of freedom to be flexible and adapt to situations and opportunities are easier to be seen. From a theoretical perspective, experience seems a crucial component in handling the unexpected. Resilience does not merely emerge in response to specific disturbances, but develops over time from a continuous training in managing and learning from risks, stresses, and strains [ 37 ]. Mental models play a central role in individual’s behavior and sustained learning based on both one’s own experiences and those of other team members [ 38 ]. Sensemaking, retrospective and prospective learning, that is arriving at a common understanding of a situation in order to adapt to and handle it adequately evolves during communication where professionals share their expertise and knowledge [ 39 ].

When planning and preparing for the expected and unexpected, it was during these processes mental models primarily were created. This was described as collecting relevant information, anticipating potential risks, and talking to the patient. This is in line with sensemaking, a social process [ 30 , 40 ], usually triggered when the team is facing an uncertain situation. It is a retrospective skill with focus on achieving plausibility, dependent on previous situational experience [ 41 ]. The same skills involved in using past experiences to find a pattern in a sensemaking process can also be used to proactively anticipate and prepare for situations that may arise. Prospective sensemaking is described as building the capacity for anticipation, which enables smooth collaboration and preparation for coping with undesired but foreseeable situations related to patient safety. Important interactions with technology in the OR have been described as prospective sensemaking, a sociotechnical process central to capturing the dynamic work in the OR supported by social and technological resources. The surgical team were shown to be constantly aware of emerging risks and were thus prepared for a rapid response [ 36 ]. Anticipating, or knowing what to expect, is also a cornerstone of resilience [ 16 ]. To some extent, planning was described differently by the three professions. The ORNs’ primary focus was on the surgical instruments, while the RNAs anticipated risks and adjusted the plan accordingly; this result is comparable to the findings of other studies of surgical teams in the OR [ 35 , 36 ], and confirms the OR as a CAS [ 7 ]. In our study, the surgeons said that usually they knew the patient, but when this was not the case they planned for the patient’s care by reading the record and created a mental model. Similarly, to our results, planning [ 35 ] coordination, behavior and adaptive coordination strategies [ 19 ] have been previously described as important strategies for surgical teams to manage their tasks. The preoperative plan also showed to serve as a shared mental model for the team [ 19 , 32 ] which allowed new situations to be contrasted and evaluated. In general, shared mental models have been described related to positive outcomes by creating effective teamwork [ 33 ] and minimizing preventable uncertain processes and performance [ 42 , 43 ] in ad-hoc constellations of teams [ 42 ]. On an individual level, mental models can also limit professionals by using familiar ways of thinking and acting. Professionals are usually not aware of these models or potential effects on their behavior [ 44 ]. When working in a CAS it can be difficult to get a sense of the whole solely from detailed descriptions such as guidelines. Sensemaking and mental models seems to have the ability to enhance planning for the expected and unexpected. However, in a dynamic CAS such as the OR, mental models need to be shared and discussed within the team [ 19 , 42 ] to avoid misunderstandings.

To be able to adapt to the unexpected, the three professional groups were unanimous in stating that prioritizing and solving upcoming problems was necessary in order to handle the unexpected. From a theoretical perspective when an unexpected event occurs, first it must be noticed, then the surgical team has to make sense of it, and then they have to do something about it [ 45 ]. To be able to adapt to unexpected events, the ORNs and RNAs described that they used previously created plans B and C, which were a part of the mental model when planning and preparing for the procedure. These results are similar to the findings of other studies in the OR context [ 19 , 35 , 36 ]. Having several plans appears to be a common key strategy to handle unexpected events in a CAS. However, the present study also shows the necessity of the planning phase being done carefully, as this appears to be a pre-requisite for a reflexive and quick response when unexpected events occur. From the perspective of resilience, adaptation is a central key factor that is not always about changing the plan, model, or previous approaches, but sometimes involves the readiness to modify plans to suit changing situations. Woods [ 46 ], describes this ability as being able to recognize and to stretch, extend, or change what is being done or had been planned to be done. In our study, prioritizing and solving upcoming issues was a crucial strategy as the problem had to be solved; inaction was not an option. The same strategies were also expressed in other OR studies; in order to respond to unexpected events, adaptability [ 33 ] and adaptive coordination were identified as important for safe performance, and were usually achieved through communication [ 19 , 31 , 32 ].

Patient safety and risk arise through variability and the managements’ ability to provide resources and pre-conditions with different degrees of freedom on which the adaptations from the surgical team are based. However, there is a need for reflection on the extent of the ability to adapt and the degrees of freedom needed in the adaptation. Resilience is often expressed as the extensibility of the system, which may result in pushing the limits for taking risks too far; this is intimately linked to exposure to risk. However, the risk of high adaptive capacity is that adaptations become normalized and signals of organizational weaknesses are masked by individual’s ability to adapt and therefore, despite system deficiencies, more difficult to be perceived by decision makers [ 47 ], balanced considerations must be considered.

Methodological considerations

One strength of this study is the inclusion of three OR core professional groups with varied gender, age, and experience. However, the mean age and experience were both quite high, probably due to that the included OR department had quite low turnover rates among staff. This can be considered as both a strength and a limitation. On one hand, individuals with a lot of experience may contribute with more rich descriptions than those with less experience. On the other hand, perceptions from less experienced could have contributed with more variations in the phenomena of study. Transferability of qualitative results is difficult, as these results are highly dependent on the studied context. To ensure trustworthiness [ 48 ] in terms of confirmability, we have presented a selection of transcripts, codes, sub-categories, and generic categories in Table 2 . To increase the credibility, interactive discussions of codes, sub-categories and generic categories took place among the authors, and quotations are presented in connection to the descriptions. Further, triangulation of sources was made of similar descriptions of the same phenomenon by the three professionals, and analyst triangulation was achieved by the research group through independent categorization. To ensure dependability, open questions were asked using an interview guide during all group interviews. The aim for choosing group interviews, instead of individual interviews was to obtain each professional group’s perceptions and experiences by dynamic group interactions. Since the OR is an unpredictable context, there was uncertainty in how many participants that could attend the planned time and day for the group interviews. The interviews were conducted at two central OR departments at one county hospital and one local county hospital in mid-Sweden by reasons as practical feasibility to obtain access to professional groups. The interviewer was an RNA, which may have affected the interpretation of the results both positively, by making it easier to interpret context-specific nuances, and negatively, by taking things for granted. As described previously, surgical teams in Sweden usually consist of six different professionals. The focus in this study was on the core professionals of the OR, including ORNs, RNAs, and surgeons. This may be considered a limitation, as not all professionals were represented.

Creating safe care in the OR should be understood as a process of anticipating, planning, and preparing in order to manage challenging and complex work processes. OR staff need preconditions and resources such as having experience and coordinating and reaffirming information, to make sense of different situations. This requires a mental model, which is created through planning and preparing in different ways. Some situations are repetitive and easier to plan for but planning for the unexpected requires anticipation from experience and coordination among team members. The main results strengthen that the four abilities in the theory of resilience is used by OR staff as a strategy to manage complexity in the OR. Managing complexity seems dependent on clinical experience. Therefore, future research should focus on how to provide effective learning of effective strategies for safe practice in a complex health care environment for less experienced colleagues.

Clinical implications

Managing complexity in the OR, being able to respond to the expected and unexpected, requires adaptive capacities such as anticipating and monitoring. Before a procedure starts surgical teams should use safety briefings to discuss potential challenges and risks and solve problems. To promote learning and to have the same goals, mental models should be shared and discussed between team members. After the surgical procedure, debriefings about what and why things went right or wrong and what could be improved may support reflective learning [ 34 ].

Availability of data and materials

Data are available on request for any interested researchers to allow replication of results provided all ethical and legal requirements are met according to GDPR, The General Data Protection Regulation for the European Union. Contact person, Center for Clinical Research, Dalarna, Uppsala University ( [email protected] ), Nissers väg 3, SE-79182 Falun, Sweden.

Abbreviations

Complex adaptive system

• Operating room

Operating room nurses

Registered nurse anesthetists

Resilience engineering

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Acknowledgements

We also thank the heads of the participating departments and the surgical teams for their willingness to participate in this study.

The Center for Clinical Research Dalarna and the Department of Anesthesia and Intensive Care Unit Falu Lasarett supported this work but was not involved in the design and running of the study. Open access funding provided by Dalarna University.

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CG, UN, ME, MU and AE contributed to the study design. CG was the project supervisor and performed the group interviews together with AE. CG also undertook the initial interpretation of the data, which was followed by discussions with UN, ME, MU and AE. Drafts of the manuscript were reviewed by UN, ME, MU and AE. All authors have read and approved the final manuscript.

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This study was conducted according to International research ethics and standards following the Declaration of Helsinki and was approved by the Swedish Ethical Review Authority in Uppsala, Sweden (No. 2016/264). To get permission to conduct the study, information was provided both verbally and in writing to the medical director of the surgical department and nurse managers at the OR department. Those who volunteered gave their written informed consent after receiving verbal and written information from one researcher (CG) including the voluntary nature of participation and the ability to withdraw at any time without further explanation, and confidential treatment of data. The manuscript had followed the reporting criteria for qualitative research according to the COREQ checklist.

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Göras, C., Nilsson, U., Ekstedt, M. et al. Managing complexity in the operating room: a group interview study. BMC Health Serv Res 20 , 440 (2020). https://doi.org/10.1186/s12913-020-05192-8

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Critical Thinking in the Operating Room - Skills to Assess, Analyze and Act PDF Download

The operating room (OR) is a complex, fast-moving environment, requiring nurses to display their specialized skills across the preoperative, intraoperative, and postoperative setting.

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A Peek Inside the Operating Room: Eight Insights From a Circulating Nurse

When you think of the operating room (OR), what comes to mind? An intense and stressful work environment? A place where you have to think and act quickly? It’s certainly all of those, and more. I spent more than 40 years working in nursing before joining 3M five years ago. For most of that time I worked in the perioperative area and I can tell you that, yes, sometimes the OR is an intense, emotionally charged place. It is also a place where teams work together with a singular focus on the patient, making it a highly rewarding environment.

I knew from my experience during clinicals that I wanted to work in the OR. At my first hospital, I visited the nursing director regularly to see if there were any openings. After about six months, I got my chance. I first learned how to scrub – setting up the instruments and handing them to the surgeon during the procedure – and then I moved into circulating, a more typical RN role of providing direct patient care before, during and after the procedure.

Curious about what it’s like? Here are a few insights from my experience:

1. your number one job is to be the patient’s advocate..

When a patient is in surgery, they need an advocate as they are unable to advocate for themselves. Some people may view the role of an OR nurse as more clinical and less caring, but I found it very patient focused. I would meet with patients before surgery to both reassure them and assess their readiness for the surgery, telling them, “I’ll be there when you fall asleep and I’ll be there until you are out of surgery.”

2. The job responsibilities can vary.

Most ORs will have nurses who perform two different functions: the more technical job of scrubbing – assisting the surgeon directly and handling instruments – and circulating. Circulating nurses’ responsibilities include:

• Knowing all the pertinent information about the patient and verifying that it’s the correct patient on the table going in for the scheduled procedure.
• Positioning the patient appropriately and properly prepping their skin for the incision.
• Managing the room, including supplies, equipment, lighting and documentation. The circulating nurse ensures there’s not a break in sterile technique. If patient status changes, you may have to switch what you are doing – stepping in to help anesthesia, for example.
• Initiating counts when it’s time to close – accounting for all sponges, blades and other instruments.

3. It took about a year to feel really comfortable in the role.

My orientation paired me with an experienced nurse for six months of scrubbing and six months of circulating, which helped me feel comfortable. Today, the orientation periods are usually shorter and nurses may have to adjust more quickly.

4. Every day may be different.

If you work at a specialty surgery center, your workday may be more predictable than if you work in a general surgery setting. Depending on the type of procedures you work on, one provider could do up to 20+ surgeries in one day. Eye surgery is an example of a surgery that may take less than 30 minutes. In this situation, you may be switching back and forth between two ORs all day. On the other hand, one complex surgery – such as a transplant or a reconstruction – can take the entire day and even extend beyond a normal shift.

Technology and increasing specialization also are changing work in the OR. Total joint replacements  used to be much more invasive procedures. Minimally invasive surgery has transformed how replacements are done, and some surgery centers focus entirely on these surgeries.

5. Every surgery is customized to the patient, but standards are always followed.

It’s important to follow protocols and standards to help ensure consistent patient care on outcomes. Every patient is different though, and care should be customized for each person depending on their scheduled procedure, skin condition, their body shape and their overall health status. It may mean you need to adjust positioning, make a different selection for skin preparation, or utilize different equipment to accommodate various needs.

6. A strong, but respectful, personality is helpful.

When you work in the OR, you are always advocating for the patient, so you need to speak up. You have to bring concerns forward in a clear, but respectful, way. Attention to detail and critical thinking skills are also crucial.

7. The hardest part of the job is the stress.

Emotions can run high in the OR. If you are working on a cardiac case, a trauma case or a ruptured aneurysm, everyone is highly focused on reaching the critical point in the surgery. You may also have irregular hours and be on-call for emergencies.

8. The best part of the job is the teamwork.

There is nothing as satisfying as working with a good team. If your team is aligned, you will probably know what the surgeon or scrub tech needs before they do. You are all focused on one patient at a time and are working together to provide excellent care for them.

I loved my years working as a nurse. While my roles varied – from staff nurse to nurse manager and clinical director and from setting up a brand-new surgery center to a pain management center – in each case, my focus has been on the patient.  If you are compassionate, want to be an advocate for your patients, love being part of a team, and don’t mind a high-stress environment, being an OR nurse might be a great fit for you, too.

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• v.9; Jan-Dec 2023
• PMC10350747

Operating Room Nurses’ Understanding of Their Roles and Responsibilities for Patient Care and Safety Measures in Intraoperative Practice

Bisma chellam singh.

1 Staff Nurse, Head and Neck Operation Theater, Manchester Royal Infirmary Hospital, Manchester, UK

Judie Arulappan

2 Department of Maternal and Child health, College of Nursing, Sultan Qaboos University, Muscat, Sultanate of Oman

Introduction

Surgical care has been a vital part of healthcare services worldwide. Several patient safety measures have been adopted universally in the operating room (OR) before, during, and following surgical procedures. Despite this, errors or near misses still occur. Nurses in the OR have a pivotal role in the identification of factors that may impact patient safety and quality of care. Therefore, exploring the OR nurses’ understanding of their roles and responsibilities for patient care and safety in the intraoperative practice, which could lead to optimal patient safety, is essential.

This study explored the understanding of OR nurses regarding their roles and responsibilities for patient care and safety measures in the intraoperative practice.

The study was conducted in one of the tertiary care hospitals in the United Arab Emirates. Qualitative, descriptive, exploratory research design was utilized. The data were collected using semi-structured face to face interviews. Purposive sampling included eight nurses. Data analysis was performed following Colaizzi's seven-step strategy.

Seven emerging themes were identified. The main themes are: patient safety, preoperative preparation, standardization of practice, time management, staffing appropriateness, staff education and communication, and support to the patient in the OR.

OR nurse leaders may take into consideration the current findings as a reference for quality improvement projects in the hospital, considering the specific characteristics of each local setting. Although the participants consider that the environment is safe and the quality of care is high in the study setting, there is still room for improvement on workflows and processes. OR workflow should be improved especially by addressing the potential patient safety issues.

Introduction/Background

Intraoperative practice is highly complex and challenging considering the vulnerability of the patient ( Peate, 2015 ). The intraoperative period starts when the patient arrives at the operating room (OR) and ends when the patient gets transferred to the postoperative ward (Salazar Maya, 2022 ). The care in the OR involves high use of technology and is different than the care provided in other settings of the hospital. OR nurses play an instrumental role in preventing infection, maintaining asepsis, handling instruments, adopting medical techniques, preventing complications, and handling biological preparations. Additionally, nurses play an essential role in planning care and collaborating with the patient, surgical team, and other healthcare providers ( Flaubert et al., 2021 ; Kelvered et al., 2012 ).

Patient safety during surgery is one of the major alarms for intraoperative teams as adverse events occurring during this period is the major cause of disability and death ( Rodziewicz et al., 2022 ). Patient safety involves decreasing the danger of superfluous harm including anticipation of errors and avoidable adverse events to shield patients from injury ( Ingvarsdottir & Halldorsdottir, 2018 ). Major complications emerge in 3%–22% of surgeries, and the mortality rate is reported as 0.4%–0.8%. As the issue of patient safety takes a major toll, the World Health Organization ( WHO, 2017 ) calls for addressing the issue in the report “Safe Surgery Saves Lives.” These complications might be avoided if patients are taken care of during this period ( Ingvarsdottir & Halldorsdottir, 2018 ).

Review of Literature

Ugur et al. (2016) claim that errors occur more in OR as the staff come from various disciplines with various educational schemes and work as groups, which may cause surgical confusions. Therefore, the preventable mistakes can be lessened when OR staff are qualified in patient safety, clear systems are pursued step by step, and control structures are created and utilized. Likewise, effective communication among the OR staff reduces the surgical errors ( Ingvarsdottir & Halldorsdottir, 2018 ) and effective communication between the patient and medical and nursing staff enhances patient satisfaction ( Allison & George, 2014 ).

Ensuring patient safety in the OR includes prevention of all avoidable medical and surgical errors including preventing wrong person, site, procedure, and retained foreign objects. These errors can be prevented by structured communication with the patient, surgeon, and other healthcare team members ( American College of Obstetricians and Gynecologists, 2010 ; Rodziewicz et al., 2018 ). Additionally, correct identification of patients who are at risk of high blood loss, anesthesia or airway issues, history of allergies, and prevention of surgical site infection is essential ( Mcdowell & Mccomb, 2014 ; Woodman & Walker, 2016 ). In addition, the errors could be prevented during the preparation of surgical environment, instrumentation, sutures, and drugs ( Taaffe et al., 2018 ; Williams & Hopper, 2015 ). Likewise, patient safety can be enhanced through proper scheduling of procedures, communicating with other colleagues, helping to ensure consistency with the surgical safety checklist, and screening the progress in the surgeries and reporting to the board ( Rothrock, 2018 ).

Despite all safety checks, there is a risk for errors, which could cause adverse events to surgical patients ( Rodziewicz et al., 2018 ). Hence, it is imperative that the nurses are knowledgeable about patient safety and do corrective actions as patient advocates. Considering the surgical risk for the patients, McGarry et al. (2018) and Brown-Brumfield and Deleon (2010) emphasize the role of nurses in intraoperative patient safety and Kelvered et al. (2012) and Blomberg et al. (2018) point out the vulnerability of patients undergoing surgery and the risks associated with the intraoperative environment. Moreover, Gutierres et al. (2018) recommend various measures to improve patient safety during intraoperative period. Furthermore, the International Council for Nurses (2013) asserts that each registered nurse has a moral and ethical duty to speak-up for the patient's best interest, show quietude, regard, secure patient autonomy, and self-esteem ( Blomberg et al., 2018 ). Besides, accountability of nurses is essential for professional nursing practice and patient safety ( Battié & Steelman, 2014 ).

At the author's department, there were few incidences, such as specimen rejection, hand hygiene issues, errors in needles, sponge counting, and skin tearing in 2017 and 2018. Similarly, there was one incidence of skin injury during this period. This urged the authors to conduct the study to explore the understanding of OR nurses’ roles and responsibilities for patient care and safety in the intraoperative practice, which could lead to optimal patient safety using evidence-based practice.

Research Aim

The study explored the understanding of OR nurses regarding their roles and responsibilities for patient care and safety measures in the intraoperative practice.

We adopted a qualitative, descriptive, exploratory research design. Nurse researchers who conduct qualitative studies are contributing important information to the nursing body of knowledge that cannot be obtained by any other research design (Burns & Grove, 2005 , p. 52). The qualitative researchers have a preference for understanding events, actions, and processes within a specific context ( Babbie & Mouton, 2001 , p. 272). In addition, explorative research examines a phenomenon of interest, rather than simply observing and recording incidents of the phenomenon ( Lobelo, 2004 , p. 20). Likewise, qualitative descriptive approaches to nursing and healthcare research provide a broad insight into particular phenomena ( Doyle et al., 2020 ). Similar research design has been utilized in a previous research ( Sehularo et al., 2012 ). This design is utilized in the current study to explore and describe the understanding of OR nurses regarding their roles and responsibilities for patient care and safety measures in the intraoperative practice.

The study was conducted in one of the tertiary hospitals in the city of Abu Dhabi in the United Arab Emirates. All Interviews were taken place in a private room within the General Surgery OR department, which was quiet, private and calm that helped the participants to feel relaxed and ready to open and share their views.

Population comprised general surgery OR nurses.

Sample and Sampling Method

The sample comprised eight general surgery OR nurses working at a tertiary hospital. Purposive sampling was adopted.

Criteria for Sample Selection

Inclusion criteria.

The study included nurses with more than 2 years of experience in OR as they had extensive experience and in-depth knowledge to share their roles and responsibilities for patient care and safety measures in intraoperative practice.

Exclusion Criteria

Nurses in management positions were excluded in this study as they are not performing direct patient care in the OR.

Ethical Considerations

The study was approved by the Royal College of Surgeons in Ireland (RCSI) - Medical University of Bahrain (MUB) - Research Ethical Committee (REC). Further approval was granted from the organization involved in accessing and recruiting participants. All audio recordings were coded, password-protected, and stored in a double-locked cabinet in the primary investigator's office. Names, address, phone number, e-mail, and staff ID were not collected. Moreover, any information that may lead to the identification of the interviewees was deleted from the interview scripts. Likewise, the findings from the study were presented in ways that ensured that individuals cannot be identified.

Data Collection Method

The data were collected through a direct face-to-face individual interview with the participants using semi-structured probing questions. The data were collected in June 2019. The questionnaire comprised six central questions ( Table 1 ). All interviews were done in English language and audio-recorded after obtaining consent and agreement from the study participants. Eight interviews were conducted individually. Each interview lasted approximately 27–55 min. The interviewer asked follow-up inquiries to clear up individual reactions and to support elaboration as deemed appropriate.

Interview Questions.

Positions and Roles in the Study

The research team had four members: the lead investigator, one researcher, one research team member with managerial responsibilities of supervision of nurses, and one research supervisor directly tied to the study organization. The research team members used online meetings to track the study's progress and conclusions. All members have experience in nursing research. No repeated interviews were conducted in this study, and it is noted that no relationship between researchers and participants might influence the responses.

Pilot of Interview

Two pilot interviews were conducted before commencing the actual interviews. The pilot interview helped the researcher to get familiar with the aptitudes in interviewing and the progression of conversation.

Statistical Analysis

The collected data were transcribed and analyzed using Colaizzi's ( 1978 ) seven-step framework. The steps are (i) transcribing all the subjects’ descriptions, (ii) extracting significant statements, (iii) creating formulated meanings, (iv) aggregating formulated meanings into theme clusters, (v) developing an exhaustive description, (vi) identifying the fundamental structure of the phenomenon, and (vii) returning to participants for validation ( Edward & Welch, 2011 ). The principal investigator performed the analysis. The supervisor and the corresponding author verified the coding and themes and cross-checked for the consistency of the information.

Credibility, Dependability, Transferability, Rigor, and Trustworthiness

To ensure credibility of the data, the researcher strongly engaged with the interviews by means of observation, documentation, and taking notes. Dependability was achieved through reviews and comments on coding accuracy given by the supervisor who has full knowledge of the study design and methodology. To establish transferability, data collected from participants and the findings could be applicable to other contexts, situations, times, and populations and the study setting. The researcher adhered to rigor by carefully collecting data via audio recordings and by taking field notes. Each interview was transcribed immediately after the interview by the Principal investigator. The transcripts were given to the participants for cross-checking and approval ( Forero et al., 2018 ; Lincoln & Guba, 1986 ). As described by Stahl and King ( 2020 ), trustworthiness was established by using an unbiased approach in selecting the participants and by participant's being honest, clearly recorded and accurately presented inputs. The samples were selected purely on the basis of inclusion and exclusion criteria. No selection bias was applicable in the study.

Sample Characteristics

The demographic variables of the study participants are presented in Table 2 . There were eight study participants. Six of them were females and two were males. Age ranged from 28 to 52 years. Nurses’ OR experience varied between 8 and 23 years. All the participants had previous OR experience. The participants either had Higher Diploma in Nursing or BSN degree.

Participants’ Demographic Characteristics ( N   =  8).

OR = operating room.

Research Question Results

There were a total of seven emergent themes developed from 20 theme clusters. The themes include patient safety, preoperative preparation, standardization of practice, time management, staffing appropriateness, staff education and communication, and support to the patient in the OR ( Table 3 ).

The List of the Final Theme Clusters and Emergent Themes.

Theme 1: Patient Safety

After comparing the statements from all the participants, patient safety was identified as the major role of all the OR nurses. Institute of Medicine defines patient safety as “the prevention of harm to patients.” Emphasis is placed on the system of care delivery that (1) prevents errors, (2) learns from the errors that do occur, and (3) is built on a culture of safety that involves healthcare professionals, organizations, and patients ( Aspden et al., 2004 ; Clancy et al., 2005 ).

Theme Cluster: Safety Checks, Pressure Over Staff, and Nursing Responsibility for Patient Safety

The participants mentioned that the nurses should check if the patient is adequately padded to prevent contact with metal surfaces and improper positioning that causes nerve damage. Also, patients should be identified correctly.

The main thing is the skin of the patient, the skin integrity. When she wakes up, I don’t want her to get blisters because of her positioning, so nurses should make sure to check from top to toe that they are properly padded, their skin is not attached to any metal especially if they are going to use diathermy, it will cause burn if any metal is attached

rushing can lead specimen being labeled incorrectly (Participant 1)

…if you are in a rush or if you are distracted, you miss out on vital information. That could have safety implication (Participant 3)

The participants suggested that patient safety should be the main goal for nurses and nurses are responsible for promoting safety and preventing injuries.

It's very important for the patient to have someone that is paying attention to them, then you can do your other works afterward, once they have gone to sleep. You must spend that time with the patient, it's only a short period before they go off to sleep, then you can proceed with the rest of your duties (Participant 3)

Another three participants also pointed out the nursing responsibilities for patient safety especially in protecting their confidentiality and prevention of falls.

Theme Cluster: Total Time Patient Spent Under Anesthesia and Appropriate Instrument Handling

The participants pointed out that if the patient spends more time under anesthesia, it can affect the safety of patient. Staff members have to prepare everything in advance so as to avoid waiting for equipment and instruments once the patient is under anesthesia.

The more prolong the patient is under anesthesia more complication it is. So, it is also reflecting the patient safety during the intraoperative period (Participant 5)

Theme Cluster: Adherence to Universal Protocol

Majority of the participants talked about the importance of universal protocol in patient safety.

The World Health Organization created the Sign-in, the Timeout, and the Sign-out, these are separate little checklists, but all for one procedure, including various aspects of care. So you pause when you do a little checklist, then you pause again before skin incision to ensure it is the right patient for the right surgery, check any allergies again and make sure the antibiotics have been given and then at the very end we do the Sign-out. This is what we do, was there any specimens, any blood loss, any issue to report, so it is checked, check all along the way. (Participant 3)

Theme Cluster: Appropriate OR Environment

The participants highlighted the importance of appropriate OR environment in patient safety. They mentioned that the OR should be illuminated adequately and the noise should be kept minimum in order to attend to the needs of the patient.

in our laparoscopic case, it is dark inside in the OR. So, it is hard to move around to help

If the music is playing, the surgeons are also teaching some of the interns, the residents, and another surgeon, so if they are talking all at the same time with the music, you wouldn’t hear what they want at first. So, they have to repeat it again until they get mad and they will shout again so it can lead to one after the other because it is very noisy in the room (Participant 7)

Theme Cluster: Staff Familiarization With Holistic Care of Patient

Two of the participants discussed the staff familiarity with the holistic care of the patient. They described that the surgeons should not operate on patients whose health status is not familiar to them, even though it is a simple surgery.

All the staff in the room, is to be aware of the patient's status (intraoperatively) at all times, for example, hemodynamic, looking at the anesthesia monitors, ECG, pulse oximeter, etc, so the second set of eyes is always a safe practice (Participant 8)

According to the participants, the same surgeon who is operating on the patient must be the one to provide care preoperatively, intraoperatively, and postoperatively to render continuity of care.

Theme Cluster: Patient Advocacy

The participants claimed that nurses are the patient's advocates and they must speak up for the patients.

When the patient is inside the OR, we are their only advocate and we should look after them very well. Because they trusted their life to us, so have to do our best

The patients are trusting us, and we have to do the best for the patient. Nurses must advocate for the patients as they cannot speak for themselves while under anesthesia and also, they are very anxious in the OR. (Participant 1)

Theme Cluster: Hand Hygiene

Most of the participants acknowledged that hand hygiene is the fundamental concept in the prevention of infection and in promoting patient safety.

So if you don’t have proper hygiene, the patient is getting infection or the disease that he didn’t have when he came to the hospital. That means, he is getting his condition worsening if you don’t have proper hand hygiene (Participant 5)

It is like disciplining yourself to do hand hygiene because we have everything around us. We have the water, we have the sink all over, we have the solution, to do the hand hygiene. So, I think it is more on the discipline of the person on how to do it. (Participant 7)

Theme 2: Preoperative Preparation

The participants argued that the preoperative readiness of instruments, equipment, and supplies prior to wheeling the patient into OR can enhance patient safety in many ways. Preoperative preparation includes the psychologic and physiologic preparation of a patient before an operation. The preoperative period may be extremely short, as with an emergency operation, or it may encompass several weeks during which diagnostic tests, specific medications and treatments, and measures to improve the patient's general wellbeing are employed in preparation for surgery ( Turner, 2006 ).

Theme Cluster: Materials and Equipment Readiness

Almost all the participants declared the importance of materials and equipment readiness prior to wheeling the patient into OR.

Everything should be set up, the equipment in the room available, because we don’t want to delay things when the patient is already on sleep, the surgeon needs this kind of equipment, as daily task, check that all the equipment available. I don’t want to put the patient asleep without having the proper equipment. (Participant 1)

The equipment-wise, make sure that it is working well, it is not malfunctioning, and then instrument wise, make sure that our instruments are not defective, working well (Participant 7)

Theme Cluster: Preoperative Preparation Prior to Intraoperative Phase

One participant mentioned about the thorough preparation of the patient in the preoperative department prior to wheeling inside OR. The assessment should be done thoroughly to prevent complications during intraoperative period.

I don’t know how the pre-op nurses do the assessment. I think the assessment should be more thorough like sometimes they miss the patient still goes to the OR with hair clips, still with jewelry. (Participant 7)

Theme 3: Standardization of Practice

Majority of the participants highlighted that the practices should be based on the policy and protocol of the hospital. In addition, it is crucial for the safety of patients and staff. Standardization of practice refers to the creation of standard clinical processes using process management in conjunction with robust, targeted measurement, and team-based care, in which measurement informs practice and practice informs evidence and further improvement ( McGinnis et al., 2013 ).

Theme Cluster: Uniformity of Practice Within the Hospital

The participants said that everyone should practice patient care with proper understanding of the policies and procedure. The staff from different backgrounds should be trained to provide uniform care. Non-uniformity can lead to delayed treatments.

We want to be safe; we want the patient to be safe, we want to provide the best care possible, that we can give, and we want to adhere to our standards and protocols. (Participant 3)

We had a different understanding of the consent and then the consent in preparation they have different understanding too… So that will just delay the treatment, utility, and flow of services. (Participant 6)

The participants mentioned the importance of uniform practice to be legally safe and also in handling instruments and sharps.

Theme Cluster: Appropriate Workflow for Specimen Handling

One of the participants mentioned that the specimen workflow of lymphoma is confusing as it has many tests under one specimen.

I think the practices are quite safe from our side except for technical issues like may be a lot of confusion regarding the lymphoma protocol, which the system can solve it for you. The Information technology (IT) can try and solve it. People are confused because the number of tests under the lymphoma protocol keeps on changing as per the surgeon and there is no lymphoma protocol built-in epic yet here. (Participant 5)

Theme 4: Time Management

The participants enumerated the importance of time management in the OR. They emphasized that time management should be done without compromising patient safety and staff injury. Time management involves the effective planning and balancing of activities in order to promote satisfaction and health ( Turner, 2006 ).

Theme Cluster: Turnaround Time

Five out of eight participants talked about various aspects of turnaround time between two surgeries.

We are after the turnaround time. We are missing something like connection between the nurses and the patients. That could affect the safety of the patient inside OR. (Participant 7)

Another thing is time management because there are only 3 people in the OR we should be able to manage our time when to go for a break. When is a good time and it should not compromise the patient safety? (Participant 1)

Theme Cluster: Teamwork

According to the participants, teamwork is greatly encouraged as it plays a pivotal role in patient care.

I think that everyone is willing to step out of their immediate role to help someone else. For instance, the circulator is willing to help the anesthesia team if needed and vice versa. (Participant 8)

It would be helpful if the preparation nurse would bring the first patient to the room, then at least we can save time. We have more time to prepare the room instead of one person going out of the room getting this patient (Participant 6)

Theme Cluster: Instrument Reprocessing

The staff pointed the reprocessing of instruments, especially during busy days. This can prevent delays. The instruments should be fast-tracked during busy schedules.

If your institution has a lot of volume of cases and all are laparoscopy imagine if you have three rooms running and all of this have just 10 cameras, how can you deal with it? You need to fast track it every now and then. So that it is one of the responsibilities of theatre nurse to make sure to fast track it (Participant 4)

Theme 5: Staffing Appropriateness

Majority of the participants mentioned about the staffing appropriateness. They affirmed that understaffing and rushing to accomplish tasks with the available staff can place the staff at risk of injuries. Staffing appropriateness is ensuring the effective match between patient needs and nurse competencies. Appropriate staffing is clearly linked to the health of the work environment. It affects everything in the unit, including nurse performance and retention, quality of care, patient outcomes, and hospital costs ( Mitchell et al., 1989 ).

Theme Cluster: Adequacy of Staffing

The participants described, when the OR is understaffed, it can affect the overall care of patients such as it reduces the chance of nurses staying with the patient. When there are more things to accomplish, there should be additional staff provided for that OR.

I think if we have more staff at night, it won’t be a problem. We could have a thorough assessment of the patient, and we won’t be in a hurry to finish the cases. We won’t mind that case would extend little bit because there are staff doing that case at night. (Participant 7)

The policy is 2.5 nurses in the room. That should be the nursing care. Not to do computer work or some other care. But, in our practice, ideally, we must be 3 nurses in the room as we don’t have a technician to help the scrub nurse to open the stuff (Participant 5)

Although six out of eight participants talked about understaffing, just one nurse talked about organizing of booking of surgeries to save staff.

Theme Cluster: Surgeon Availability

One of the participants highlighted the presence of surgeon during preparation especially while positioning. He emphasized that they should take part in positioning the patient.

For patient safety, the surgeon should also be there in positioning the patient because they are the one who knows what position will be needed for the case. So, I think they should be really part of the positioning of the patient. (Participant 7)

Theme Cluster: Health Status of Staff

The participants felt that nurses should be fit enough to carry outpatient care. They should get adequate rest and breaks so as to function well.

First of all, I prepare myself. I go to work in good condition. So, if I am not feeling well, I will not go to work. Because I know that I can’t compromise the safety of the patient. So, I make sure that I am well. I am in a condition to go then study the procedure, analyze it and give my 100%. (Participant 4)

Research has proven that fatigue can impact patient safety, it can impact our reaction time or our concentration level. (Participant 3)

Half of the participants stressed the importance of staff fitness and rest. They said these two can affect patient safety in large proportion.

Theme 6: Staff Education

The participants urged that staff training and education can make the nurses more knowledgeable and enhance their performance. Staff education involves training to improve the performance or knowledge of the employees or workforce or a company ( Turner, 2006 ).

Theme Cluster: Staff Training

Although the majority of them pointed the staff training, one participant talked about robotic training, which should be improved to avoid chaotic situations.

I feel the Robotics area needs to be improved upon. We have some good robotically trained nurses here already, but I think the flow needs to be better, more consistent. Set up of the room should be more consistent and less chaotic (cords and equipment mismatched, etc) (Participant 8)

We do the in-service every Thursday that gives us updates with the new technologies; at the same time updated in the practice of what we should do, what should not do (Participant 6)

Among the participants who mentioned about the staff training, one of them stressed the importance of training anesthesia technicians in patient handling and another one emphasized that staff should be rotated in all specialties in order for them to be familiar in all surgeries.

Theme 7: Communication With and Support to Patient in the OR

The participants talked about the patient's overall experience during the intraoperative period as it can impact patient safety. This has two subthemes: establish a better rapport and empathy with the patient, and proper communication with the patient. Communication involves imparting or exchanging of information by speaking, writing, or using some other medium ( Merriam-Webster, 2018 ). Empathy is the action of understanding, being aware of, being sensitive to, and vicariously experiencing the feelings, thoughts, and experience of another ( Merriam-Webster, 2018 ).

Theme Cluster: Establish a Better Rapport and Empathy With the Patient

The participants affirmed the importance of establishing a better rapport with the patient during intraoperative period.

Try not to leave the patient unattended as much as possible (Participant 2)

Make sure that the patient is well padded, comfortable, putting a blanket, making sure, not exposing the patient and putting the gel pad is very important. Just think that the patient is your own relative (Participant 7)

Four out of eight participants talked about rapport and empathetic care. They urged to stay with the patients as the environment itself is scary and they do not know what to expect.

Theme Cluster: Proper Communication With the Patient

The participants explained the importance of verbal and non-verbal communication as it relieves stress and anxiety.

Try to talk to them and ask them how they are feeling, how the day is going. I think it can alleviate the anxiousness (Participant 2)

You should be making the patient relaxed, make them feel at ease. Even if there is a language barrier, use your non-verbal skills, you can touch them, or you can even just look at them, eye contact. There are always ways, you can smile, you can smile through your eyes, even though you are wearing a mask (Participant 3)

Communication with the patient was emphasized by three of the participants. They said communication has the ability to alleviate the anxiety of the patient.

Patient safety was the major theme that emerged from this study, and it showed that OR nurses play a pivotal role in intraoperative patient safety. The OR nurses consider that the intraoperative safety of patients depend on the overall intraoperative nursing care as nurses are in close proximity to patients. Also, nurses can act as advocates when the patients cannot do for themselves. These findings coincide with the result of a previous study, which points out that intraoperative nursing care creates confidence-based relationship and event-related wellbeing. It ensures persistent wellbeing and safety by keeping a watchful eye. Thus, strategies should be designed to make a safe environment that enhances wound healing, recovery, and wellbeing ( Kelvered et al., 2012 ). Moreover, frontline employees including nurses are in best position to watch and distinguish concealed preconditions that inadvertently advance from anticipated behaviors ( Graling & Sanchez, 2017 ; Gutierres et al., 2018 ).

The findings of the present study also emphasize that in all aspects of intraoperative practice, nurses have to make sure that the patient safety is the main goal and nurses are responsible for preventing injuries and promoting patient safety. Likewise, Cole et al. (2013) concluded that recognizing and correcting an inaccurate count is a basic segment of OR nurse's duty. The present study also affirmed that adherence to universal protocol is a crucial component of patient safety. Similarly, Collins et al. (2014) also declared that checklists alone cannot counteract all errors. In addition, effective comprehension of the nature of gaffes, perception of the intricate dynamic between frameworks and people, and making a just culture support a common vision of patient safety. Furthermore, the Association of periOperative Registered Nurses (AORN) recommends to articulate commitment to safety at all levels of the organization. Safety must be valued as the top priority in every healthcare organization and incentives and rewards must be provided to promote patient safety culture. In addition, AORN recognizes that the patient safety initiatives will fail in the absence of viable safety culture ( Association of periOperative Registered Nurses, 2006 ).

In the current study, the participants mentioned that everything should be set up for the surgeries including the materials and equipment in order not to delay things. These study results are in line with previous study conducted by Rose (2010) , which concluded that preoperative planning can improve surgical results and counteract unexpected issues; it improves correspondence with different individuals from the surgical team. Moreover, with insightful planning, suspensions and misperception can be effectively evaded. Additionally, Boggs et al. (2019) warrant that the hospitals are intricate frameworks and OR administration is centered on cost reduction to create efficiencies that offers value-based care, forms value control actions that support efficiencies, and improve patient access to core services. Likewise, the AORN emphasize the need for ongoing education about disinfection and sterilization techniques to improve the understanding of the improper instrument handling ( Goss, 2012 ).

The participants in our study mentioned that the instruments and equipment should be available and ready according to the specified surgery before wheeling the patient to avoid harm. Weerakkody et al. (2013) confirm that there is clear advantage in the utilization of preoperative checklist-based frameworks, by which an enormous extent of equipment-related errors can be decreased. Our study highlights that the preoperative assessment prior to intraoperative phase is vital. Consistently, Malley et al. (2015) affirm that OR nurses continually watch out for the patient and the nurses assumes a significant role in distinguishing patients’ needs and hazard factors that may influence the surgical outcome.

In the current study, almost all the participants said that the staff from different backgrounds of practice must be trained to provide uniform care to the patient. The practices must be based on policy and protocol of the hospital, and it is vital for patient and staff safety. Having an institutionalized policy that speaks the best practices is an initial move towards accomplishing patient safety ( Norton et al., 2012 ). Moreover, if the staff grasp and follow institutionalized and proficient procedures, they can counteract potential negative incidences and lead to clinical enhancements ( Shirey & Perrego, 2015 ). Standardized care at the minimum in the healthcare facility can lessen or eradicate workarounds by reaching consensus among care providers ( Gurses et al., 2012 ).

The current study suggested that uniform standards and protocol be followed by all the staff. Consistently, Brown-Brumfield and Deleon (2010) concluded that the surgical team members are in charge of utilizing every single sensible measure to secure the patient. Established guidelines, best practice proposals, and protocols are accessible and ought to be constantly pursued to diminish the probability of medication labeling mistakes and harm to the patients who depend on care provided by the nurses. Benze et al. (2021) very recently published 18 perioperative nursing scope and standards of practice that can be utilized by the nurses to follow the uniform standards of perioperative nursing practice.

The participants of the present study proclaimed that the appropriate workflow of specimen is essential and communication between surgical and laboratory team is vital for proper specimen handling. This finding is in line with the study conducted by Tracey Lee Rn (2015), which concluded that the specimen collection process depends on a human capacity, which makes it susceptible against human components and administrative impacts like time pressures. Institutionalizing a procedure, for instance, takes consistency into consideration and sets a standard by which desires for training are set.

The OR nurses in this study reported that nurses should manage their time in the workplace without compromising patient safety. They also mentioned, rushing to have quick turnaround can be injurious to staff and patients. Those findings are corroborating with findings from the literature, which concluded that the perioperative environment is one of the most challenging environment for nurses because of patient acuity, high-stress environment, production pressures, and risk of physical harm ( Morath et al., 2014 ). The participants in the study declared that complex cases cannot have 30 min of turnaround time. These findings were in line with previously described findings of Morgenegg et al. (2017) , which concluded that OR turnaround times were essentially influenced by the time of the surgical procedure, age of the patient, staffing changes, length of the surgery, and the utilization of equipment and materials requiring additional preparation time.

This study is consistent with the reviewed studies conducted on the surgical technologist's perception of teamwork and the culture of safety in the OR in Trident University International. The discoveries of the study demonstrated that teamwork had a noteworthy constructive outcome on the culture of safety. Teams with learning, specialized and non-specialized aptitudes, and safety attitudes are significant for the result of the culture of safety ( Murphy, 2018 ).

The qualitative analysis in this current study suggested that during busy schedules, fast tracking of the instruments has to be made sure to avoid any delays. This coincides with the study conducted by Weart (2014) , which concluded that the management of surgical instruments reduces the incidence of Immediate Use Steam Sterilization that is critical in the success of OR, which can positively impact patient safety goals. Improved communication and coordination between the OR and sterile processing unit must occur to bring the process under control. Understanding, managing, and improving the instrument reprocessing can have a positive impact on the safety of patients and prevents delays.

Prolonged work periods without adequate rest may contribute to diminished performance by perioperative personnel, placing both patients and workers at risk. AORN guidance statement of safe on-call practices in perioperative practice settings may assist managers and clinicians in developing policies and procedures for safe call practices ( Association of Perioperative Registered Nurses, 2005a , 2005b ).

In the current study, the participants debated that adequacy of staffing is crucial. When the OR is understaffed and there is rushing, it can affect patient safety. These findings are in line with the findings of Tørring et al. ( 2019 ) who reported that, in surgical teams, healthcare experts are exceptionally reliant and work under time pressure. It is of specific significance that collaboration is well-working so as to accomplish quality treatment and patient safety. One study also affirmed that Extreme workloads may expand patient safety dangers, and patients are adversely influenced ( Yu et al., 2019 ). The findings of Weart (2014) also affirmed that inadequate staffing can cause personnel to rush, make errors, and possibly curtail established hospital procedures. Therefore, AORN guidance statement on perioperative staffing warrants the perioperative nursing leaders to develop effective staffing plan relative to surgical patient's needs ( Association of periOperative Registered Nurses, 2005a , 2005b ).

Nurses involved in the research conveyed that the health status of the staff is vital. Nurses should be fit to work, and staff fatigue can harm the patient. This is similar to the findings of the study conducted by Seyman and Ayaz (2016) . It states that the OR can cause numerous dangers to patient and staff safety. It is suggested that in-service training on patient and staff safety issues ought to be expanded, measures ought to be taken against dangers in the OR, and the quantity of OR nurses and assistants ought to be expanded. This study agrees with the findings of Pashley (2012) who highlighted that burnout can negatively affect an individual's relationships, health, and job. If registered nurses experience burnout, incidents of sentinel events or medical errors could occur and affect patient care.

Throughout the interviews, staff training was defined clearly by most of the participants. They agreed that nurses must have adequate training related to the nursing profession, which can enhance their performance and make them more knowledgeable. These findings are in coherence with the findings of Ugur et al. (2016) , which depicts that surgical complexities on account of medical errors can be diminished when OR staff individuals are trained in patient safety. A previous quasi-experimental study conducted by Sousa et al. (2015) portray that it is the nurse's responsibility to be continuously up-to-date with scientific knowledge, and to disseminate this knowledge among their staff in order to upgrade the skills of the professionals, so that in this way, the patients can be assisted with excellence.

Theme 7: Communication With and Support to the Patient in the OR

The participants of this study explained that nurses have to communicate and establish better rapport and empathy with the patient. A study conducted by Norman et al. (2016) on “Creating healing environments through the theory of caring” declared that making a trusting association with patients enables nurses to better care for them when they are at their most susceptible condition. Building up a believing relationship can be troublesome in the perioperative care as the patient's emotional condition and nervousness levels before and after surgery vary.

Nevertheless, another study conducted on the Responsibility for patient care in perioperative practice by Blomberg et al. (2018) also declared that a typical duty in the surgical team is to take good care of and not relinquish the patient. In circumstances where patients show vulnerability about the sickness and have a need to talk before the operation, the members recounted a longing to make themselves accessible ( Kelvered et al., 2012 ). More recently, the new AORN “Guideline for team communication” provides guidance on using standardized processes and tools to improve the quality of team communication: the key points address hand overs between phases of perioperative care; a briefing to share the surgical plan; a time out to verify the correct patient, procedure, site, and side; and a debriefing to discuss what was learned and how to improve ( Link, 2018 ).

Strengths of the Study

This is the only study conducted in the United Arab Emirates to explore the understanding of the OR nurses regarding their role and responsibilities for patient care and safety in the intraoperative practice. A qualitative descriptive exploratory approach was identified as more suitable to gain insight into the participant's understanding rather than testing research idea.

Semi-structured, exhaustive interviews helped the researcher to explore the OR nurses’ understanding of their role and responsibilities for patient care and safety in intraoperative practice. The information obtained by the researcher from each nurse was of great value in terms of intraoperative patient safety. The author used several strategies to ensure methodological rigor and minimize bias such as pilot interviews, data saturation, and member checks. One of the biggest strengths of this study is the consistency of findings identified by the participants. The themes identified were mentioned by most of the participants. This gives a strong meaning to the findings.

Limitations of the Study

Being a small-scale qualitative study, this research has some limitations. The findings in the General Surgery OR may not be applicable to other OR such as Cardiology, Neurology, and Ophthalmology where the workflow varies slightly from the general surgery OR. The present study did not include surgeon, anesthesiologist, or anesthesia technicians as the aim was to explore the understanding of OR nurses regarding their role and responsibilities for intraoperative patient safety. However, these professionals could be included in studies in the future. As a novice qualitative researcher, the principal investigator had initial difficulty in the in-depth interviewing process and coding, which was guided and supported by the supervisor.

Implications for Practice

Based on these findings, as well a growing body of related literature, the nursing leadership should consider that in the study setting, despite the environment being safe and the quality of care is high, there is always room for improvement and processes. They should work on improving these aspects of care with more adaptive methods of patient safety. These study findings highlight the quality of speak-up culture of nurses when patient safety concerns arise. Speak-up culture could strengthen patient safety by guarding against mistakes and identifying and solving errors. It is imperative that nurses know and implement the most current evidence to prevent harm to patients and promote the best possible outcomes. The present study findings affirm various nursing skills for patient safety in intraoperative practice. Nurses have to possess the ability to be efficient in knowledge and skills to render safe patient care. Also, they have to work in harmony with the other members of the surgical team to deliver optimal patient safety. The findings of this study described some of the hurdles in intraoperative patient safety such as staff shortage and time pressure. If the nursing management reviews the finding, it could help to reduce the work overload and improve patient safety and quality of care.

Recommendations

The findings of this study could influence the clinical education, practice, and future research. The nursing leadership should encourage a safe environment for the patients and caregivers by establishing standardized, consistent, and measurable tools and processes to anticipate and prevent patient harm. The OR nurses should report any errors and near misses so that the OR department together with other team members could work on the aftermath of the unsafe incidences, near misses, and improve patient safety by identifying and preventing errors. Trust is the cornerstone for patient safety and quality care. Creating a culture of safety by encouraging raising concerns and being transparent is vital in intraoperative nursing care. For future research, it is recommended to apply and assess the great practices offered in this research through an intervention to improve a safe environment in the OR. Also, it is hoped that this study will provide a catalyst for future investigations and interventions that will maximize patient safety.

The issues identified by the participants in the study are directly linked to patient safety but not all are under nurse's responsibility. Also, some of the identified themes reflect the OR nurses’ understanding over other issues mainly connected to patient experience. Therefore, the aim of this study is achieved as all the themes identified as nurses were able to express their thoughts on their roles and responsibilities towards patient safety in their practice. There are opportunities for improvement based on the study findings even in a safe and high quality of care OR department. As nurses are the ones with more proximity to patients, they are in a privileged position to identify issues related to patient safety and quality of care.

The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Funding: The author(s) received no financial support for the research, authorship, and/or publication of this article.

ORCID iD: Judie Arulappan https://orcid.org/0000-0003-2788-2755

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Critical Thinking in the Operating Room: Skills to Assess, Analyze, and Act (Critical Thinking (HcPro)) 1st Edition

- Chief nursing officers - Directors of nursing - Nurse managers - Nurse educator

• ISBN-10 1601462050
• ISBN-13 978-1601462053
• Edition 1st
• Publisher HCPro Inc
• Publication date March 27, 2008
• Language English
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About the author.

Karen Gurnick, RN, BSN, has a background in critical care, post anesthesia care, inpatient care, and ambulatory surgery. She is the director of surgical services and respiratory care at Nashoba Valley Medical Center in Ayer, MA.

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• Publisher ‏ : ‎ HCPro Inc; 1st edition (March 27, 2008)
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• ISBN-10 ‏ : ‎ 1601462050
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About the author

Shelley cohen.

Although emergency nursing has been my passion for more than 35 years, I realized that many critical thinking skills cross nursing specialties. I also learned the value of nurse leadership in staff development, retention, and impact on work culture.

Combine all of the above and I have had the privilege to speak internationally on triage, leadership, and critical thinking skills. The content for these programs evolved into the release of more than 15 books and numerous articles.

I continue to work (this is my 42nd year as a nurse!) as a prn staff nurse in an emergency department in Tennessee. My clinical hours keep me grounded in the realities nurses and nurse leaders continues to face and the growing needs we have for professional development.

From authoring online triage courses to the critical thinking series as well as working with Kathleen Bartholomew on the Image of Nursing- the journey as an author has made me a better nurse.

When I do take off my stethoscope and close up the laptop, my husband Dennis and I sponsor Purple Heart heroes on our property for hunting events. This work is done through Wounded Warriors in Action Foundation (www.wwiaf.org).

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