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Learning and Teaching in the Operating Theatre: Expert Commentary from the Nursing Perspective

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• Rachel Cardwell 5 ,
• Emmalee Weston 6 &
• Jenny Davis 7  

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The operating theatre environment is dynamic, fast-paced, and challenging. Increasing complexity in modern surgical techniques and advancing technology means that patients require more intensive nursing care and interventions. Safe and effective surgical care relies heavily on the highly specialized skills and experience of operating theatre nurses who function as part of multidisciplinary teams. Nursing roles in the perioperative environment are diverse and highly specialized and continue to expand. This nursing workforce is however challenged by shortages and recruitment impacted by declining exposure of undergraduate nurses to this specialty area of practice. This chapter discusses learning and teaching in this unique clinical environment and begins with an introduction to the setting and roles of the operative team. It then discusses the challenges and approaches to learning and teaching in this specialist area of nursing practice.

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Austin Health, La Trobe University, Melbourne, VIC, Australia

Rachel Cardwell

Austin Health, Melbourne, VIC, Australia

Emmalee Weston

La Trobe University, Melbourne, VIC, Australia

Jenny Davis

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Debra Nestel

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Gabriel Reedy

School of Nursing and Midwifery, La Trobe University, Bundoora, VIC, Australia

Lisa McKenna

Faculty of Health Sciences and Medicine, Bond University, Gold Coast, Australia

Suzanne Gough

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Cardwell, R., Weston, E., Davis, J. (2021). Learning and Teaching in the Operating Theatre: Expert Commentary from the Nursing Perspective. In: Nestel, D., Reedy, G., McKenna, L., Gough, S. (eds) Clinical Education for the Health Professions. Springer, Singapore. https://doi.org/10.1007/978-981-13-6106-7_66-1

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DOI : https://doi.org/10.1007/978-981-13-6106-7_66-1

Received : 14 October 2020

Accepted : 10 June 2021

Published : 14 September 2021

Publisher Name : Springer, Singapore

Print ISBN : 978-981-13-6106-7

Online ISBN : 978-981-13-6106-7

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Operating Room Research Topic

Specialties Operating Room

Published Sep 17, 2012

I am at a surgery center for one of my clinicals. I have to do a research project and present it to the staff. My topic can be anything related to the perioperative experience and I am not sure where to begin. Any ideas for good topics that would be appropriate for nurses who have been working in the OR for years?

• + Add a Comment

canesdukegirl, BSN, RN

1 Article; 2,543 Posts

You have a myriad of things to choose from!

1. Greatest fears of the patient pre-operatively

2. Hypothermia during open abd cases-causes and effects

3. ABX usage:procedure. Why do some surgeons insist on using a certain ABX for a procedure and why do some elect not to use an ABX?

4. How noise in the OR affects induction and emergence

5. Positioning, and the importance of using gel pads/foam during surgery

6. General anesthesia v. conscious sedation

7. Consent issues with patients that do not speak English. Consent issues for prisoners. Consent issues for intubated patients that have no family to consent for them.

8. Turnover times and the effect it has on the bottom line

9. University/teaching hospitals v. community hospitals and how they differ in regards to productivity

10. Sterility issues and lack of instrumentation for cases.

11. Lateral violence in the OR and how to deal with challenging issues with personnel.

canesdukegirl-love reading your posts. Always very well thought out and have lots of information.

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Article Contents

Introduction, acknowledgements.

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Surgical incidents and their impact on operating theatre staff: qualitative study

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N Serou, S P Slight, A K Husband, S P Forrest, R D Slight, Surgical incidents and their impact on operating theatre staff: qualitative study, BJS Open , Volume 5, Issue 2, March 2021, zraa007, https://doi.org/10.1093/bjsopen/zraa007

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Surgical incidents can have significant effects on both patients and health professionals, including emotional distress and depression. The aim of this study was to explore the personal and professional impacts of surgical incidents on operating theatre staff.

Face-to-face semistructured interviews were conducted with a range of different healthcare professionals working in operating theatres, including surgeons and anaesthetists, operating department practitioners, and theatre nurses, and across different surgical specialties at five different hospitals. All interviews were audio recorded, transcribed verbatim, and analysed using an inductive thematic approach, which involved reading and re-reading the transcripts, assigning preliminary codes, and searching for patterns and themes within the codes, with the aid of NVivo 12 software. These emerging themes were discussed with the wider research team to gain their input.

Some 45 interviews were conducted, generally lasting between 30 and 75 min. Three overarching themes emerged: personal and professional impact; impact of the investigation process; and positive consequences or impact. Participants recalled experiencing negative emotions following surgical incidents that depended on the severity of the incident, patient outcomes, and the support that staff received. A culture of blame, inadequate support, and lack of a clear and transparent investigative process appeared to worsen impact.

The study indicated that more support is needed for operating theatre staff involved in surgical incidents. Greater transparency and better information during the investigation of such incidents for staff are still needed.

Los incidentes quirúrgicos pueden tener efectos significativos tanto en los pacientes como en los profesionales de la salud, entre los que se incluyen el trastorno emocional y la depresión. El objetivo de este estudio fue explorar los efectos personales y profesionales de los incidentes quirúrgicos en el personal del quirófano.

Se llevaron a cabo entrevistas semiestructuradas, cara a cara, a cirujanos y anestesistas, técnicos ( operating department practitioners , ODP) y enfermeras de quirófano de varias especialidades quirúrgicas en cinco hospitales diferentes. Todas las entrevistas se grabaron en audio, se transcribieron textualmente y se valoraron mediante un análisis temático inductivo, que implicó leer y releer las transcripciones, asignar códigos preliminares, y buscar patrones y temas en cada código, todo ello con la ayuda del programa NVivo v12. Los temas que surgieron se discutieron con un equipo de investigación ampliado para conocer sus comentarios.

Se llevaron a cabo 45 entrevistas que duraron generalmente entre 30 y 75 minutos. Se detectaron tras temas principales: el impacto personal y profesional; el impacto del proceso de investigación; y las consecuencias positivas. Los participantes recordaron haber experimentado emociones negativas después de incidentes quirúrgicos que dependían de la gravedad del incidente, del resultado en el paciente y del apoyo recibido por parte de los profesionales de plantilla. Una cultura de culpa, el recibir un apoyo inapropiado y la falta de un proceso de investigación claro y transparente pareció empeorar los resultados.

Este estudio indica que el personal de quirófano involucrado en incidentes quirúrgicos precisa más apoyo. Durante la investigación de este tipo de incidentes aún sigue siendo necesaria una mayor transparencia y proporcionar una mejor información al personal.

Medical errors are thought to affect around 16 per cent of patients admitted to hospital, with 50 per cent of these occurring during surgical procedures 1 , 2 . A ‘surgical incident’ can occur during a surgical or invasive procedure, and may result in patient harm. A recent assessment of the problem in the UK National Health Service (NHS) identified 314 reported surgical incidents in the interval between April 2019 and December 2019, with 165 due to wrong-site surgery, 91 a retained foreign object, and 58 a consequence of wrong implant/prosthesis 3 .

Health professionals have been recognized as secondary victims of medical errors 4 , 5 , defined as ‘a health care provider involved in an unanticipated adverse patient event, medical error and/or a patient related-injury, who becomes victimized in the sense that the provider is traumatized by the event’ 5 , 6 . Studies 7 , 8 have highlighted that, following a surgical incident, surgeons, theatre nurses, and other health professionals can experience emotional distress and depression, with symptoms similar to those of post-traumatic stress syndrome. A survey of 7900 surgeons indicated that, following their involvement in a surgical incident, they experienced low quality of life, anxiety, burnout, and depression in the following 3 months 5 , 6 Such experiences not only affect surgeons and their families, but can also have an adverse impact on the provision of care, clinical performance, and patient safety 4 , 5 . These surgical incidents can have enduring effects and, in some instances, the individuals may never fully recover and may consider changing profession 7 , 9–11 . Some studies indicate that an adverse event can lead to increase in use of illicit drugs 9 , addiction to alcohol, decrease in quality of life, depression, and burnout 12 , 13 .

A systematic review 14 to investigate the impact surgical incidents can have on operating theatre staff highlighted how little had been published on the impact of surgical incidents on the wider operating team beyond surgeons and anaesthetists, or how surgeons and other a health professionals might change their behaviours following a surgical incident.

The main aim of this qualitative study was to explore the psychological, emotional, and behavioural impact of surgical incidents on all operating theatre staff, and how their attitudes or behaviours might change following such events.

The study was classified as a service evaluation by a University Ethics Committee and Health Research Authority, and registered as such within the organization (research site) concerned (IRAS ID: 237980/1158905/37/907). This study was conducted at five teaching hospital sites within one large NHS Trust that provides multispecialty surgical procedures including emergency and major trauma. A recruitment pack including an invitation letter and information sheet was e-mailed to all theatre staff (medical and non-medical) working across the five hospital sites, asking them if they would be willing to participate in the research study. A range of healthcare professionals working within operating theatres (surgeons, anaesthetists, theatre nurses, operating department practitioners (ODPs), and theatre support workers) were approached and asked if they would like to participate in this study. Purposeful sampling was employed to recruit relevant health professionals working in operating theatres with varied experiences across the five hospitals. Some 129 operating theatre staff were identified through investigation records as being involved in a surgical incident and were all contacted by e-mail. The snowball sampling technique was also used to identify potential participants. Posters promoting the study were displayed on Trust noticeboards and in rest rooms. A summary of the study was also presented to medical and non-medical staff who attended any one of 4 different audit days, and three quality and safety meetings attended by staff working in different specialties, and a broad range of other staff, including patient safety advisors and managers involved in risk management and incident investigations, between March and November 2018. A summary of the study was also presented to the Trust’s Safer Surgery Committee and Trust’s Safety Culture Committee, chaired by the Trust Board of Directors, encouraging them to both promote and participate in the study. Health professionals were given the opportunity to ask the researcher questions about the study before participating.

All face-to-face interviews took place at a convenient time and location for the interviewee, and without any other individual present. A standard interview topic guide was used to help guide the interview (available on request). Questions in the topic guide were informed by a literature review, and consultation with patient safety and qualitative research experts. The interview schedule was piloted with four experienced theatre nurses for face validity, and included general questions on the possible causes of surgical incidents, the effects these incidents had on the participant, strategies they used to cope with the incident, any change in attitude and behaviour following the event, and their perspectives of the culture of learning from incidents at both an organizational and individual level, and relevant prompts. All interviews were conducted by a single researcher, audio recorded, transcribed verbatim, and analysed using a reflexive inductive thematic approach 15 with the aid of NVivo 12 (QSR International, Melbourne, Victoria, Australia) 16 , 17 . Saturation was achieved when the themes suggested by interviewees from different professional groups began to repeat themselves, and subsequent participants from the different professional group interviews yielded no major new insights. The researcher used a reflexive thematic approach by familiarity with the data through reading and re-reading the transcripts, and assigning preliminary codes to the interviews transcribed. The researcher also began to identify themes within each transcript (content analysis) 16 , 17 . Consideration was given throughout this process to the study objectives, and the identified themes of emotional and behavioural impact of surgical incidents on operating theatre staff, and how their attitudes or behaviours might change after such events. The researcher then generated an index or conceptual framework by which the raw data could be labelled and sorted. This involved identifying recurring themes and concepts, together with the terms used in the interview schedule and wider literature. A workable list of main themes and subthemes was compiled and applied systematically to the whole data set. The researcher interpreted the data and assigned a description to them. Patterns were investigated and relationships between all levels (such as personal and professional impact and nature of the incident) were noted. The researcher also began to build explanations for the recurring patterns and associations in the data. This process involved interrogating the data set as a whole to identify linkages between sets of phenomena and exploring why such linkages occurred. These linkages were displayed on a series of maps to further improve understanding and clarity.

Throughout the analysis, four other researchers independently coded a selection of interview transcripts, and compared and discussed these codes in depth with the initial researcher to reduce researcher bias. Themes or trends generated from each step of the data analysis, or any sections of data that did not support generating themes, were also discussed with the other researchers to uncover bias.

Some 45 face-to-face interviews were conducted between February 2018 and December 2018, each lasting between 30 and 75 min. Participants included eight surgeons, eight anaesthetists, 12 theatre scrub nurses, nine ODPs and eight healthcare assistants from different surgical specialties across five hospital sites ( Table 1 ). All participants described incidents that could be considered moderate in severitythere was moderate increase in treatment following surgery.

Details of study participants

ODP, operating department practitioner.

Personal and professional impact

Most of the theatre staff interviewed (36 of 45) felt that surgical incidents had both a personal and professional impact on them. One member of the junior theatre staff described how it had a ‘very big impact on personal life and on professional life’, influencing the way she worked and work-related decision-making. An ODP questioned her ability to do her job, leading to a sense of low esteem, whereas another theatre staff member described how it ‘made me doubt in my abilities to be a scrub nurse, to count, to see with my eyes, to trust what my eyes are seeing’.

Some 32 participants described short- or long-lived negative emotional impacts. In the short term, these included loss of confidence, personal life interference (social impact), anger, anxiety, sadness, worrying about their job and career progression, sickness, and depression. In the long term, negative impacts included losing trust and confidence in other health professionals, and being overcautious or risk-averse in clinical practice. The latter sometimes led to confusion and misinterpretation within the team. One general surgery consultant described feeling sad about surgical incidents that had happened in the past and having to deal with it in his own way. A vascular theatre nurse described how recalling a past incident evoked an emotion of anger and frustration: ‘ Last year a patient was anaesthetized and is on the operating table and all of a sudden during the ‘time-out’ phase of the Surgical Safety Checklist we realized that the patient did not sign the consent form. Surgery was cancelled and the patient was rescheduled. It is a massive surgical incident due to negligence from the team as no one checked the patient consent form before putting her to sleep. It really infuriated me; I was really mad on that day and even now’.

It was noted how the same or similar surgical incidents could occur more than once. One consultant anaesthetist explained that ‘we can accept that it [surgical incident] is a one-off and we aim to learn from the incident. If the same incident happens again in a month and again in two months’ time, then it is very depressing’. A theatre support worker described the range of emotions experienced when a cancer specimen was lost, including guilt, sadness, anger, and rage. The same participant felt that staff were reluctant to admit responsibility owing, in part, to a perceived blame culture.

One anaesthetic trainee recalled how the impact of surgical incidents experienced by theatre staff might be related to the associated risks of the procedure. She gave two examples: one high-risk patient who died during a procedure; ‘even though the death in theatres was termed as a surgical incident, my emotional reaction was less negative as we did everything for the patient’. In a second incident , the patient had been given a regional block on the wrong side of his leg before surgery. The operation was performed, and the patient had severe postoperative complications; ‘I was devastated, speechless and the negative emotions I had at that time were severe because it should have not happened’.

Impact of the investigation process

The majority of participants (32 of 45) highlighted a lack of transparency in how the investigative process was conducted following surgical incidents. One junior member of theatre staff explained how she was ‘not asked to do anything, not scrub, not even for simple cases’ and worried about the long-term implications for her future. Another explained how she ‘did not know what was going on’ during the investigative process, with ‘the most stressful bit being because there’s a belief around that the surgeons will always try and wriggle themselves out of it and then lay the blame on the scrub staff or on the theatre staff’.

Positive consequences

Despite the overwhelmingly negative experiences of surgical incidents, several participants emphasized how surgical incidents had a positive impact on their career and professional development. They highlighted the importance of attentiveness and cautious practice, with one junior ODP recalling: ‘I took a positive spin on it [surgical incident] of being more cautious the next time, over checking and being more thorough in my checks and I think it had a positive effect on my overall ability to perform’. One senior anaesthetic nurse explained how it had a positive long-term impact on their professional practice and theatre practices in general: ‘professionally it developed me as a practitioner, which I am now, out of that adversity it made me cautious, and from early point of my career, I was able to measure what was expected of me’.

This qualitative study explored the second-victim phenomenon with regard to healthcare professionals, especially those working in operating theatres, in the setting of the UK NHS. This study identified the profound impact of surgical incidents on medical and non-medical operating theatre staff. Consistent with previous research, participants predominantly recalled negative emotions, irrespective of their profession and years of experience 5 , 11 , 18–22 . These negative emotions could be mapped to earlier studies describing six stages to recovery for second victims 23 , with most participants in the present study experiencing immediate chaos and confusion after the surgical incident, followed by re-evaluation in isolation, seeking support, worrying about restoring personal and professional integrity, and finally moving on or surviving the surgical incident, but constantly being beleaguered by it ( Table 2 ). The majority of participants described the overall impact as long-lasting.

Examples from study mapped to six stages to recovery of Scott and colleagues 23 for second victims

This study found little difference between the impact that medical and non-medical theatre staff experienced following a surgical incident. Similar to previous studies 7 , 9 , 10 , 24 , most participants emphasized that the surgical incidents affected them both personally and professionally. The severity of the negative emotions experienced appeared to depend on the nature and severity of the incident, patient outcomes, causative factors, support received, and the investigative process. Participants felt that the negative impact was very profound after what was perceived to be a preventable or avoidable surgical incident, compared with those that were perceived as non-preventable or inevitable.

The present study found that operating theatre staff were affected both by the incident itself and by the manner in which the incident was handled, as noted elsewhere 20 , 21 , 25 . A culture of blame, inadequate support, and a lack of a clear and transparent investigation seemed to deepen and extend the impact of the original incident. Clinician-led reviews created suspicion among those being investigated, leading staff to question how much information they should disclose. Most participants commented on inadequate organizational support and, when support was received, that it was often chaotic. This study suggests that more support needs to be offered during the investigative process, and in an organized fashion, to operating theatre staff involved in surgical incidents.

Medical errors cause patient harm primarily owing to human or systemic factors 2 , 10 , 26–28 . There is a risk of human error behind every endeavour, but health professionals should be held accountable only for things under their control. Following patient safety incidents, the current practice in NHS organizations often includes system improvements, such as change of policy or clinical practice based on ‘one size fits all’ 26 , 27 , 29 . Researchers from improvement science propose complex adaptive theory, which requires the NHS hierarchy to move away from standard responses to patient safety incidents, and instead reflect on the complexity of the healthcare system and how to support clinical staff adequately 29 . The complex nature of everyday clinical work still needs to be acknowledged correctly, and that far more things get done correctly than wrongly 26 , 27 , 29 .

The importance of promoting just culture in organizations following incidents has been emphasized elsewhere 30–33 , including guidelines for NHS leaders and managers 34 . The aviation industry and military employ trained human factors experts to support organizations, managers, and staff during the investigative and learning process following safety incidents 35–38 . More work needs be to done by healthcare organizations to explore how these roles could be adopted to promote effective investigation and safe learning systems. Multidisciplinary team input to review or investigate the incidents, to improve shared learning and emphasize the importance of safety, has been suggested as a reasonable approach 27 , 39 , 40 .

Some participants in the study highlighted the positive impact that the surgical incidents had on them, which was primarily dependent on the support they received, a finding widely highlighted in previous research 4 , 5 . Resilience and adaptability are considered key to the sustainability of the workforce in complex healthcare system such as the NHS 29 , 41 .

Several institutions in the USA and Europe have developed formal second-victim support programmes that allow health professionals to cope with their emotional distress by obtaining timely support in an empathetic, confidential, non-judgemental environment 4 , 6 , 42 . The Resilience in Stressful Events (RISE) programme is a multidisciplinary second-victim work programme initiated by John Hopkins University, which supports healthcare workers who were involved in a patient safety incident 42 . Research needs to be conducted to explore how these supporting structures could be adapted for use in the NHS. A list of potential recommendations is shown in Table 3 .

Potential recommendations from study

NHS, National Health Service.

This study has a number of limitations. It was confined to staff working in either the anaesthetic room or operating theatre. Staff working in preassessment and postanaesthetic care or recovery units, who can be considered part of the surgical team, were excluded. There is a risk of self-selection bias, as health professionals chose whether or not to participate in this study, although participants varied in profession, sex, and years in practice. The extent to which the findings can be generalized across the NHS is unknown, but the present results do seem to echo the findings in other healthcare systems.

The authors thank K. Moorthy, consultant surgeon, and K. Brown, lead theatre nurse, for support and guidance to the main author during this research study; and all operating theatre staff on their contribution to, and participation, in this study.

Disclosure . The authors declare no conflict of interest.

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• health personnel
• operating room
• surgical procedures, operative
• qualitative research
• anesthetists

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Best Nursing Research Topics for Students

What is a nursing research paper.

• What They Include
• Choosing a Topic
• Best Nursing Research Topics
• Research Paper Writing Tips

Writing a research paper is a massive task that involves careful organization, critical analysis, and a lot of time. Some nursing students are natural writers, while others struggle to select a nursing research topic, let alone write about it.

If you're a nursing student who dreads writing research papers, this article may help ease your anxiety. We'll cover everything you need to know about writing nursing school research papers and the top topics for nursing research.  

Continue reading to make your paper-writing jitters a thing of the past.

A nursing research paper is a work of academic writing composed by a nurse or nursing student. The paper may present information on a specific topic or answer a question.

During LPN/LVN and RN programs, most papers you write focus on learning to use research databases, evaluate appropriate resources, and format your writing with APA style. You'll then synthesize your research information to answer a question or analyze a topic.

BSN , MSN , Ph.D., and DNP programs also write nursing research papers. Students in these programs may also participate in conducting original research studies.

Writing papers during your academic program improves and develops many skills, including the ability to:

• Select nursing topics for research
• Conduct effective research
• Analyze published academic literature
• Format and cite sources
• Synthesize data
• Organize and articulate findings

About Nursing Research Papers

When do nursing students write research papers.

You may need to write a research paper for any of the nursing courses you take. Research papers help develop critical thinking and communication skills. They allow you to learn how to conduct research and critically review publications.

That said, not every class will require in-depth, 10-20-page papers. The more advanced your degree path, the more you can expect to write and conduct research. If you're in an associate or bachelor's program, you'll probably write a few papers each semester or term.

Do Nursing Students Conduct Original Research?

Most of the time, you won't be designing, conducting, and evaluating new research. Instead, your projects will focus on learning the research process and the scientific method. You'll achieve these objectives by evaluating existing nursing literature and sources and defending a thesis.

However, many nursing faculty members do conduct original research. So, you may get opportunities to participate in, and publish, research articles.

Example Research Project Scenario:

In your maternal child nursing class, the professor assigns the class a research paper regarding developmentally appropriate nursing interventions for the pediatric population. While that may sound specific, you have almost endless opportunities to narrow down the focus of your writing. 

You could choose pain intervention measures in toddlers. Conversely, you can research the effects of prolonged hospitalization on adolescents' social-emotional development.

What Does a Nursing Research Paper Include?

Your professor should provide a thorough guideline of the scope of the paper. In general, an undergraduate nursing research paper will consist of:

Introduction : A brief overview of the research question/thesis statement your paper will discuss. You can include why the topic is relevant.

Body : This section presents your research findings and allows you to synthesize the information and data you collected. You'll have a chance to articulate your evaluation and answer your research question. The length of this section depends on your assignment.

Conclusion : A brief review of the information and analysis you presented throughout the body of the paper. This section is a recap of your paper and another chance to reassert your thesis.

The best advice is to follow your instructor's rubric and guidelines. Remember to ask for help whenever needed, and avoid overcomplicating the assignment!

How to Choose a Nursing Research Topic

The sheer volume of prospective nursing research topics can become overwhelming for students. Additionally, you may get the misconception that all the 'good' research ideas are exhausted. However, a personal approach may help you narrow down a research topic and find a unique angle.

Writing your research paper about a topic you value or connect with makes the task easier. Additionally, you should consider the material's breadth. Topics with plenty of existing literature will make developing a research question and thesis smoother.

Finally, feel free to shift gears if necessary, especially if you're still early in the research process. If you start down one path and have trouble finding published information, ask your professor if you can choose another topic.

The Best Research Topics for Nursing Students

You have endless subject choices for nursing research papers. This non-exhaustive list just scratches the surface of some of the best nursing research topics.

1. Clinical Nursing Research Topics

• Analyze the use of telehealth/virtual nursing to reduce inpatient nurse duties.
• Discuss the impact of evidence-based respiratory interventions on patient outcomes in critical care settings.
• Explore the effectiveness of pain management protocols in pediatric patients.

2. Community Health Nursing Research Topics

• Assess the impact of nurse-led diabetes education in Type II Diabetics.
• Analyze the relationship between socioeconomic status and access to healthcare services.

3. Nurse Education Research Topics

• Review the effectiveness of simulation-based learning to improve nursing students' clinical skills.
• Identify methods that best prepare pre-licensure students for clinical practice.
• Investigate factors that influence nurses to pursue advanced degrees.
• Evaluate education methods that enhance cultural competence among nurses.
• Describe the role of mindfulness interventions in reducing stress and burnout among nurses.

4. Mental Health Nursing Research Topics

• Explore patient outcomes related to nurse staffing levels in acute behavioral health settings.
• Assess the effectiveness of mental health education among emergency room nurses .
• Explore de-escalation techniques that result in improved patient outcomes.
• Review the effectiveness of therapeutic communication in improving patient outcomes.

5. Pediatric Nursing Research Topics

• Assess the impact of parental involvement in pediatric asthma treatment adherence.
• Explore challenges related to chronic illness management in pediatric patients.
• Review the role of play therapy and other therapeutic interventions that alleviate anxiety among hospitalized children.

6. The Nursing Profession Research Topics

• Analyze the effects of short staffing on nurse burnout .
• Evaluate factors that facilitate resiliency among nursing professionals.
• Examine predictors of nurse dissatisfaction and burnout.
• Posit how nursing theories influence modern nursing practice.

Tips for Writing a Nursing Research Paper

The best nursing research advice we can provide is to follow your professor's rubric and instructions. However, here are a few study tips for nursing students to make paper writing less painful:

Avoid procrastination: Everyone says it, but few follow this advice. You can significantly lower your stress levels if you avoid procrastinating and start working on your project immediately.

Plan Ahead: Break down the writing process into smaller sections, especially if it seems overwhelming. Give yourself time for each step in the process.

Research: Use your resources and ask for help from the librarian or instructor. The rest should come together quickly once you find high-quality studies to analyze.

Outline: Create an outline to help you organize your thoughts. Then, you can plug in information throughout the research process. 

Clear Language: Use plain language as much as possible to get your point across. Jargon is inevitable when writing academic nursing papers, but keep it to a minimum.

Cite Properly: Accurately cite all sources using the appropriate citation style. Nursing research papers will almost always implement APA style. Check out the resources below for some excellent reference management options.

Revise and Edit: Once you finish your first draft, put it away for one to two hours or, preferably, a whole day. Once you've placed some space between you and your paper, read through and edit for clarity, coherence, and grammatical errors. Reading your essay out loud is an excellent way to check for the 'flow' of the paper.

Helpful Nursing Research Writing Resources:

Purdue OWL (Online writing lab) has a robust APA guide covering everything you need about APA style and rules.

Grammarly helps you edit grammar, spelling, and punctuation. Upgrading to a paid plan will get you plagiarism detection, formatting, and engagement suggestions. This tool is excellent to help you simplify complicated sentences.

Mendeley is a free reference management software. It stores, organizes, and cites references. It has a Microsoft plug-in that inserts and correctly formats APA citations.

Don't let nursing research papers scare you away from starting nursing school or furthering your education. Their purpose is to develop skills you'll need to be an effective nurse: critical thinking, communication, and the ability to review published information critically.

Choose a great topic and follow your teacher's instructions; you'll finish that paper in no time.

Joleen Sams is a certified Family Nurse Practitioner based in the Kansas City metro area. During her 10-year RN career, Joleen worked in NICU, inpatient pediatrics, and regulatory compliance. Since graduating with her MSN-FNP in 2019, she has worked in urgent care and nursing administration. Connect with Joleen on LinkedIn or see more of her writing on her website.

Plus, get exclusive access to discounts for nurses, stay informed on the latest nurse news, and learn how to take the next steps in your career.

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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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