Aseptic practice recommendations for

circulating operating theatre nurses

Teija-Kaisa Aholaakko and Eija Metsälä
practices, ensure the development of skills and make
Abstract guidelines and recommendations available at national and
Aseptic practices prevent exposure of a surgical wound to microbes, regional levels. These represent globally applied standards
operating theatre environment and personnel. The circulating nurse and recommendations for operating theatre teams to
assists the operating theatre personnel and supervises aseptic practices achieve the optimal level of technical and aseptic practices
preventing surgical site infections. In the absence of analytical tools, (Association of peri-Operative Registered Nurses (AORN),
few studies exist on intraoperative nursing-related aseptic practices. 2013). However, no direct evidence exists that these
This study introduces recommendations to assess the role of the recommendations (exceptº those for hand hygiene) reduce
circulating nurse in aseptic practices. The authors used international surgical site infections in patients (Rathnayake, 2014).
recommendations and research findings to construct a 20-item self- Developing the content and conceptual structure of these
report instrument with a demonstrated reliability across the scale. recommendations represent important steps to ensure that
The authors structured the scale based on three phases: establishment; they better address all phases of surgical procedures. Once
maintenance; and disestablishment of a sterile operating field. The developed, critically assessing and increasing the evidence
tool was tested among operating theatre and day surgery nurses, and base, and measuring the effectiveness and cost-effectiveness
compared the differences in the mean acceptance rates of aseptic of aseptic practices, becomes possible.
practice recommendations based on background characteristics. This study aimed to develop the assessment of intraoperative
College-level nurses and nurses with 15 or more years’ work aseptic practices, with the objective of studying intraoperative
experience accepted the recommendations at higher levels than aseptic practices performed by circulating nurses. The research
bachelor-level nurses and nurses with less work experience. Continual questions included:
assessment of the evidence base and comprehensive evaluation ■■ Which of the aseptic practice recommendations did nurses
represent important components in further developing the tool. A accept for circulating nurses during the establishment,
reasonable number of items covering clinical practice are necessary for maintenance, and disestablishment of the sterile field?
assessing the effectiveness and cost-effectiveness of aseptic practices, ■■ Did the Aseptic Practices among Circulating Nurses scale
and a larger response rate is needed to validate the tool in future. reliably measure acceptance of the roles of circulating
nurses in the aseptic practice recommendations?
Key words: Infection control ■ Infection prevention ■ Antisepsis
■■ Were any differences detected in nurses’ acceptance of
■ Asepsis ■ Aseptic technique ■ Surgery ■ Operating theatre
aseptic practice recommendations between hospitals,

I
working environments, education levels, work experience
n the EU approximately 4  million patients acquire in a surgical unit in general, and work experience in the
healthcare–associated infections each year. The most current position?
frequent infections include urinary tract infections,
respiratory infections, postoperative infections and Background
blood stream infections. Approximately 20–30% of these Since 1995 international recommendations for aseptic practices
may be prevented through intensive hygiene and infection have been applied and locally validated in the surgical
control programmes. Effective infection prevention is departments of a university hospital in Finland (Aholaakko,
defined as one of the key components of safe patient care 2011; Aholaakko et al, 2013). Similar to findings by Fung-
globally (EU Council, 2009; World Health Organization Kee-Fung et al (2009), challenges in their application include:
(WHO), 2011; Association for Professionals in Infection establishing trust among health professionals and health
Control and Epidemiology (APIC), 2012; European Centre institutions; collecting accurate, complete and relevant data;
for Disease Prevention and Control (ECDC), 2015). clinical leadership; securing institutional commitments; and
The EU Council (2009) has encouraged the establishing infrastructure and methodological support for
development of a specific approach to promote safe quality management.
The results of this intervention showed no improvements,
but others found an increase in surgical site infection rates
Teija-Kaisa Aholaakko, Principal Lecturer in Research, Development
after breast surgery (Aholaakko et al, 2013). Tame (2013)
and Innovation Unit, Laurea University of Applied Sciences, Vantaa; Eija
reported negative results including no behavioural changes,
© 2015 MA Healthcare Ltd

Metsälä,Principal Lecturer, Metropolia University of Applied Sciences,

Health care and Nursing, Helsinki, Finland but finding increased confidence and assertiveness after
continuous perioperative education. In a study by Sinkowitz-
Accepted for publication: June 2015 Cochran et al (2012), nursing staff became better engaged
and possessed greater knowledge of infection prevention

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 INTRAOPERATIVE ASEPTIC PRACTICE

To control airborne, blood- and body fluid–borne, contact and vector-associated contamination
of the surgical patient, personnel and environment during invasive operations

Aseptic technique Establishment Aseptic behaviour

of the
Controlled handling of sterile items and barriers Operating theatre traffic
sterile field
Controlled discussions during surgery Hand hygiene
Controlled handling of patient’s skin Prevention of contact contamination
Prevention of air-borne contamination
Maintenance Prevention of blood- and body fluid–borne
Preparation and protection of of the contamination
the patient for surgery sterile field

Preparation of the personnel

Central services of the equipment practising in the sterile field
used during the surgery Disestablishment
of the
sterile field Environmental services

Figure 1. Model for intraoperative aseptic practices constructed for quality development in the operating theatre

than other healthcare workers. In another study by Sessa et technique recommendations and a context for the perioperative
al (2011), infection prevention knowledge was significantly aseptic practices.
higher among nurses with a higher level of education. The authors then completed a cross-sectional descriptive
Studies on surgical practices demonstrate that awareness study to measure the acceptance of aseptic practice
of role-related social order represents an important aspect recommendations in 2013. Using a four-point scale (1
of operating theatre culture, at times hampering the represented strong disagreement while 4 represented strong
implementation of recommendations (Nestel and Kidd, 2006; agreement) they constructed positive and negative multi-item
Aholaakko, 2011; Tame, 2013). Disregarded recommendations statements rather than single-item rankings to avoid distorted
(Adams et al, 2011; Aholaakko, 2011), individual knowledge results and improve reliability. Items were coded using a
(Gillespie et al, 2008;Tame, 2012), and skill-based intraoperative four-point score so that higher numbers represented stronger
incidents (Angelillo et al, 1999) or errors (Flin et al, 2006; Jeffs agreement with the recommendations.
et al, 2008; Smith, 2010) persist. The authors created the data collection instrument in early
Previous studies (McGarvey et al, 2004; Timmons and 2000. In an initial study, a hard-copy questionnaire was piloted
Tanner, 2005; Gillespie et al, 2008; Richardson-Tench, 2008; among 22 operating theatre personnel unaffiliated with the
Sinkowitz-Cochran et al, 2012; Yang et al, 2012) have shown study group in the project hospital district in 2000. In total,
that the role and influence of nurses are essential to operating 17 nurses and physicians responded, assessing statements as
theatre practices. In one study, the adherence of operating easy to answer and the statements content as valid. Based
theatre personnel to aseptic practice recommendations on their feedback, the authors improved and clarified the
varied and circulating nurses found such variation stressful wording of some statements. The revised instrument was
(Aholaakko, 2011). The development of well-structured used among registered operating theatre personnel from
recommendations with a sound evidence base may improve two hospitals in 2000 and 2001. In 2001, 106 of 234 (45%)
not only infection status among surgical patients, but also the questionnaires were returned.
wellbeing of operating theatre team members. In 2013, the authors updated the initial assessment tool and
created an online questionnaire using some statements from
Methodology the initial survey based on previous recommendations (AORN,
Aseptic Practices among Circulating Nurses scale 1999). In addition, the authors formulated questions according
The authors developed the Aseptic Practices among Circulating to AORN recommendations (2013). The instrument used in
Nurses scale, a self-report instrument, following the three the present study comprised 20 statements. Owing to variations
phases of the operation: establishment of the sterile field before in the evidence base and the structure of the conceptual model,
operation; maintenance of the sterile field during the operation; a separate tool for measuring hand hygiene will be created.
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and disestablishment of the sterile field after the surgical

wound is closed. The disestablishment of the sterile field does Ethical approval
not mean that the sterile field is contaminated. Figure 1 shows The ethics board of the university hospital district and the
aseptic practice as a concept, serving a structure for the aseptic heads of medicine and nursing departments approved and

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 RESEARCH

accepted this study. Nurses were informed of the study during minimum=3.00; maximum=4.00) than a previous study
staff meetings and via email as part of the questionnaire. from 2001 using a five-item scale (a=0.564). All but one
Returning the questionnaire was considered to be informed of the recommendations were rated as highly acceptable
consent for the study. with a mean value of 3.61, with six recommendations
receiving a mean value of 3.86 or higher. One of the
Data collection recommendations focused on the selection of sterile
Online surveys were distributed to nurses from the operating items, while nine recommendations focused on aseptic
theatre units of two university hospitals between October technique when establishing a sterile field. Acceptance of
and November 2013. From a total of 242 nurses, 73 (30%) the recommendation ‘Create the sterile field less than an
responded. From Hospital 1, 16 (27%) operating theatre hour before the operation’ received a lower acceptability
nurses and 10 (21%) day surgery nurses responded after than other recommendations (mean=3.23). Removing
receiving two online reminders and a reminder from nursing this item would increase the reliability of the scale overall;
managers. From Hospital 2, response rates reached 33 of 95 however, given its relevancy in clinical practice, the authors
(35%) and 12 of 40 (30%), respectively. Two respondents did did not remove it from the analysis.
not identify their place of work and their questionnaires were When testing the scale, statistically significant differences
not completed. Missing values were not replaced and owing were found in the acceptance of recommendations according
to the low response rate, valid responses were analysed as a to the respondents’ education, general work experience and
single study group. time spent working in the current operating theatre. Senior
Among all respondents, 45% held a bachelor-level nurses with college-level education (n=38) accepted the
nursing degree, while 55% were senior nurses who had recommendations to a higher degree (mean=3.84; SD=0.201)
received a college-level degree in nursing. All but three than nurses with a bachelor’s degree (n=30, mean=3.69;
undergraduate bachelor-level nurses were registered. These SD=0.309), a statistically significant difference (p=0.045).
three represented graduating students awaiting official Acceptance was significantly higher (p=0.023) among nurses
registration upon completion of their practical placements. with 15 or more years’ work experience in a general surgical
Among all respondents, 45% had worked in operating theatre unit (n=32; mean=3.84; SD=0.242) than among nurses
units in general for 15 years or more. In terms of their current with less work experience (n=36; mean=3.72; SD=0.270).
positions, 40% of respondents had worked in their current There was a significantly higher (p=0.011) acceptance of
unit for less than 5 years, while 21% had worked in their recommendations among nurses with 5  years or more spent
current units for more than 15 years. in their current position (n=42; mean=3.84; SD=0.227) than
among nurses with less than 5 years’ work experience in their
Data analysis current surgical unit (n=26; mean=3.68; SD=0.289).
In total, the authors used 20 recommendations (none for hand
hygiene) to describe aseptic practices from the circulating Aseptic practices for maintaining a sterile field
nurses’ points of view. First, the authors completed descriptive The authors constructed a sub-scale for the ‘Maintenance
statistics to introduce the acceptability of recommendations. of a Sterile Field’ using a summated variable for seven
Second, they counted summation variables according to (7/20) recommendations. The authors found a moderate
the phases of specific operations. The aim was to construct reliability for the sub-scale (a=0.639; mean=3.58; SD=0.362;
a clinically relevant and reliable scale with three sub-scales: minimum=2.29; maximum=4.00). The reliability was higher
establishment of a sterile field; maintenance of a sterile field; and than the reliability of an eight-item scale from 2001 (a=0.620).
disestablishment of a sterile field.The authors chose meaningful There was high acceptance for recommendations on constantly
constructions with possibly high alpha (a) values. The scale supervising the sterile field, keeping doors closed and limiting
was tested by analysing the acceptance of recommendations the number of people in the operating theatre. There was less
according to the respondents’ background characteristics. The acceptance for the recommendation on limiting conversations
Mann-Whitney U-test was used to explore the differences during surgery. Only differences in the acceptance of
between ranked mean values for skewed data. For all analyses, recommendations between nurses with 15 or more years’ work
results yielding p<0.05 were considered statistically significant. experience in the current operating theatre (n=14; mean=3.76;
SD=0.272) and nurses who had worked for a shorter time in
Results the current operating theatre (n=52; mean=3.53; SD=0.370)
The authors constructed the Aseptic Practice among Circulating were statistically significant (p=0.018).
Nurses scale with an overall reliability of a=0.782. Table 1 and
the sub-scale reliability analyses show the acceptability of the Aseptic practices for disestablishing sterile field
recommendations and the characteristics of the summated The authors constructed a sub-scale for the ‘Disestablishment
variables. As a final step, the authors introduced the differences of the Sterile Field’ using three (3/20) recommendations. There
in acceptance based on background characteristics. was a moderate reliability for the scale (a=0.617; mean=3.90;
SD=0.232; minimum=2.67; maximum=4.00). In 2001, only
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Aseptic practices for establishing a sterile field one recommendation focused on the disestablishment of the
The authors coded a 10-item (10/20) summated variable sterile field. In this study, a high level of acceptance for all three
for the ‘Establishment of a Sterile Field’ sub-scale. Better recommendations was found, with mean values of more than
reliability was found (a=0.605; mean=3.77; SD=0.232; 3.8. These recommendations focused on the prevention of

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 Table 1. The Aseptic Practices among Circulating Nurses scale
Aseptic Practices among Circulating Nurses scale Mean (SD)* Cronbach’s a reliability a if item deleted
coefficient
3.44 0.782
Establishment of a Sterile Field sub-scale 3.77 0.605
Sterile indicators inspected before use† 3.95 (0.278) 0.532
Indicator gloves taken for high-risk operations† 3.95 (0.213) 0.519
Not using a sterile item after expiration date 3.94 (0.244) 0.536
Integrity of package inspected 3.89 (0.403) 0.541
Fluid transparency inspected before use† 3.89 (0.362) 0.435
Not using a damp sterile package* 3.86 (0.467) 0.513
Not using an opened sterile package* 3.73 (0.623) 0.551
Fluids and medicines decanted near use† 3.67 (0.714) 0.371
Filter needle used with liquids† 3.61 (0.748) 0.550
Sterile field created less than an hour before operation† 3.23 (1.046) 0.663
Maintenance of Sterile Field sub-scale 3.58 0.639
Sterile field constantly supervised† 3.85 (0.404) 0.589
Doors kept closed during operation 3.80 (0.403) 0.622
Number of persons in operating theatre limited during operation 3.75 (0.501) 0.600
Defects in aseptic practices documented 3.71 (0.744) 0.623
Unscrubbed person not moving between two sterile fields 3.66 (0.594) 0.572
Circulating nurse stayed in operating theatre during operation† 3.26 (0.776) 0.638
Considering the intraoperative conversation aseptically important* 3.00 (0.901) 0.564
Disestablishment of Sterile Field sub-scale 3.90 0.617
Gloves used during disestablishment of the sterile field† 3.97 (0.173) 0.388
Bloody gloves not removed outside operating theatre*† 3.91 (0.290) 0.578
Not disestablishing sterile field during wound closure*† 3.83 (0.414) 0.659
*Items
reverted into 4-point scoring so that higher numbers represent stronger agreement with the recommendations
†Appears in the 2013 updated recommendations

blood-borne infections and protecting the wound until it closes. identify the risk factors for surgical site infections (Aholaakko
Removing the item ‘No disestablishment of the sterile field et al, 2013) through a review of records from more than 1000
during wound closure’ (mean=3.83) would increase the overall breast surgery patients.Virtually no evaluative documentation
reliability of the scale; however, this item was not removed from of nursing-related aseptic practices was found. Given this, it
the analysis given its clinical relevance. was necessary to begin constructing tools for the assessment
In the analysis, there was a significantly higher (p=0.017) of intraoperative aseptic practices. In the costly work of
acceptance of the scale recommendations among senior nurses operating theatre teams, relevant, reliable and valid tools to
with a college-level education (n=37; mean=3.96; SD=0.105) perform and assess clinical performance are essential.
than among nurses with a bachelor’s degree (n=29; mean=3.83; This article introduces a tool that may serve as the starting
SD=0.317). Nurses with 15 or more years’ general operating point in developing performance, assessment, effectiveness and
department work experience (n=30; mean=3.97; SD=0.108) cost-effectiveness measurement of aseptic practices within a
accepted the recommendations at a higher rate than nurses sterile operating field to protect the surgical patient, personnel
with less work experience (n=36; mean=3.85; SD=0.292), a and environment. Through this tool, it may be possible
statistically significant difference (p=0.039). to enhance constructive communication and increase the
engagement of circulating nurses and the entire operating
Discussion theatre team facilitating multidisciplinary improvements in
This study aimed to assess the role of circulating nurses aseptic practices (Nestel and Kidd, 2006; Gillespie et al, 2008;
in intraoperative aseptic practices. Local recommendations Aholaakko, 2011; Sinkowitz-Cochran et al, 2012; Tame, 2013).
were updated according to international recommendations
(AORN, 2013), and studied among day surgery and operating Reliability of the scale
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theatre nurses. A previous qualitative study in one of the Precise and comprehensive scales accepted by health
two operating theatres (Aholaakko, 2011) highlighted the professionals are essential in measuring the performance
necessity of developing the tool given the stress associated and assessment of intraoperative aseptic practices. During
with performing aseptic practices. Another study aimed to the development of the assessment criteria, discussions must

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 RESEARCH

address the influence of statistical tools used to complete the where relevant research does not exist. When maintaining a
focus of the evaluation. In the assessment of aseptic practice sterile field, such nurses may also accept clinical reasoning
recommendations, this equates with aiming to reach only when receiving collegial support from senior nurses who rely
high reliability values. Thus, numerous clinically relevant on traditional practices.
assessment criteria may be lost. In this study, there was a Initially, interpretation of the lack of differences in
satisfactory reliability for the constructed scale (a=0.782). recommendation acceptance levels comparing nurses with 5 or
Despite the limitations, the results of this study may more years’ general work experience in surgical departments
serve as a starting point for the further development and to nurses with less than 5  years’ work experience proved
validation of assessing the role of the circulating nurse in difficult. There were differences within recommendations
aseptic practices. The reliability values for the three sub- for the establishment of a sterile field between nurses with
scales varied, indicating partial premature acceptance of less than 5  years’ and nurses with 5 or more years’ work
international recommendations. In particular, the sub-scale experience in the current setting. Sinkowitz-Cochran et
for the disestablishment of a sterile field may require critical al (2012) found better self-reported hygiene performance
review. Furthermore, a reasonable number of items (and and high staff engagement was related to recommendations
respondents) are needed for future analysis. and hospital leadership. It may be that the development of
capabilities in aseptic practices takes longer than general
Aseptic practice recommendations expectation and requires the engagement of the operating
The evidence-based aseptic practice recommendations theatre culture and staff. The development of expertise may
warrant consideration through the actions, skills and concepts begin with the establishment of a sterile field and extend to
of the nursing profession (Niiniluoto, 1993; 1996). As expertise in the maintenance and disestablishment of a sterile
technical norms they provide goals for practical action, express field. These last two stages may require longer and more
professional expertise and facilitate efficiency in practice. extensive work experience, and a greater understanding of
Recommendations cannot always be deduced from general aseptic practices than establishing a sterile field.
theory alone, but may be supported ‘from below’. According High acceptance of recommendations among nurses with
to Niiniluoto (1993), the conditions regarding technical longer work experience supports this interpretation. There
norms demand that they hold social relevance in factual was a higher acceptance of the recommendations for
situations; they should be at least potentially acceptable among maintaining a sterile field among nurses with 15 or more
some social groups; they contain evaluative and normative years’ work experience in their current unit than among
terms; and their relationship to the value system varies from nurses with less work experience. In addition, acceptance of
the positivistic ideal. They only become binding among those recommendations for the establishment and disestablishment
who accept the premise of their conditional value. of a sterile field was higher among nurses with 15 or
more years’ general work experience than among nurses
Differences in acceptance of the with less experience. It may be that managing demanding
recommendations in scale testing intraoperative aseptic practices like an expert requires time.
In this study, there were no differences in the acceptance of An explanation for this may exist in the operating theatre
aseptic practice recommendations between project hospitals culture. Senior nurses may possess more confidence and
or between operating theatre and day surgery nurses.This may assertiveness to create and express solid opinions related to
indicate solid organisational and professional support for the adhering to the recommendations in a multidisciplinary team
role of circulating nurses in aseptic practice recommendations (Gillespie et al, 2008; Tame, 2013).
(Fung-Kee-Fung et al, 2009). Instead, there were differences
in the acceptance of recommendations between nurses Limitations
with a previous college-level education and nurses with a The results are not generalisable, but should be used in the
contemporary bachelor-level education. local development of aseptic practices. The small sample size
Nurses with a bachelor’s degree reported less acceptance and the absence of medical staff in the data collection limit
of recommendations for establishing and disestablishing the transferability and comparability of the findings to earlier
sterile fields than nurses with a college-level education. The results. Owing to the low overall response rate in 2013,
difference was not statistically significant for recommendations further testing of the acceptance of the recommendations
related to maintaining a sterile field. This may indicate a lack and the scale reliability proved necessary. In early 2000, when
of relevant research or personal knowledge. It may be that development of the recommendations began, the authors
acceptance among nurses with a bachelor’s degree suffers applied both factor analysis and principal components
because they critically reflect on the knowledge base of the analysis aiming to create relevant and valid scales. None of
recommendations. These results did not support the results the analyses managed to reduce the variables to logical and
of Sessa et al (2011) which indicated that a higher level of practically meaningful factors. Finally, the survey items did
knowledge was associated with a higher level of education. not properly cover clinical performance.
In addition, Sinkowitz-Cochran et al (2012) reported that
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more knowledge was associated with a high engagement with Recommendations

clinical recommendations.Thus, it may be that the knowledge By using relevant, valid and reliable tools in the assessment
base around independent clinical decision-making among of intraoperative aseptic practices, continuously improving
nurses with a bachelor’s degree remains weaker in situations the outcomes of surgery and the capabilities of the operating

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 Conflict of interest: none
KEY POINTS
Acknowledgements: the authors would like to acknowledge all
In
n the absence of analytical tools, few studies exist on intraoperative the surgery nurses and physicians, colleagues and supervisors who
nursing-related aseptic practices contributed to this study. The authors would like to thank Vanessa
n In this study there were differences in the acceptance of aseptic practice Fuller for her contribution to the use of English in this article.Thanks
recommendations for circulating nurses according to education and general also to FORNA, EORNA and Laurea UAS from their practical
and current work experience in operating theatre units and financial contribution in developing surgical AP during the
initial AP project in early 2000.
n Continual assessment of the evidence base and comprehensive evaluation
represent important components in further developing the tool Adams JS, Korniewicz DM, El-Masri MM (2011) A descriptive study
exploring the principles of asepsis techniques among perioperative
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assessing the effectiveness and cost-effectiveness of aseptic practices, and a Aholaakko T-K (2011) Reducing surgical nurses’ aseptic practice-
related stress. J Clin Nurs 20(23-24): 3339–50. doi: 10.1111/j.1365-
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