EMPIRICAL STUDIES doi: 10.1111/scs.

12532

Enhancing patient safety in the operating theatre: from the

perspective of experienced operating theatre nurses

Eydis Ingvarsdottir RN, MS (OTN)1,2 and Sigridur Halldorsdottir RN, MSN, PhD (Professor and Head)1
1
Faculty of Graduate Studies, School of Health Sciences, University of Akureyri, Akureyri, Iceland and 2Akureyri Hospital v. Eyrarlandsveg,
Akureyri, Iceland

Scand J Caring Sci; 2017 each moment, making contact with the patient and
recognising how the patient loses all control by being
Enhancing patient safety in the operating theatre:
anaesthetised or sedated and is, therefore totally depen-
from the perspective of experienced operating theatre
dent on OT staff. It also involves the OTN navigating the
nurses
patient as safely as possible through the perioperative
process by careful preparation, the use of protocols and
The study’s rationale: Surgical care is an extensive compo- checklists and taking measures to prevent complications
nent of modern health care, but patient safety issues and and harm. Moreover, it involves contributing to a culture
complications of surgery have been identified as a major of safety by improving work conditions in the OT. Cer-
cause of death and disability. tain competencies of the OTN are essential for the
Objective: The aim of this study was to identify, from the enhancement of patient safety in the OT. These involve
perspective of experienced operating theatre nurses both nontechnical and technical competencies.
(OTNs), how patient safety in the operating theatre (OT) Conclusions: Constantly managing risk and preventing the
can be enhanced. OT patient from harm is essential according to the expe-
Research methodology and methods: In this phenomenologi- rienced OTNs, who are in a key position to identify
cal study, 14 individual interviews were conducted with threats to patient safety and should be empowered to
a purposive sample of 11 participants: ten women and enhance patient safety as a constant endeavour.
one man. Work experience as an OTN spanned 10–
40 years. Mean experience was 16 years. Keywords: patient safety, operating theatre, operating
Results: The enhancement of patient safety in the OT theatre nurses, perioperative nursing, phenomenology,
from the perspective of the experienced OTNs is a con- interviews.
stant endeavour of managing risks and preventing patient
harm it involves respecting the vulnerability of the Submitted 3 March 2017, Accepted 5 September 2017
patient in the OT by being attentive to the patient at

complications and mortality remain too high (1). Patient

Introduction
safety has been defined as reduction of risk of unneces-
The World Health Organization (WHO) addresses the sary harm associated with delivery of health care to a
issue of patient safety in the operating theatre (OT) in minimum (2) as well as the prevention of errors and
the report Safe Surgery Saves Lives, in which complica- avoidable adverse events, to protect patients from injury
tions related to surgical care are identified as a major (3). Eighty different tasks relating to safe and effective
cause of death and disability worldwide (1). The report care in the OT have been identified that need to be com-
states that unexpected, major complications arise in 3– pleted by the surgical team for successful surgery (4).
22% of surgical procedures, that the death rate is esti- Risk cannot be eliminated from healthcare delivery, but
mated as 0.4–0.8% in industrialised countries and that a increased awareness and effort should be put towards
large proportion of these complications may be pre- managing, controlling, responding to and decreasing risk
vented. Progress has been made regarding patient safety in healthcare settings (5).
in the OT in recent decades, but the rates of The demands for effectiveness and productivity are
high in the OT, and such demands can lead to an array
Correspondence to: of unexpected events, incidents and threats to patient
Eydis Ingvarsdottir, Akureyri Hospital v. Eyrarlandsveg, 600 safety. The surgical team is under pressure to perform
Akureyri, Iceland. their work with maximal efficiency in a minimal amount
E-mails: eydisi@icloud.com and ei0708@sak.is of time. Stress, problems and interruptions can also affect

© 2017 Nordic College of Caring Science 1

2 E. Ingvarsdottir, S. Halldorsdottir

the performance of the team, lead to increased surgical

Data collection and analysis
time and increased risk of unexpected events and, there-
fore, negatively affect patient safety in the OT (6). Suc- Data were collected through individual interviews and
cessful surgery does not only depend on the technical analysed in order to find the essence of patient safety
aspects of the work, which has received much attention enhancement in the OT from the perspective of experi-
during professional training and education, but it also enced OTNs. Data collection and analysis were performed
depends on effective communication (7, 8). Training and according to the 12 steps of the research process accord-
experience makes each individual team member more ing to the Vancouver School (see Table 1). In the Van-
competent in managing risk and ensuring patient safety couver School, data analysis is essentially a within-case
(5). Certain nontechnical skills, situation awareness, analysis (steps 1–7) followed by a cross-case analysis
communication, teamwork, task management and coping (steps 8–12). In every step, the primary researcher went
with stress have been identified as key aspects of success- through the research process of the Vancouver School
ful performance as an OTN (9). Research has shown that (see Table 1).
OTNs strive to combine the nursing care of their patients The first step in a Vancouver School phenomenological
with the highly technical aspects of their work (10, 11). study is selecting dialogue partners (the sample). Eligibil-
Nursing in the OT revolves around ensuring the delivery ity for participation was based on present employment as
of safe and continuous care, in which trust is built with an OTN and extensive OTN experience. A purposive sam-
the patient and a safe OT environment is created in the ple of participants was chosen, based on the aims of the
OT and throughout the surgical process (9). study and the research question. The reason for the
In a definition of the core elements of perioperative choice of sample is because purposive sample is empha-
nursing, patient safety was found to be a fundamental sised in the Vancouver School, that is to select partici-
element of OT nursing care (11). In another study, pants who have extensive experience of the
hospital nurses regarded patients as ‘always at risk’ in phenomenon and are most likely to provide rich infor-
a hospital and considered patient safety as their main mation about it. Participants were found through various
role (12). Similar results were also found in a study of ways of recruiting participants. To further explain the
OT nursing care in which OTNs emphasised the ways recruiting process, a clinical specialist in perioperative
they ensured the continuity of patient care and man- nursing contacted potential participants, of whom five
aged risk factors while at the same time making con- became participants. The primary researcher also con-
tact with the patients and protecting their dignity tacted potential participants eligible for participation via
within the OT (13). personal e-mail messages or private Facebook messages,
The aim of this study was to explore the enhancement of whom five became participants. One participant, who
of patient safety in the OT from the perspective of experi- had heard about the study, contacted the primary
enced OTNs. The research question was: ‘How can researcher directly and volunteered to participate and
patient safety be enhanced in the OT from the perspec- became a participant. Altogether 15 OTNs responded and
tive of experienced OTNs?’ agreed to participate. Of these, only 11 were chosen to
become participants in order to better preserve anonym-
ity. Of these 11, five were previously known by the pri-
Research methodology
mary researcher.
The Vancouver School of phenomenology, a unique The second step is silence. Because the study is a process,
blend of hermeneutic phenomenology and construc- this reflective silence is re-entered repeatedly throughout
tivism (14), was chosen as the research approach for the study (14). In the silence, the primary researcher
answering the research question. This research methodol- reflected on preconceptions about the phenomenon to
ogy is intended to increase the understanding of human identify own experience, ideas and thoughts on the sub-
phenomena, in this case the enhancement of patient ject, and wrote them down. Throughout the study, the
safety in the OT from the perspective of experienced primary researcher kept a reflective journal of her own
OTNs. As applies to most studies based on phenomeno- thoughts about the study that was enfolding.
logical traditions, this study is based on the philosophy of The third step of the Vancouver School involves open-
holism and existential psychology, as well as on the pre- ended in-depth interviews. The first author, the primary
mise or theory that reality is individually constructed as a researcher, conducted all the interviews. Data were col-
result of lived experience (15). The Vancouver School is lected through individual interviews, conducted in pri-
one of the few phenomenological schools based on vate, either at the home of the participants or at private
Ricoeur and has been widely used in nursing research offices. Each interview took 30–60 minutes. Eleven par-
(16). The number of participants within the Vancouver ticipants were interviewed, 10 women and one man,
School is typically 5–15 and the number of dialogues or aged 36–61 years, with a mean age 49 years. The experi-
interviews at least 10 (14). ence working as an OTN spanned 10–40 years. Mean

© 2017 Nordic College of Caring Science

 Enhancing patient safety in the operating theatre 3

Table 1 The 12 steps of the research process according to the Van- the operating theatre, what comes to mind?’ and ‘How
couver School of doing phenomenology (18) do you see the role of the OTN when it comes to patient
safety?’ Each interview was audio-taped and transcribed
Steps of the research process What was done in the current study verbatim. Interviews were conducted over a 4-month
Step 1. Participant selection Eleven participants were selected period, from January to April of 2016. Eleven interviews
through purposive sampling were conducted. Three participants were interviewed
Step 2. Preparation of the Preconceived ideas were analysed again, using shorter interviews, to seek clarification on
mind, silent reflection and put aside specific questions. Thus, 14 interviews were conducted
Step 3. Data collection Participants interviewed, one or two for the study.
interviews, a total of 14 interviews Steps 4–6. After the interviews had been recorded
Step 4. Beginning data Notes taken after each interview. and transcribed the transcripts were analysed for main
analysis Each interview was transcribed themes and subthemes through thematic analysis.
verbatim. Preliminary coding of
Codes, for example focus, concentration, time, trust,
each interview
were extracted from the transcripts (deconstruction).
Step 5. Coding and themes Analysis of codes, arranged into
Those were then arranged into themes, for example
themes in order to capture the
essence of the experience of each vulnerability of the patient, dangers in the environ-
participant ment (reconstruction). The findings for each partici-
Step 6. Constructing of Organisation of codes and themes pant were constructed into an analytic framework, in
individual analytic from each interview into accordance with steps 4 through 6. The primary
frameworks individualised analytic frameworks researcher repeated this procedure for every partici-
Step 7. Individual verification Each individualised framework pant, constantly repeating Steps 1–6 until a holistic
verified by the relevant participant understanding of each participant’s experience was
Step 8. Final analytic Each individual framework compared constructed.
framework constructed. with the others and used to
In Step 7, the primary researcher verified each case
Developing the essential construct a final analytic
construction with the relevant participant and
structure of the framework, the essential structure
repeated this procedure for every participant. This is
phenomenon of the phenomenon
Step 9. Comparison of the Transcripts revisited and compared one of the main strengths of the Vancouver School
essential structure with the to the final essential structure of because the researcher’s interpretation regarding each
research data the phenomenon participant needs to be verified by the relevant
Step 10. Construction of the Constantly managing risks and participant.
overarching theme of the preventing harm to the OT patient: Step 8. After the primary researcher’s initial work, both
study The essential structure of researchers were involved in analysing the data. The pri-
enhancing patient safety in the OT mary researcher went into a dialogue with the second
from the perspective of experienced author about the preliminary findings. All possible varia-
OTNs
tions were explored independently and together and after
Step 11. Final verification The final analytical framework was
much deliberation the essential structure of the enhance-
verified by three participants of the
ment of patient safety in the OT was constructed. This
study
Step 12. Multivoiced Results of the study written up, process took about 2 months.
reconstruction using direct quotes from all Step 9. The primary researcher then performed step 9,
participants to ensure credibility ensuring that the findings were based on the actual data
and how the results reflect the data by rereading all the transcripts and comparing them with
the findings.
OP, operating theatre; OTN, operating theatre nurses.
Step 10 is about constructing the overarching theme of
the study which was constructed by both authors as
‘constantly managing risks and preventing harm to the
experience was 16 years. Data collection was stopped OT patient’ which was deemed to be the essence of
when data saturation was reached and no new informa- enhancing patient safety in the OT from the perspective
tion was obtained as judged by the primary researcher. of the experienced OTNs since the OTNs emphasised that
During the interviews, the primary researcher had an this needs to be a constant endeavour.
interview guide but strived to ask open questions and Step 11. The results and the conclusions were then ver-
encourage the participants to express themselves freely, ified by three of the participants in a face-to-face meeting
also seeking confirmation of emerging themes and prob- to increase the validity of the findings.
ing further into individual topics arising during the inter- Steps 12. In writing up the findings, the participants
view. Interview questions were for example: ‘Tell me were quoted directly to increase the trustworthiness of
about your experience and thoughts on patient safety in the findings and conclusions.

© 2017 Nordic College of Caring Science

4 E. Ingvarsdottir, S. Halldorsdottir

for and attempt to control several risk factors and poten-

Results
tially harmful stimuli that the patient can be exposed to
The main result of the study was, according to the expe- in the OT, similar to the homeostatic mechanisms con-
rienced OTNs, the balancing act of the OTNs constantly trolling the body’s internal physiology. They thought of
managing risks and preventing the OT patient from harm in themselves as supervisors, overseeing challenges and cir-
which the patient is the primary focus throughout the cumstances in order to prevent complications and harm.
entire perioperative period. The participants emphasised Risk management and prevention, with the patient
that this effort needs to be a constant endeavour. In always as the primary focus, were considered one of the
order to enhance patient safety in the OT, the OTNs had main roles of OTNs. A distinction could be made between
to be attentive to four main areas of concern, respecting environmental risk factors and risk factors pertaining to
the vulnerability of the patient, navigating the patient as the patient’s condition. The challenges came from inside
safely as possible through the perioperative process, con- the OT, due to the technical environment, including sur-
tributing to a culture of safety within the OT and having gical challenges, as well as from the physical and mental
some essential competencies as an OTN. The main find- states of the patients. The management of individual
ings are illustrated in Fig. 1. units or healthcare facilities posed challenges, as well as
the conditions provided for healthcare delivery.

Enhancing patient safety in the OT: Constantly managing

risks and preventing harm Respecting the vulnerability of the patient

The overarching theme of the study of enhancing patient The OTNs emphasised how vulnerable the patient is
safety in the OT is constantly managing risks and preventing when arriving at the OT for surgery and how they
harm. The OTNs considered it their role to compensate needed to respect this vulnerability, which involved two

Figure 1 Enhancing patient safety in the operating theatre by managing risk and preventing harm.

© 2017 Nordic College of Caring Science

 Enhancing patient safety in the operating theatre 5

main aspects: being attentive to the patient at each important factor in this respect. This included informa-
moment and making contact with the patient. tion relating directly to the patients as well as informa-
tion regarding the planned procedures and operations.
Being attentive to the patient at each moment. All control is Misleading information or lack of information negatively
taken away from patients, as they are anaesthetised or affected teamwork and cooperation. It was vital that
sedated and they become totally dependent on the surgi- information was correct and readily available to everyone
cal team and their capabilities. The OTNs asserted how within the team. Improved access and flow of informa-
they strived to live up to this responsibility, with respect tion as well as increased feedback regarding their work
for patients and being attentive to them and their indi- they felt could have a positive effect and serve to
vidual needs as a focal point at each moment. improve the quality of care delivered in the OT. The
OTNs prepared for their work by reviewing the patients’
Making contact with the patient. The OTNs had limited medical history and health conditions, as well as by being
time to make contact with their patients, gain their trust knowledgeable about the relevant protocols and check-
and convey a sense of caring. They strived to evaluate lists and by setting up for surgery and ensuring that all
the needs of each patient while being aware of their necessary tools were at hand. Thorough preparation of
physical and mental state and meet their needs for pres- each patient as well as the OT and provisions necessary
ence and reassurance. These brief moments provide valu- for surgery were an important part of the OTNs work.
able opportunities to influence the patient’s perception Because many factors could influence this process, being
and experience of being in the OT. One of the roles of ready for change and capable of reacting to change was
the OTNs was seen to provide sense of caring emphasis- also considered very important.
ing patients’ safety and mental well-being. OTNs also
emphasised that it was every patient’s right to have the Using protocols and checklists. Effectively using established
full attention and focus of the operating team, as well as work protocols and checklists as tools to ensure the con-
being thought of as an individual. tinuity and safe delivery of care was generally considered
You don’t have a machine; you have a living, important to patient safety. These applied to basic ele-
breathing person, and it doesn’t take a big mistake ments of nursing care in the OT as well as directions and
to put a life at risk (J). guidelines regarding individual tasks relating to patient
care and preparations. The OTNs used these aides to
maintain control of the complex environment of the OT,
Navigating the patient through the perioperative process
as well as to uphold professional standards and help to
The process through which the OTNs guided the patient meet the many challenges of their work, both related to
began with the patient’s arrival for surgery and lasted the patient and to different surgical procedures and cir-
throughout the completion of the procedure and until cumstances. The WHO’s Surgical Safety Checklist was
the patient was delivered to the next point of care, often mentioned in this context and considered as a valu-
including oversight of various aspects of the process and able tool. Despite the widespread, formal agreement on
considerations regarding safety issues. In this way, the the usefulness of established work protocols, guidelines
OTNs acted as navigators, guiding the patient through the and checklists and their usefulness in practical work, the
perioperative period. The roles of the OTNs in following OTNs pointed out how common sense also had to be
the patient through the surgical process were twofold: applied. It was considered necessary to be able to adjust
direct nursing care of the patient, with regard to both the procedures according to needs and not be too literal
physical and mental well-being, and tasks linked to the in their usage and interpretation. The protocols had to be
delivery of the surgical procedure. In this navigation pro- of practical use to the OTNs and not have a life of their
cess, communication and teamwork was a recurring topic own. This is where the professional insight of the OTNs
emphasised regarding the enhancement of patient safety had to be applied. Increased training and experience
and constructive communication and coordination, as enabled them to adjust the protocols and guidelines to
well as communication difficulties and factors compro- their needs in order to ensure patient safety, without
mising good communication and teamwork were fre- making the rules irrelevant. There seemed to be an infor-
quently mentioned. Navigating the patient through the mal agreement on such adjustments among the OTNs.
perioperative process involved three main aspects: careful ‘With some rules, there is a mutual understanding that
preparation, effectively using established work protocols they are bent’ (E). However, it seemed that some proto-
and checklists, and preventing complications and harm to cols, regarding the daily work of the OTNs’ directly, were
the patient. issued without consulting them. Such protocols were
Careful preparation was essential in order to navigate sometimes not applicable to the work environment or
the patient through the perioperative process. Access to were idealistic and impossible to follow, making them a
correct and reliable information was considered a very nuisance and creating uncertainty. Examples of such

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6 E. Ingvarsdottir, S. Halldorsdottir

protocols were cited in the interviews and pointed out The OTNs felt that constant interruptions should be
how, when something is not in accordance with reality, decreased and work conditions improved to enhance
it becomes a hindering factor. patient safety.
I think there are too many people who are inventing Interruptions and distractions, they are a problem.
such stuff, and sometimes we are making rules about The phones ring constantly, people are coming and
how we want things to be, not how they really work going, and there is a lot of talking in the operating
(E). room, by others than those who are concentrating
Preventing complications and harm was mostly linked to on their work. This is distracting, and it increases the
the OTNs’ reflections on adverse events and unexpected risks of making mistakes. Distractions during surgery
incidents. It seemed that the documentation of adverse are way too common, and they are a problem and a
events was not consistent, and the processing of such threat to patient safety (D).
documentation was incomplete, not enabling the OTNs Part of contributing to a culture of safety was con-
to make necessary reviews and improve their work, in tributing to an effective and multidisciplinary team,
order to make the delivery of perioperative care safer and which was considered a key to patient safety and suc-
more efficient. Follow-up was limited as well as opportu- cess in the OT. In order for the surgical team to work
nities to talk through difficult or sensitive issues. Formal effectively, it was important that team members knew
opportunities for open and honest discussions, where the and respected their role within the team and worked
surgical team could reflect on the need for improvement, together towards a common goal, with the patient’s
as well as focus on building a positive and supportive safety as the focal point. The OTNs emphasised the
work environment and emphasising the strengths of the importance of speaking their mind and opening up if
surgical team, were lacking. There seemed to be some something was going wrong or improvements could be
confusion and uncertainty around the definitions of made. This was important, even if it was not always
adverse events and incidents, including what should be likely to be popular. ‘Look, I don’t mind being unpop-
documented as such and by whom. These decisions often ular, if it’s in the patients best interest (E)’. To have a
seemed to be made by individual assessment, not specific voice, to take the initiative and speak up on behalf of
guidelines. There also seemed to be a tendency not to the patient, was considered a vital part of patient safety
document adverse events and incidents, as the purpose and a contribution to effective teamwork. However, the
of the documentation was not obvious or because of a OTNs also recounted how difficult or disruptive individ-
fear that the information could be used to look for scape- uals within the team could have a detrimental effect
goats or point fingers at individuals. This fear of being on team performance, and how such behaviour was
made a scapegoat or assigned blame was considered a too often tolerated. Uncertainty related to the patient’s
real threat to patient safety in the OT. condition or the surgical procedure was a part of the
work environment in the OT and the provision of sur-
gery and the OTNs felt they needed to be able to man-
Contributing to a culture of safety in the OT
age this uncertainty.
The OTNs talked at length about the importance of im-
proving work conditions in the OT and thus contributing to Essential competencies of OTN. The essential competencies
a culture of safety as part of enhancing patient safety in of the OTN important for enhancing patient safety in the
the OT. One of the main factors in improving work con- OT were considered manifold. These include both non-
ditions was decreasing stress, interruptions and distrac- technical and technical skills.
tions. The OTNs’ experience was that the work was very Nontechnical skills the OTNs emphasised as part of
stressful, that stress and pressure were increasing and enhancing patient safety were having discipline, organi-
that patient acuity seemed to be increasing with worsen- sation skills and focus, intuition, flexibility, creativity and
ing general health status of patients. Furthermore, staff- interpersonal skills, as well as having serenity under pres-
ing issues, such as understaffing and lack of sufficiently sure and the ability to cope with stress. These were also
trained staff, were a great concern to the OTNs, and this being observant, able to prioritise and ‘read the environ-
was thought to have a negative effect on patient safety in ment’ as well as having a holistic view of the patient and
the OT. This caused considerable stress and relentless of the situation.
demands for more efficiency and speed, in the light of Technical skills, such as manual dexterity, tenacity and
long waiting lists. The OTNs were concerned that these resilience in difficult and demanding work conditions,
pressures were a threat to patient safety and emphasised were also mentioned.
the importance of decreasing understaffing. The working The OTNs mentioned that these competencies, both
environment was characterised by time pressures and on nontechnical and technical, should be nurtured in profes-
performing efficiently but also by understaffing, work sional education and continuing education for OTNs.
conditions and constant interruptions and distractions. Proper training and varied experience were generally

© 2017 Nordic College of Caring Science

 Enhancing patient safety in the operating theatre 7

considered key elements, providing the ability to deliver teamwork climate enables the surgical team to manage
high quality care in the OT for enhancing patient safety. challenging moments and risk.

Discussion Having a voice as an OTN

Within the overarching theme of the study, the constant The OTNs regarded their ability to voice their concerns
endeavour of managing risks and preventing the OT patient and opinions regarding the delivery of care as an essen-
from harm, the experienced OTNs identified four main tial part of enhancing patient safety. This was, however,
aspects for the enhancement of patient safety in the OT: influenced by the situation and the atmosphere within
respecting the vulnerability of the OT patient, navigating the team. The OTNs pointed out how difficult or disrup-
the patient as safely as possible through the perioperative tive individuals within the team could have a detrimental
process, contributing to a culture of safety in the OT and effect on team performance, and how such behaviour
the essential competencies of the OT nurse for the was too often tolerated. Such behaviours negatively
enhancement of patient safety. affect the work environment and compromise patient
safety (20). The results of a study on collegiality and peer
monitoring among nurses by Padgett are partly contradic-
The vulnerability of the OT patient in a risky environment
tory to the findings of the present study. Padgett found
The results of the present study, with the vulnerability that nurses avoid criticising the work of colleagues, creat-
of the patient in the OT and prevention from harm as ing mutual tolerance and an atmosphere in which any
prominent themes, are consistent with the results of a comments made are taken as personal attacks. In this
study of hospital nurses managing risk (12). This is also atmosphere, it is easier to keep silent about concerns and
in harmony with the results of a study on healthcare worries (21). However, the OTNs emphasised the impor-
providers’ attitudes towards risk (5). The OTNs empha- tance of speaking up and voicing concerns even if such
sised using their limited time with the patient to create comments were not well received, in the interest of
a feeling of security, caring and being in capable and enhancing patient safety.
competent hands. This is also in accordance with the
concept analysis on the feeling of safety during hospi-
Demanding working conditions
talisation, in which the author reaches the conclusion
that in order to feel safe, the patient needs to perceive The OTNs described immense time pressures and demands
a sense of security and freedom from harm, by being on their attention, but also the importance of being able to
cared for and experiencing trust, presence and knowl- concentrate on their work, in the interest of patient safety.
edge (17). Such results can also be found in studies by Groves et al.
(12) and Bunkenborg et al. (22) pointing out how heavy
work demands and pressures can negatively influence
Navigating the patient as safely as possible through the
patient safety. Moreover, Chan et al. (23) illustrate how
perioperative process
nurses experience working in time-pressured environ-
The OTNs saw themselves as navigators, navigating the ments, while having to fulfil various work demands, and
patient as safely as possible through the perioperative how prioritising different tasks to make their daily work
process. This enabled them to follow up on safety issues more efficient was prominent among nurses. In the pre-
and the well-being of the patients. This is consistent with sent study, pressure and demands seemed to characterise
the results of a study on OTNs’ perceptions of caring in the working conditions of the OTNs, in the light of perfor-
perioperative practice, in which the OTNs describe how mance demands, staffing difficulties, heavy patient loads
they follow the patient throughout the entire process, and working environments full of interruptions. Thus, it
thus ensuring the continuity of care and watching out seems obvious how low staffing levels and lack of suffi-
for the patient (13). These results are also consistent with ciently trained staff can threaten patient safety, as was
the findings of a study on nursing care in the OT, in pointed out by the OTNs in the present study. Every day
which maintaining the continuity and safety of care, cre- was a struggle to achieve balance between using time to
ating a sense of well-being and safe conditions were con- attend to safety issues as opposed to ensure efficiency and
sidered the goals of intra-operative nursing care (18). In saving time in the OT similar to that presented in the study
the navigation process, communication and teamwork by Høyland et al. (24). Research has illustrated the effects
was a recurring topic emphasised regarding the enhance- of stress on performance in the OT. Stress can be related to
ment of patient safety in the present study. Research has technical problems, problems regarding the patient, com-
shown how communication in the OT can greatly affect munication breakdowns, interruptions and even personal
patient safety (7, 8), and Bogdanovic et al. (19) point out issues or the instruction of students (25, 26). The various
how coordination and adaptation as well as a positive interruptions identified by the OTNs were considered as

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8 E. Ingvarsdottir, S. Halldorsdottir

stressors and had the potential to negatively affect patient nursing found that excellent perioperative nursing per-
safety but also seemed to characterise their work environ- formance was characterised by flexibility and an out-
ment. Similar working environments are described in the standing ability to combine the technical aspects of the
study of intra-operative interruptions and distractions (6). work as well as the understanding of individual patients
and their overall situation. Situational awareness, com-
munication, teamwork, leadership, fatigue management,
Established work procedures and checklists
effective task management and coping with stress have
The OTNs emphasised the value of having established been identified as important characteristics for OTNs (9,
guidelines, checklists and protocols, as useful tools to 35, 36). The OTNs mentioned that both nontechnical and
enhance patient safety. The Surgical Safety Checklist technical skills should be nurtured in professional educa-
published by WHO was regarded as a particularly useful tion and continuing education for OTNs. They considered
tool regarding safe delivery of care in the OT. This view proper training and varied experience key elements. This
has also been illustrated in other studies in which the view supports those in other studies in that there is
checklist was widely used, in order to maintain patient increasing recognition of the need to train and assess
safety but also to aid in the efficient use of time in the nontechnical skills in the OT (37–39) and not only social
OT (27). Such protocols were sometimes implemented and cognitive capabilities but also emotional ones (39).
without consulting the OTNs or were difficult to put to and the study by Koh et al. (40) indicates that experi-
use in practical work. Padgett (21) has pointed out how ence positively affects OTNs nontechnical skills and that
this can lead to the protocols being ignored or their use experienced OTNs have greater resistance to interruptions
becoming subject to personal preference. Such tendencies than novice OTNs. Professionalism and experience were
were also found in the present study. In this context, it is also considered important for OTNs with regard to
interesting to view the results of Szymczak on the effects enhancing patient safety in the OT. This is in accordance
of the usage and interpretation of the concept of ‘safety with the results of a study of the effect of professionalism
culture’ (28). in nursing and how it influences the performance of clin-
ical monitoring and judgements (22).

Ineffective dealing with adverse events and incidents

Strengths and limitations
The importance of incidence reporting has been widely
identified as a means towards increasing patient safety The study is not intended to generalise about the role of
(29, 30) as well as the importance of support from man- OTNs in the enhancement of patient safety in the OT but
agers, continuous education, feedback and open commu- to be a part of the ongoing and important discussion on
nication regarding adverse events and incidents, without how to constantly manage risks and prevent harm to OT
casting blame or searching for scapegoats (31). The OTNs patients. The primary researcher is also a practicing OTN
in the present study felt that incident reporting seemed with 10 years of experience in perioperative nursing. This
ineffective as a means to improve patient safety and con- prior experience can both strengthen and weaken the
veyed a feeling that the processing of the information study. The researcher has deep insight into the subject but,
gained from incident reports was inadequate, along with unavoidably, certain preconceived ideas. However, a
a considerable feeling of uncertainty as to when or who determined effort was made to put preconceptions and
should report incidents or adverse events. This leads to biases aside and avoid direct influence on participants (41,
the loss of valuable information and missed opportunities 42), for example by keeping a research diary in which pre-
to improve patient safety. Unreported incidents and conceived ideas were pondered upon and consciously writ-
adverse events have also been linked to different or ten down. An example of a preconception of the primary
unclear definitions and the fear of repercussions (32). It researcher was that she expected communication and
is possible that the definition of incidents and adverse communication problems to be a major theme. However,
events is unclear among the OTNs. This seems to be the to her surprise ‘patient vulnerability’ in the OT turned out
case with medical errors in general, leading to both to be much more on the OTNs minds and ‘respecting
underreporting and underestimation of the harm caused patient vulnerability’ turned out to be one of the main
to patients in the delivery of health care (33). themes in the study. The research process of the Vancou-
ver School has inbuilt strategies designed to increase valid-
ity and reliability, particularly member checking (see steps
The essential competencies of OTNs for the enhancement of
7 and 11 in Table 1), which is an important part of verifi-
patient safety
cation. The researcher triangulation in this study proved
The OTNs emphasised combining technical and nontech- fruitful where the expertise of two professionals, an expe-
nical skills. This is in consensus with the results of Søren- rienced OTN and a professor in nursing science and an
sen et al. (34) who in their study on perioperative expert in the methodology, was combined.

© 2017 Nordic College of Caring Science

 Enhancing patient safety in the operating theatre 9

Ethical considerations Conclusion

The National Bioethics Committee in Iceland provided The importance of OTNs’ constant risk management and
the ethical clearance to perform this study. All partici- preventing harm for the enhancement of patient safety in
pants were provided written and verbal information the OT was clear in the study. Experienced OTNs are in a
before they agreed to participate in the study, and key position to identify threats to patient safety and should
before each interview, each participant was presented be empowered to enhance patient safety in the OT as a
with a letter of information about the study. All the constant endeavour. These results add important insights
participants provided informed consent before the into the unique roles of OTNs with regard to enhanced
interviews were conducted, and confidentiality was patient safety throughout the perioperative process and
assured, both verbally and in writing. At the end of the delivery of high quality nursing care in the OT.
the study, all recordings of the interviews were
deleted and information that could be traced to indi-
Acknowledgements
vidual participants was erased from the transcripts.
The participants were all assigned pseudonyms to pro- We thank the participants of the study for their valuable
tect their anonymity. contribution and the University of Akureyri and Akureyri
Hospital for their important support.
Implications of the study
Author contribution
OTNs are like navigators who identify risk factors and
strive to protect OT patients from dangers and follow Eydis Ingvarsdottir and Sigridur Halldorsdottir involved
them through the perioperative process as safely as possi- in study conception/design. Eydis Ingvarsdottir involved
ble. The study summarises the enhancement of patient in data collection. Eydis Ingvarsdottir and Sigridur Hall-
safety in the OT from the perspective of experienced dorsdottir involved in data analysis. Eydis Ingvarsdottir
OTNs who could be used in the teaching of OTNs and in involved in drafting of manuscript. Sigridur Halldorsdottir
continuing education. The research findings indicate that involved in critical revisions for important intellectual
training in cognitive and social skills of OTNs can be content. Sigridur Halldorsdottir supervised the study.
strengthened in order to enhance the safety of OT
patients. The study provides insight into working condi-
Ethical approval
tions in OTs, and this information could be used as part
of an important discussion about safety culture and work The National Bioethics Committee in Iceland provided
atmosphere in OTs. Finally, research findings indicate the ethical clearance to perform this study.
that deeper analysis could be explored within OTs, which
could include the analysis of unexpected incidents, docu-
Funding
mentation of those and their processing in order to
enhance patient safety in the OT. Constantly managing The important financial support of the University of
risks and preventing harm to OT patients need to be a con- Akureyri and Akureyri Hospital is gratefully
stant endeavour. acknowledged.

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© 2017 Nordic College of Caring Science