Volume 32 Issue 3 Article 2

9-1-2019

The patient, case, individual and environmental factors that impact on the surgical count process: An integrative review

Victoria Ruth Warwick Dr Fiona Stanley and Fremantle Hospital Group, [email protected]

Brigid M. Gillespie PhD Griffith University - Australia, [email protected]

Anne McMurray Griffith University, School of , [email protected]

Karen G. Clark-Burg The University of Notre Dame Australia, [email protected]

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Recommended Citation Warwick, Victoria Ruth Dr; Gillespie, Brigid M. PhD; McMurray, Anne; and Clark-Burg, Karen G. (2019) "The patient, case, individual and environmental factors that impact on the surgical count process: An integrative review," Journal of Perioperative Nursing: Vol. 32 : Iss. 3 , Article 2. Available at: https://doi.org/10.26550/2209-1092.1057 https://www.journal.acorn.org.au/jpn/vol32/iss3/2

This Article is brought to you for free and open access by Journal of Perioperative Nursing. It has been accepted for inclusion in Journal of Perioperative Nursing by an authorized editor of Journal of Perioperative Nursing. Peer-reviewed article

Authors Dr Vicky Warwick The patient, case, individual DrN, MN, RN Perioperative nurse unit manager, Fiona and environmental factors that Stanley Hospital and Fremantle Hospital Group, Perth, Western Australia impact on the surgical count Professor Brigid M Gillespie PhD RN FACORN Professor of Patient Safety, School of process: An integrative review Nursing and Midwifery, Griffith University and Gold Coast University Hospital, Gold Abstract Coast Health, Nursing and Midwifery Education and Research Unit Problem identification Professor Anne McMurray AM, PhD, RN, FACN The surgical count is an integral component of the perioperative nurse’s role Emeritus Professor, School of Nursing and designed to reduce the risk of unintentional retained items (URIs) during Midwifery surgery. Current literature provides statistical data that URIs continue to Principle Research Fellow, Integrated occur which has exposed a lack of adherence to the surgical count process Care Program, Centre for Applied Health as a possible contributing factor. This review was undertaken to identify what Economics is currently known about perioperative nurses’ practices in relation to the Menzies Health Institute Queensland, Griffith University, Gold Coast Campus surgical count and the perceived barriers and enablers when trying to follow best practice as outlined in ACORN’s Standards for Perioperative Nursing in Associate Professor Karen Clark-Burg Australia. Acting Dean School of Nursing and Standards for Perioperative Midwifery, The University of Notre Dame Literature search Australia The objective of the search was to identify empirical data relating to nurses’ Corresponding author knowledge and practices in relation to the surgical count. We identified 215 Dr Vicky Warwick research papers in the literature search using search terms consisting of DrN, MN, RN instrument counts, culture and patient safety. The ACORN Standards for Perioperative Nursing in Australia Perioperative nurse unit manager, Fiona Stanley Hospital and Fremantle Hospital Data evaluation synthesis constitutes the specialty knowledge of the perioperative Group, Perth, Western Australia [email protected] Studies from 2003 to 2018 were categorised methodologically as qualitative, nursing community in Australia and represents the accepted quantitative and mixed methodologies. All papers were reviewed by the authors separately to extract key information around design, sample size, aim, standard for professional practice. key findings and limitations. Studies were critically appraised using the mixed method appraisal tool (MMAT) for mixed method studies and the QualSyst tool for quantitative and qualitative studies. The literature search identified a total of 215 studies, 109 of which were identified for further review using the ‘preferred reporting items for systematic reviews and meta-analysis’ (PRISMA) e-Subscription Bundle flow chart. Six exclusion criteria were applied to exclude a further 52 articles Print edition and from the final review, which resulted in ten articles being included in the final The online edition is Print edition e-subscription for the sample. perfect for facilities to ultimate convenience. Implications for practice or research Easy hands-on access to share among multiple ACORN’s evidence-based users. The review demonstrates that statistical data around URIs is widely reported. standards in a traditional print However, little is documented about the patient, case, individual and environmental factors that may impede perioperative nurses in following best format. Available only in a practice when undertaking a surgical count. bundle. Keywords: surgical, perioperative, count, patient safety, best practice, retained items Available online at acorn.org.au/standards/shop. Members of ACORN receive a heavily reduced price on the individual e-subscription and individual bundle. Journal of Perioperative Nursing Volume 32 Number 3 Spring 2019 acorn.org.au 9 Problem identification further research is needed to identify counts which provide an in-depth and describe perioperative nurses’ understanding of the potential Counting surgical instruments and perceived barriers and enablers to problems surrounding the surgical consumables in facilities undertaking best practice. count1. The research question that (HCFs) is an important component provided the focus for this review of perioperative practice in relation Literature search was ‘what factors contribute to URIs to patient safety. Despite HCFs’ in surgery?’ duty to comply with best practice The researchers undertook an integrative mixed method review standards in relation to surgical Inclusion and exclusion using Whittemore and Knafl’s1 counts, sentinel events concerning criteria unintentional retained items (URIs) integrative review framework. This during surgical procedures continue enabled a comprehensive review Papers were included if they were to occur. Contributing factors include of the surgical count process, using full-text, English language, primary non-adherence to hospital policy, qualitative and quantitative research. research articles, referred to the procedure, process and guidelines; The integrative review identifies the surgical count from a quantitative poor communication; a fast-paced current empirical evidence and gaps or qualitative perspective and were work environment and the levels of in knowledge related to surgical published between January 2000 and knowledge, skills and competence of February 2018. The time frame was chosen to ensure current relevance practitioners involved. MEDLINE, CINAHL, COCHRANE, Google Scholar to the chosen topic and to provide This integrative literature review 2000–2017 breadth and depth of relevant describes the surgical count process 189 citations literature to be included in the review. and its relationship to patient safety Research papers other than those and the perioperative nurse’s role written in English were excluded as in ensuring the count process is 26 hand searched references were papers that referred to the key undertaken in accordance with best search terms but had no reference practice principles. To date, there to the surgical count process in the is limited research that describes 215 articles screened article. Quantitative studies that factors that impact on the surgical provided data pertaining to retained count. There is an abundance of items were also excluded if they did literature that provides statistical 153 articles excluded including duplicates not detail the reasons these items data related to URIs but little in were retained and relevance to a relation to the operational aspects surgical count process or nursing of managing the count process. 62 articles screened concerns. Government reports were The review revealed a number of also excluded as these did not themes that researchers attributed expand on the issue underlying URIs. to incorrect counts. These included 62 full text articles Papers based on literature reviews, assessed for eligibility patient, case, individual and quality improvement projects or environmental factors. All of the with no abstract available were also studies examined showed little 48 articles excluded 4 articles excluded excluded. documentation of best practice in after full text screen during data extraction relation to the count. No studies Search strategies were found that directly addressed A computerised literature search perioperative nurses’ perceptions 10 articles included was undertaken to identify relevant of factors related to the patient, journal articles. Search terms case, individual and environment, or Figure 1: PRISMA diagram of related to surgical counting included their perceptions of nurses’ ability integrative review ‘retained sponges’, ‘foreign bodies’, to follow best practice and policy. ‘instrument counts’, ‘surgical counts’, Because undertaking accurate Adapted from Moher D, Liberati A, Tetzlaff J, Altman DG, PRISMA Group. ‘sentinel/adverse events’, ‘incorrect and appropriate count processes Preferred reporting items for systematic counts’, ‘culture’, ‘accountable items’ is prescribed by professional reviews and meta-analyses: The and ‘patient safety’. organisations as an integral PRISMA statement. PLoS Medicine component of quality and safety, 2009;6(7):e1000097. doi:10.1371/journal. A health librarian assisted with the pmed.1000097. searches of the Cumulative Index to

10 Journal of Perioperative Nursing Volume 32 Number 3 Spring 2019 acorn.org.au Nursing and Allied Health Literature appraise individual quantitative and Findings (CINAHL) Plus, Cochrane Library, qualitative study designs. MEDLINE (Ovid) and Google Scholar. Descriptive characteristics Papers that involved a mixed Boolean connectors ‘and’ and ‘or’ methodology were assessed using The literature search identified a were used to combine the key words the mixed methods appraisal total of 215 studies. Of these, 189 and medical subject headings (MeSH) tool (MMAT). The MMAT checklist were obtained through electronic were used in the execution of the tool allows assessment of the searching and a further 26 identified MEDLINE database searches. methodological quality of studies through manual searches of The reference lists of sourced journal that have diverse designs based on reference lists of the included articles were hand-searched for predetermined objective criteria. It research articles. Following screening, further relevant articles. Identified provides five domains that a study 109 were identified for further review articles were screened by the can be assessed against with a using the preferred reporting items research team in reference to the maximum total of 11 criteria3,4. for systematic reviews and meta- aims of the review and the inclusion analysis (PRISMA) flow chart5 as and exclusion criteria. Quality scores shown in Figure 1. The QualSyst scoring process for Data extraction and Six exclusion criteria (detailed in the quantitative studies included 14 synthesis Table 1) were applied to exclude a set criteria and for the qualitative further 52 articles from the final The articles collated for this review studies, 10 criteria. Both types review. In total, 10 articles were included quantitative, qualitative of studies were scored as either included in the final sample, with a and mixed methods research which 0 (‘no’) if the criteria were not date range of 2003 to 2018. Six papers were synthesised to provide a clearer included or discussed, 1 (‘partial’) if originated from the US, two from picture of the research available some elements of the criteria were Australia and two from the UK. The relative to the included studies. The included but not fully discussed, articles included in the final review content of the results and discussion or 2 (‘yes’) if the criteria were related to patient, case, individual sections of the included articles was fully included or discussed in the and environmental factors that affect synthesised using inductive thematic literature. Mixed methods papers the process of undertaking a surgical were assessed against the three analysis. Themes were generated count. based on patient, case, individual domains recommended in the MMAT and environmental factors that checklist, including qualitative, A summary of the included contribute to URIs. Data extraction quantitative descriptive and mixed descriptors from the qualitative, from the integrated literature review methods, with the responses quantitative and mixed methods included the lead author, year, corresponding to 0 (‘no’), 0 (‘can’t research articles describing each country, study aim, design, sampling tell’) and 1 (‘yes’). study is presented in Tables 2, 3 and 4. and results. Limitations of each of the studies were identified and considered in relation to internal and external validity of study findings and Table 1: Exclusion criteria listed in the final review study quality. Data verification was performed independently by two of Reason for exclusion Number of articles the researchers who met regularly to consider whether papers met the No reference to the surgical count process 40 inclusion criteria. Nursing concerns referring to the count process 6 Quality assessment but not providing any further information

To assess the quality of the included Quality improvement projects 3 papers, the QualSyst appraisal tools developed by Kmet, Lee and Cook2 Literature reviews 1 were used. QualSyst tools are a hybrid of research assessment tools Root cause analysis studies 1 that provide a framework to critically Practice reviews 1

Journal of Perioperative Nursing Volume 32 Number 3 Spring 2019 acorn.org.au 11 Table 2: Included quantitative studies (n=5)

Lead author, Quality year, country Design and sample Aim of the study Key findings Limitations scores

Elsharydah et al. Design: To assess trend Patient-related factors: Retrospective use of an 23/28 (2016)7 • retrospective review rates of URI • morbidly obese patients administrative dataset incidents. from patient discharge United States • 2007 to 2011 Case-related factors: To identify information. • inclusion of abdominal and • elective surgeries patient, Errors in coding pelvic surgeries only procedure • abdominal and pelvic and the inability to • case controlled against similar and hospital procedures incorporate relevant procedures with no URI characteristics Environmental factors: data other than that Sample: associated with • teaching and rural hospitals provided. • multiple hospital sites URIs. No follow-up • 1144 patients out of information about 8 677 863 cases procedures and outcomes. • accessed through the Nationwide Inpatient Sample No ability to investigate of Healthcare cost utilisation complications from a project of the Agency for retained foreign body. Healthcare Quality and Lack of information Research about other risk factors, e.g. instrument counts and blood loss. Reliance on secondary data and self-reporting may be unreliable and inaccurate.

Cima et al. Design: To identify the Patient-related factors: No matched 13/28 (2008)8 • retrospective review of all incidence and • increased vigilance for patients comparison to similar characteristics cases that did not United States actual or potential URIs with a high body mass index reported to a sentinel event of potential (BMI) experience a retained and actual foreign object. phone line Case-related factors: URI events in Reliance on secondary • 2003–2006 • emergency surgeries surgical patients. data and self-reporting, Sample: • URIs more common in routine may be unreliable and • two acute care facilities on the surgery inaccurate. same site individual factors: • 191 168 cases • breakdowns in communication • 98 ORs including three obstetric • complacency around count ORs and three labour/delivery process suites Environmental factors: • 68 reported URIs (34 true URIs • majority of URIs occurred with and 34 ‘near misses’) correct counts • needles and swabs most common URI

Gawande et al. Design: Identify risk Patient-related factors: Reliance on secondary 18/28 (2003)9 • retrospective case-controlled factors for • High BMI data and self-reporting, URIs to provide may be unreliable and United States design Case-related factors: direction for inaccurate. • 1985–2001 inclusive • emergency procedures ameliorative Based on malpractice • data review of malpractice efforts. • unplanned changes in claims so could be insurance files from a single procedure underestimated. insurance company covering • increased blood loss 22 hospitals Lack of procedure- • most body cavities involved specific data. • cases that had a URI and the control cases with similar • median time frame to detection procedures but no URI of retained foreign object 21 days • computerised search screened by a physician to review for • 69 per cent cases had retained inclusion suitability sponges and 31 per cent retained instruments • surgeon interviews Environmental factors: • surgical demographics • 88 per cent of retained foreign Sample: object involved in cases where • 10 hospitals final count was documented as • 60 URI cases identified correct • four case controls per URI case

12 Journal of Perioperative Nursing Volume 32 Number 3 Spring 2019 acorn.org.au Lead author, Quality year, country Design and sample Aim of the study Key findings Limitations scores

Rowlands Design: To examine Patient-related factors: Human error with data 22/28 (2012)10 • cross-sectional correlational relationships • patient BMI extraction. between the United States design Case-related factors: Permission not occurrence of given from relevant • surgical procedure as level of an incorrect • complicated procedures analysis personnel to include count and • length of procedure procedure. • data from perioperative records nurse/patient characteristics • unplanned procedures Limited sample size • collected primary data from of perioperative perioperative nurses including • multiple surgical teams intra-operative operating at the same time personnel checking Sample: circumstances influence of nurse • increased number of characteristics. • two hospitals – one academic and staff perioperative nurses/ (medical level, one trauma member technologists (more than two Reliance on secondary unit), 600 beds, 14 specialties involvement. involved in the procedure) data and self-reporting, and 18 631 procedures; one may be unreliable and community hospital, 150 inaccurate. beds, 12 specialties and 6 593 surgeries • review of 2540 medical records • identified 1122 procedures with URI • 65 per cent at academic unit and 35 per cent at community hospital • 69 RNs

Greenberg et al. Design: To identify Individual factors: Use of malpractice 16/28 (2007)11 • descriptive study of surgical communication • a single intra-operative claims as a proxy for breakdowns safety in health care. United States errors in closed claims at breakdown that involved a four malpractice insurance between broadcast of information to Reliance on secondary companies perioperative multiple providers and at least data and self-reporting, team members. • part of a larger study examining three team members may be unreliable and 444 surgical claims • 81 communication breakdowns inaccurate. • 258 cases relevant to patient • 11 related to miscounts Attending surgeon injury most likely to be • counting errors accounted named in a lawsuit so Sample: for 10 of the 16 instances of is highly likely to be • 60 cases had contributing communication breakdown the named instigator factors to communication where the nurse was the for communication breakdown transmitter breakdown. • study discussed miscounts but • 10 of the 12 where the nurse Does not represent all were excluded from the study was the receiver contributed to contributing factors. a count error

Notes: BMI = body mass index, RN = .

References 1. Elsharydah A, Warmack KO, Minhajuddin A, Moffatt-Bruce SD. Retained surgical items after abdominal and pelvic surgery: Incidence, trend and predictors – observational study. Ann Med Surg 2016;12:60–64. doi:10.1016/j.amsu.2016.11.006. 2. Cima RR, Kollengode A, Garnatz J, Storsveen A, Weisbrod C, Deschamps C. Incidence and characteristics of potential and actual retained foreign object events in surgical patients. J Am Coll Surg 2008;207(1):80–87. 3. Gawande AA, Studdert DM, Orav EJ, Brennan TA, Zinner MJ. Risk factors for retained instruments and sponges after surgery. New Engl J Med 2003:348(3):229–235. doi:10.1056/NEJMsa021721. 4. Rowlands A. Risk factors associated with incorrect surgical counts. AORN J 2012;96(3):272–284. doi:10.1016/j.aorn.2012.06.012. 5. Greenberg CC, Regenbogen SE, Studdert DM, Lipsitz SR, Rogers SO, Zinner MJ et al. Patterns of communication breakdowns resulting in injury to surgical patients. J Am Coll Surg 2007;204(4): 533–540. doi:https://doi.org/10.1016/j.jamcollsurg.2007.01.010.

Journal of Perioperative Nursing Volume 32 Number 3 Spring 2019 acorn.org.au 13 Table 3: Included qualitative studies (n=3)

Lead author, Quality year, country Design and sample Aim of the study Key findings Limitations scores

Rowlands, Design: To identify Case-related factors: Perspectives of 13/20 Steeves • hermeneutic retrospective • untidy work space surgeons were 12 narration of not obtained (2010) phenomenology • hunting down of equipment methodology participant and could United States experiences • fast-paced have provided • face-to-face interviews with regarding an • many different circulating nurses additional staff involved in an incorrect incorrect count. information. count within 12 hours of it individual factors: occurring Participants’ • lack of respect for others stories may • demographic questions and • lack of adherence to standards and not have personal experiences hospital policy encompassed Sample: • inconsistency in count practices other structural or process • two hospitals – one • not working effectively together academic, medical information. centre, 500 beds, 26 ORs, • not sharing relevant information 13 specialties covering Environmental factors: complex surgery, 140 nurses • loud music, excessive talking, talking and technicians, 18 631 at critical moments when counting, procedures; one community deafening (not a reflection of a safety hospital, 150 beds, 7 ORs, culture, more a threat to patient 13 specialties (minimal safety) complex), 35 nurses and STs, 6593 surgeries • use of unskilled personnel to fill voids • 22 participants (55 per cent RNs, 45 per cent STs),12 at academic medical centre and 10 at community centre

Riley et al. • ethnography using To explore power Case-related factors: Perceptions 13/20 (2006)13 observations and interviews relationships in • speed and efficiency in direct conflict of other team communication members, such Australia • part of a larger study with patient safety on communication interactions as surgeons, not between surgeons, • dual roles for scrub nurses. Nurses sought relationships between unable to undertake a count due to nurses and doctors nurses and doctors Results derived in the OR as they power exercised by surgeon when • three hospitals – large having to assist. from the engage in the larger study of metro hospital, outer practice of the • counts not seen as important suburban public hospital communication surgical count. during an emergency, nurses using practices and inner-city public professional judgement hospital between nurses • surgeons unaware of count process and doctors and • observations 230 hours decisions not specifically • 11 individual, semi- • counts varied at each institution and related to the structured interviews with disparities in interpretation of the count process. nurses as key informants guidelines and how they applied to Rituals and • four group interviews with each situation practices in the participants from each site. individual factors: count process not reflected. • researcher diary over two • misinterpretation of hospital policy years • relationships of power control between nurses and doctors, and nurses with nurses (experienced vs inexperienced)

14 Journal of Perioperative Nursing Volume 32 Number 3 Spring 2019 acorn.org.au Lead author, Quality year, country Design and sample Aim of the study Key findings Limitations scores

McDonald et al. Design: To explore the individual factors: Small sample 11/20 (2005)14 • qualitative, ethnographic attitudes towards • doctors and nurses have opposing size. guidelines of United Kingdom study using observations views on protocol violation Single hospital and interviews doctors and nurses site. working together • nurses are more fastidious in adhering • part of a larger two- in surgical teams to documented procedures year ethnographic study and to examine • doctors eschew guidelines and rely on exploring threats to patient the extent to experience and tactical knowledge safety in the OR which trusting • differing views on guidelines and • document analysis relationships are what constitutes safe clinical practice Sample: maintained in a affects relationships between doctors context governed by and nurses • large teaching hospital in explicit rules. northern England • 14 consultant surgeons • 14 consultant anaesthetists • 15 nurses (scrub nurse, modern and nursing team managers)

Note: ST = surgical technologists, RN = Registered nurse

References: 1. Rowlands A, Steeves R. Incorrect surgical counts: A qualitative analysis. AORN J 2010;92(4):410–419. doi:10.1016/j.aorn.2010.01.019. 2. Riley R, Manias E, Polglase A. Governing the surgical count through communication interactions: Implications for patient safety. Qual Saf Health Care 2006;15(5):369–374. doi:10.1136/qshc.2005.017293. 3. McDonald R, Waring J, Harrison S, Walshe K, Boaden R. Rules and guidelines in clinical practice: A qualitative study in operating theatres of doctors’ and nurses’ views. Qual Saf Health Care 2005;14(4):290–294. doi:10.1136/qshc.2005.013912.

Table 4: Included mixed methods studies (n=2)

Lead author, Quality year, country Design and sample Aim of the study Key findings Limitations scores

Butler et al. Design: To identify type Case-related factors: Poor survey 9/11 (2010)15 • exploratory descriptive and frequency of • count errors occurred during elective response rate, count errors. impact on Australia study using survey surgery with one instrument and one generalisability. • 30 months, completed in To evaluate circulating nurse 2005 impact of various • complexity of cases – type of surgery, Data based on procedural and self-reporting. Sample: unplanned changes, need for large personal factors quantity of items during case High turnover of • seven hospitals (five public in count errors. research team and two private) • rushing – fast pace, causing difficulty in completing prescribed process for the members. • 12 researchers count Self-selection • 140 surveys (23 questions • time pressure from surgeon/anaesthetist meant that not included in the analysis) to get the next patient on the table all count errors were reported. • completed by RN who was • instrument handling – managing small the primary nurse for cases micro needles on non-ratcheted needle with a URI holders individual factors: • documentation errors – failure to add items to count sheet, adding items to the wrong column, adding wrong item to a column, adding same item more than once • lost accountable items – recognition by team and course of action to be taken • team performance – cooperation and communication, relief circulating nurses and agency staff • behaviour of surgeons – problematic surgical technique, refusal to accept a count error

Journal of Perioperative Nursing Volume 32 Number 3 Spring 2019 acorn.org.au 15 Lead author, Quality year, country Design and sample Aim of the study Key findings Limitations scores

Smith, Burke Design: To audit nurses’ Case-related factors: Single hospital 6/11 (2014)16 • observations and survey perceptions • rushing site. of policy and United Kingdom • observation of 15 • more than one circulator Limited sample competencies. size. procedures over two Individual factors: months that were randomly To audit selected documentation • 80.4 per cent respondents reported of having read reading count policy • survey using Likert scale policies, who and open-ended questions • 90 per cent reported that they followed documents it’s count policy (not conclusive with Sample: been done and observations) effect on PDRs. • one large hospital site • 20 per cent were observed to follow • ten ORs, four day surgeries policy and two obstetric theatres • staff observed to be multitasking, not • nurses, ODPs and HCAs fully concentrating on count • 65 in the sample group • perceived lack of delegation, leadership, • 47 questionnaires returned teaching, coaching (scrub and circulating only) • observed poor practices left unchallenged • length of service observed as having no bearing on count process being followed • observed no compliance with tray list use • no change-over counts observed

Note: RN= Registered nurse, ODP = operating department practitioners, HCA = health care assistants, PDR = professional development review

References: 1. Butler M, Ford R, Boxer E, Sutherland-Fraser S. Lessons from the field: An examination of count errors in the operating theatre. ACORN J 2010;23(3):6. 2. Smith Y, Burke L. Swab and instrument count practice: Ways to enhance patient safety. Brit J Nurs 2014;23(11):590–593. doi:10.12968/bjon.2014.23.11.590.

Quality assessment range of 68 to 1122 incidences and contributing to URIs was a high body including a mixture of needles, mass index (BMI). A high BMI may Six quantitative papers were scored sponges and instrumentation. They lead to deep surgical incisions that against the 14 criteria, with a identified areas of perioperative could fill with bodily fluids and make maximum score totalling 100 per cent. practice that may have contributed it difficult to keep track of surgical The quality score of these papers to URIs during surgery or the surgical packs and instrumentation7–10. ranged between 46 per cent and count process. The following sections 82 per cent, with an average score present a narrative synthesis of Case-related factors of 66 per cent. Three qualitative the findings of this review under papers were reviewed against this Case-related factors encompassed the following categories: patient- criterion with a maximum score of 20 emergency, unplanned and planned related, case-related, individual and points. The quality scores for these surgery and length of time to environmental factors. papers ranged from 45 per cent to undertake a procedure. Multiple 65 per cent, with an average score surgical teams, perioperative Implications for nurses undertaking dual roles and of 57 per cent. Two papers were perioperative nursing reviewed using the MMAT tool with multiskilling are documented factors the total of ‘yes’ responses divided practice or research that may contribute to URIs. Five studies identified emergency and by the total criterion (11) to provide Patient-related factors an overall percentage assessment. unplanned surgery as circumstances The final assessment ranged from Although age, gender and that contribute to incorrect counts. 55 per cent to 82 per cent. comorbidities may contribute to Emergency procedures, a change in increased risks during surgery6, the the patient’s status and a sudden All the studies related to the only patient-related factor that was change in the surgical procedure may incidence of URI with a reported identified in four of the papers as leave insufficient time to account

16 Journal of Perioperative Nursing Volume 32 Number 3 Spring 2019 acorn.org.au for all surgical instruments and Difficulty in handling certain the potential to culminate in a consumables at the commencement pieces of equipment (for example, URI. Although the count procedure of the procedure9,10,13,15,17. In contrast, ratcheted and non-ratchet needle is considered a clearly defined, three papers identified planned holders)15, and disparate views of straightforward, step-by-step surgery as a contributing factor, with team members in relation to count process, the integrative review perioperative personnel deemed practices can contribute to a URI14 studies identified instances where more complacent during the count and led to surgeons not being aware perioperative nurses struggle to process for elective procedures7,15,17. of which count process is being follow the count process7–17. followed or documented13. Complications and length of time to The review identified individual, non- undertake a procedure was identified Environmental factors technical factors that influence count as a case-related factor in three behaviours from a multidisciplinary papers10,13,15. One study identified Environmental factors influencing team perspective. Teamwork and multiple teams in a surgical the count process included rural communication include respect procedure as potentially contributing and teaching facilities, loud music, for each other, from surgeons, to an incorrect count10, and another excessive talking and nursing perioperative nurses and other team study identified the instrument nurse skill mix. Non-technical factors members. Limited communication having to undertake a dual role as a encompassed communication may reduce the ability to process contributing factor13. breakdowns, adherence to policy, required information and influence respect for each other, hierarchy the ability to follow policy and individual factors structures, multiple perioperative procedure. An increase in idle teams and surgical counts being Adherence to hospital or conversation and noise escalation documented as correct (even when departmental policy was a major were also identified as behaviours the count was later found to be contributing factor discussed in five that contributed to an ineffective incorrect). 18–22 of the review papers12–16. This was also count process . identified as complacency around the One study identified that teaching Time pressures related to the surgical 17 count process , with documentation and procedures in rural hospitals and anaesthetic teams pushing to get 15 errors also identified . Rowlands may affect the outcome of an patients in and out of the OR quickly 12 7 and Steeves found that teams incorrect count . Loud music and evidently had a negative impact working together ad hoc were less excessive talking along with poor skill on nurses’ ability to undertake 12 likely to share relevant case-related mix were identified in another study . the count process and complete information, contributing to an Two studies identified that URIs were documentation12,15,23. Team fatigue incorrect count. found in cases that had had a correct leading to diminished concentration count documented. It was unclear Individual factors contributing to and change of perioperative why this phenomenon occurred, with incorrect counts included the type of personnel mid-procedure was the URI only picked up following leadership in an operating room (OR) identified as a contributing factor routine radiography9,17. and the manner in which tray lists to poor documentation and count were used16. The impact of hierarchy A breakdown in communications process9,10,24–26. was identified with surgeons was identified in three papers as A lack of professional respect, idle sometimes not allowing nurses a major contributor to incorrect conversation and noise escalation 11,15,17 to undertake the correct count counts and that the sheer pace were identified as behaviours 13 procedure . Two papers identified of surgery, process pressure and that influenced count practices in the need to treat other members of time constraints were also causative many of the papers but the missing 10,13,15 the perioperative team with respect factors . link in the literature is why these in the perioperative environment as behaviours can continually affect the 12,15 Discussion an individual factor . way the count process is undertaken. Two studies documented individual Papers in this review examined Undertaking observational research factors contributing to incorrect patient, case, individual and will help to uncover why such counts as untidy instrument environmental deviations that behaviours occur in real time and trolleys and the inability to find account for inconsistencies in the increase understanding of the instrumentation in a timely fashion9,12. prescribed surgical count standard circumstances that lead to these of practice. These factors have behaviours.

Journal of Perioperative Nursing Volume 32 Number 3 Spring 2019 acorn.org.au 17 While the surgical count is identified early in the research affect their ability to carry out the considered a technical skill, it also process that few studies have prescribed process. involves non-technical skills such examined nurse perceptions Empirical evidence supports the as communication, situational of incorrect counts and the contention that human error awareness and cooperation24,27,28. patient-related, case-related and continues to occur in relation to the Team communication is integral to environmental factors perceived by surgical count. Although the surgical the culture and smooth running of perioperative nurses in undertaking a count is sometimes considered the HCF and an important component surgical count process. onerous and repetitive, counting of reducing surgical errors12,22,24,28,29. It Only five of the ten papers in this and documentation are pivotal tasks is important that individual members review described nurses’ concerns related to patient safety in surgery. in the team can voice their concerns regarding the count process and The safety culture of an organisation if issues arise before, during or provided some reflection on is the product of individual and after surgery, irrespective of their causative factors and preventable group norms, beliefs, attitudes and hierarchical standing15,23. actions. Studies not available in values. These attributes determine Ineffective communication has English were omitted from this an organisation’s commitment to been identified as a major causative review. Such studies may have managing critical safety issues. A factor for perioperative nurses provided further insights into the culture of safety should provide a failing to follow correct policy and phenomenon. Research papers on framework that limits variability procedure in relation to the surgical surgical counts may not represent in practice and, therefore, has the count11,12,17,22,24,28. The inability to follow all works in relation to nurses’ potential to reduce inconsistency and accepted count practices is often perceptions of the count process human error. associated with the hierarchical and therefore may have limited structure in the OR, such as nurse- the scope of this review. Finally, References to-surgeon and male-to-female appraisal of empirical research 1. Whittemore R, Knafl K. The integrative ratios11,17,29,30. is somewhat subjective. However, review: Updated methodology. J Adv Nurs using previously validated tested 2005;52(5):546–553. doi:10.1111/j.1365- Hierarchical confrontations between 2648.2005.03621.x. tools2,3 provided rigour in the review experienced and inexperienced 2. Kmet LM, Lee RC, Cook LS. Standard quality process in relation to evaluating and nurses contributed to junior nurses assessment criteria for evaluating primary scoring papers based on content and having difficulty challenging more research papers from a variety of fields. methodology. Vol. 22. Alberta, Edmonton: Alberta Heritage senior staff regarding the process Foundation for Medical Research; 2004. 13,23 of undertaking the surgical count . Conclusion 3. Pace R, Pluye P, Bartlett G, Macaulay Likewise, perioperative nurses who AC, Salsberg J, Jagosh J et al. Testing have worked together for years may Throughout this review it was evident the reliability and efficiency of the pilot have adapted the count process that patient, case, individual and Mixed Methods Appraisal Tool (MMAT) environmental factors may contribute for systematic mixed studies review. Int to suit their needs and developed J Nurs Stud 2012;49(1):47–53. doi:10.1016/j. shared understandings based on to URIs during surgery and that these ijnurstu.2011.07.002. 27,31,32 work history . factors have some impact on the 4. Souto RQ, Khanassov V, Hong QN, Bush surgical count process. Quantitative PL, Vedel I, Pluye P. Systematic mixed The authors of several studies data about how many URIs occur studies reviews: Updating results on identified that nurses relied on their and the causative factors related to the reliability and efficiency of the Mixed Methods Appraisal Tool. Int J Nurs own professional judgement when this phenomenon is in abundance. deciding on what to count. This led Stud 2015;52(1):500–501. doi:10.1016/j. However, qualitative research into ijnurstu.2014.08.010. to disparate interpretations of the these contributing factors and 5. Moher D, Liberati A, Tetzlaff J, Altman DG, guidelines and their relevance to the implications for perioperative PRISMA Group. Preferred reporting items 8,9,12,13,15,31,33 each surgical situation . nurses is limited. The surgical count for systematic reviews and meta-analyses: The PRISMA statement. PLoS Medicine process is a key component of the Limitations 2009;6(7):e1000097. doi:10.1371/journal. perioperative nurse’s responsibility pmed.1000097. While this review has strengths, towards patient safety, yet this review 6. Triantafyllopoulos G, Stundner O, it also has limitations. A robust demonstrates that there is limited Memtsoudis S, Poultsides LA. Patient, research process was undertaken, research about this subject and surgery, and hospital related risk factors for encompassing identifying major surgical site infections following total hip the contributing factors that may arthroplasty. ScientificWorldJournal 2015;1–9. key words and MeSH terms. It was doi:10.1155/2015/979560.

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