Volume 33 Issue 4 Article 6

12-9-2020

Identifying research priorities for improving patient care in the perioperative environment: A descriptive cross-sectional study

Pat F. Nicholson Dr [email protected]

Lois Hamlin RN, DNurs, FACN, FACORN [email protected]

Jed Duff [email protected]

Brigid M. Gillespie PhD RN FACORN [email protected]

Carollyn Williams FWISTERIollow thisA@BIGPOND and additional.NET works.AU at: https://www.journal.acorn.org.au/jpn

Part of the Perioperative, Operating Room and Surgical Commons

This work is licensed under a Creative Commons Attribution 4.0 License.

Recommended Citation Nicholson, Pat F. Dr; Hamlin, Lois RN, DNurs, FACN, FACORN; Duff, Jed; Gillespie, Brigid M. PhD RN FACORN; and Williams, Carollyn (2020) "Identifying research priorities for improving patient care in the perioperative environment: A descriptive cross-sectional study," Journal of Perioperative Nursing: Vol. 33 : Iss. 4 , Article 6. Available at: https://doi.org/10.26550/2209-1092.1095 https://www.journal.acorn.org.au/jpn/vol33/iss4/6

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 Associate Professor Patricia Nicholson Identifying research priorities PhD, RN, FACORN Course Director, Master of Nursing for improving patient care in the Practice (Perioperative) and HDR Coordinator, Deakin University, Geelong, Victoria perioperative environment: A Dr Lois Hamlin descriptive cross-sectional study DNurs, RN, FACN, FACORN(Hon) Senior Lecturer, Faculty of Health, Introduction This study was undertaken to identify University of Technology Sydney (retired) research priorities in perioperative Professor Jed Duff Changes in the delivery of patient nursing and identify areas of practice PhD, RN, FACORN care, the rapid evolution of technology that could inform the development Professor of Nursing, Queensland and the complexity of the current of new standards of practice for University of Technology environment require perioperative nurses. Chair of Nursing, Royal Brisbane and health professionals to make clinical Women’s Hospital decisions that are both current and Background Professor Brigid M Gillespie evidence-based1,2. Perioperative PhD, RN, FACORN nursing has a long history steeped Optimising nurses’ contribution Professor of Patient Safety, School of to timely and effective translation Nursing & Midwifery, Griffith University in tradition and routine practice and of research into clinical practice and Gold Coast Hospital and Health although evidence-based practice 9 Service, Queensland (EBP) has existed for decades, a remains a challenge . In an integrative review exploring the Carollyn Williams number of barriers to implementing M Hlth Sc (Nur), FACN, FACORN this practice in the operating room state of readiness for EBP, although have been identified3,4. Perioperative nurses reported being familiar with nurses are accountable for the care EBP, divergent views were reported, provided to patients presenting for including difficulty in searching, surgery; therefore, implementation retrieving and critically appraising 10 of EBP is important for standardising research articles . The introduction patient care1 and supporting positive of sophisticated surgical techniques patient outcomes. By incorporating and advances in technology in the 11–15 EBP skills in perioperative nursing, operating room have resulted a rationale for current practices in from innovations and application 14 the operating suite is also justified1. of scientific research , with the With increased accountability for development of specialist nursing the quality of care provided in the knowledge considered crucial perioperative environment, the value for safe and effective patient 5,12–14,16 of perioperative nurses’ contribution outcomes . It is therefore to patient care has been questioned5. important that perioperative nurses participate in activities that improve In order to increase the quality patient outcomes and advance and efficiency of patient care, the nursing profession by actively perioperative nurses’ contribution seeking opportunities to engage to research and research utilisation in EBP and quality improvement in the perioperative environment is projects or participate in research9. 6 crucial . It is important to identify With engagement in these priority, relevant research questions to activities, traditions are validated address the gap that exists between or challenged17. There is also an data that is generated by researchers emphasis on the importance of and the information that is required incorporating new research findings 7 by end-users . Despite the importance into daily health care practice and of this, there is limited evidence about improving patient safety18. how research priorities should be established8.

Journal of Perioperative Nursing Volume 33 Number 4 Summer 2020 acorn.org.au e-29 Evidence from research, guidelines nursing and intensive care nursing Sample and setting and standards of practice provide a have increased substantially over Members were invited via email foundation on which perioperative the past 20 years, similar outputs are through the ACORN membership nurses can develop their capacity not reported for publications related database to participate in the survey, as consumers of research as well to perioperative nursing23. With the with a follow up email sent one as integrate EBP into their clinical aim of supporting and encouraging month later. Only those residing practice17. The peak professional research in perioperative , and those who opted body for perioperative nurses, and promoting evidence-based to participate in research studies ACORN (the Australian College of practice, ACORN established a advertised through the College, were Perioperative Nurses, originally the research committee (RC). The primary invited to participate. Confederation of Operating Room function of the RC is to guide and Nurses which became a College in coordinate all aspects of research Data collection tool 2000) plays an important role in activity for the College. To inform the these efforts. ACORN was formed in scope of the committee’s purpose The data collection tool included 1977 with the aim of standardising a national research and networking two sections. The questionnaire perioperative nursing practice and workshop was held during the 2018 contained 20 items clustered around educating perioperative nurses19,20. ACORN and ASIORNA Conference. This five topic areas into which the ACORN The mission of ACORN included the interactive research activity explored, standards are grouped: staff and development of the ACORN Standards, among other things, the research patient safety, professional practice, guidelines and policy statements evidence supporting the Standards, asepsis and clinical care, equipment (‘the Standards’). The Standards gaps in the evidence base related to and environment, and management were first developed in 1980 and the Standards, and the challenges and staffing. The choice of these reviewed triennially to guide nurses associated with implementing the particular items was predicated on in providing optimum quality care Standards in clinical practice24. Four the data collected at the research for the patients admitted to the research priorities were identified workshop held during the 2018 operating room. With the advances during the workshop: patient ACORN and ASIORNA Conference. occurring in perioperative nursing, and staff safety, equipment and Participants were asked to read a a review of the 2004 Standards technology-related issues, the series of topic area items and rate was undertaken to incorporate uptake and audit of the Standards them according to level of relevance an international model, through and the culture of the perioperative and level of importance using a the establishment of teams of environment1. To explore in more 5-point Likert scale, from 1 (not at perioperative nurses representing depth potential research priorities all relevant / not at all important) each state and territory in Australia. in the perioperative setting, the RC to 5 (extremely relevant / extremely Extensive literature reviews were conducted a national survey inviting important). Thus, higher scores completed by each team resulting ACORN members to participate in indicated higher levels of relevance in standards that were referenced ranking topic areas developed from and importance for each survey and reflected an evidence-based the networking workshop in 2018. item across the five standards topic underpinning with the aim of areas. A five-point Likert scale was contributing to the highest standard Aim used to increase the response rate of patient care and professional and quality of the responses. The The aim of this study was to competence in the perioperative survey also comprised open-ended categorise priority research topics in setting21,22. The Standards continue questions for each of the five topic perioperative nursing. A secondary to be updated every two years areas. Participants were invited to aim was to identify gaps for and provide a valuable resource make any comments or suggest areas consideration and inclusion in the for perioperative nurses and for further research. Demographic Standards. other professionals involved in information was included in the managing surgical patients as well as questionnaire. The questionnaire was promoting implementation of EBP in Method developed and reviewed by the RC the operating suite. Study design members for feasibility in terms of readability, clarity of the questions In a recent editorial it was A descriptive cross-sectional study and time taken to complete. The highlighted that while research design was used to identify research development of the questionnaire publications in both emergency priorities in perioperative nursing25. was informed by the findings from

e-30 Journal of Perioperative Nursing Volume 33 Number 4 Summer 2020 acorn.org.au the ACORN conference workshop24. average of 20 years (SD = 10.3) Table 1: Demographic data of (See supplemental material for a experience in the operating suite. participants (n = 113) copy of the questionnaire.) The main area of practice was represented by instrument or Characteristics n % Data analysis circulating nurses, or both (38.9%), Gender The quantitative data were analysed with 34 (30.1%) indicating their role in Female 104 92.0 using the Statistical Package for the operating suite involved multiple Social Sciences (SPSS v24, IBM, New clinical roles. Eight (7%) nurses were Male 9 8.0 employed in an anaesthetic role or York, NY, USA). Descriptive statistics Age group were used to calculate absolute in the Post Anaesthesia Care Unit 21–30 6 5.3 (n) and relative frequencies (%) for (PACU) (n = 7; 6.2%) or both (6 = 29, categorical, means and standard 29.7%). Further demographic details 31–40 15 13.3 are presented in Table 1. deviations (SD) for survey items. 41–50 42 37.2 Composite scoring was used to As shown in Table 2, most 51–60 41 36.3 combine items that represented each participants had completed a of the items included in the survey. postgraduate certificate or diploma 60+ 9 8 This created a score for each item in in perioperative nursing (n = 28, Registration the relevance and importance scale 24.8% and n = 29, 25.7% respectively). RN 108 95.6 by producing a single composite Twenty-four (21.2%) respondents 26 EN 5 4.4 score . For example, to create a had completed a master’s degree, composite score for ‘consider risk with two (2.8%) having completed Perioperative nursing mitigation in the operating suite’, a doctoral degree. Principle place role the average of the mean score for of work was in the operating CNS/CNC/ANUM 27 23.9 relevance (4.4) and importance (4.4) suite, day surgery settings or a Clinical nurse 49 43.7 was calculated. combination of the two, in both PNSA 1 0.9 The second phase of analysis the public and private sector. Most involved qualitative data which respondents (n = 68; 60.18%) worked NUM/POSD 17 15.0 was gathered from the comments in metropolitan settings, with 36 Clinical educator / 18 15.9 section of the survey. Inductive (31.86%) employed in regional academic settings. The remainder were rurally content analysis was undertaken Quality coordinator 1 0.9 to identify patterns and themes27, based (n = 9, 7.96%). All respondents which involved a systematic coding were a member of ACORN, with Main area of practice and categorising approach, while other memberships including the Instrument/ 44 38.9 exploring text to determine trends Australian Nursing College (n = 36, circulating 31.9%), the Australian Nursing and and patterns of words used, their Anaesthetic/PACU 29 29.7 frequency and their relationships28,29. Midwifery Federation (n = 55, 48.7%), Multiple clinical roles 34 30.1 Two RC members undertook this and other speciality organisations analysis, independently initially, (n = 42, 37.1%). Further clinical Non-clinical role 6 5.3 demographics are included in Table 2. then together reached a consensus Years of experience about whether the themes were an National research priorities 0–10 27 23.9 accurate representation25. Respondents ranked items in the 11–20 32 28.3 Results ‘staff and patient safety’ topic area 21–30 34 30.1 highest across both relevance and Of the 5251 members in the ACORN 31–40 18 15.9 importance, with means ranging from database, 113 responded, with a 3.7 (SD = 1.12) to 4.5 (SD = 0.83). The 41 or more 2 1.78 response rate of 2.2 per cent. The average rating for the ‘professional majority of respondents were CNC = clinical nurse consultant; CNS = practice’ topic area was second females (n = 104, 92%) with clinical nurse specialist; ANUM = associate highest across both relevance and an average age of 48 years nurse unit manager; PNSA = perioperative importance ranging from 3.5 (SD = nurse surgeon assistant; NUM = nurse unit (SD = 9.90). Most were registered 1.17) to 4.3 (SD = 0.82); the ‘equipment manager; POSD = perioperative services nurses (n = 108, 95.6%) with an and environment’ topic area rated director

Journal of Perioperative Nursing Volume 33 Number 4 Summer 2020 acorn.org.au e-31 Table 2: Clinical demographics to ten scored higher for relevance equipment, and intangible, e.g. (n = 113) (4.1 to 4.5/5) and importance (3.9/5 practice protocols. The former to 4.5/5) and related to safe patient included the potential for surgical Characteristics n % care, encompassing topics such as site infections (SSI), e.g. ‘more culture, risk mitigation, bullying and attention to protecting the sterile Highest level of disruptive behaviour and practices field, explore breaches and discuss qualification that prevent adverse patient speak up culture of this. Way Hospital certificate / outcomes, for example medication more important than what’s on 7 6.2 diploma safety. The items that were ranked people’s heads’. [Respondent 108, Bachelor of Nursing 23 20.4 between 11 and 20 scored lower perioperative services director] for relevance (3.0/5 to 3.9/5) and Other tangible risks included Postgraduate importance (3.0/5 to 4.0/5) and 57 50.5 medication management, equipment certificate / diploma related to safety in the perioperative issues (e.g. laser safety) and the Master’s / doctoral environment, for example instrument 26 23.0 need for adequate staffing and skill degree tracking and noise reduction in the mix to provide acceptable patient operating theatre, with most topics Location of setting care. Examples of an intangible risk not included in the current edition of for patients were lack of access to or Metropolitan 68 60.2 the Standards. use of standards (ACORN and others), Regional 36 31.9 Key themes also a lack of situational awareness. Rural 9 8.0 One respondent noted, ‘senior Participants responded to the executives are the main barriers with Type of setting open-ended questions regarding providing resources and equipment Public 72 63.7 the national research priorities. The to meet ACORN and MoH [Minister of Private 37 32.7 process of coding, categorising and Health] standards’. [Respondent 57, repeated crosschecking revealed nurse unit manager] Other 4 3.5 two overarching themes. These There were also tangible and Practice setting were ‘management of risk’ (both intangible risks to staff. Tangible risks patient and staff) and ‘culture of the Operating suite 95 84.1 included exposure to plume, cement perioperative environment’ (which (fumes), high noise levels, excessive Day surgery 1 0.9 was expressed in negative terms). workloads and associated fatigue. For Operating suite / day The first theme, ‘management of risk’, 12 10.6 example, ‘staff fatigue in relation to surgery was linked to both patients and staff, on call, overtime and late / no meal and was evident in the quantitative Other 4 3.5 breaks’. [Respondent 81, instrument data, as highlighted in Table 3. The nurse] One comment supporting Professional second theme identified was ‘culture an intangible risk included ‘we membership of the perioperative environment’, eat our young’. [Respondent 37, ACN 36 31.9 which was described negatively. multiple clinical roles] Some risks However, topics associated with ANMF 55 48.7 were deemed relevant to both this theme were expressed less patients and staff. To illustrate this Other 42 37.1 frequently than those topics sub-theme one respondent stated associated with the management of that we should ‘analyse the patient ACN = Australian College of Nurses; risk. Within these two themes, five ANMF = Australian Nursing and Midwifery and staff risks associated with the sub-themes were identified, with Federation. implementation of poorly designed each one composed of one or more (user interface) digital medical topics (see Table 4). The sub-theme records e.g. ieMR’. [Respondent 97, third. Overall, the standards topic ‘safety’ comprised eight topics and anaesthetic nurse] areas that were ranked relative to the remaining sub-themes each relevance were ranked similarly contained two, except for ‘staffing’, The issue of ‘the culture of the in relation to importance. Table 3 which had only one topic. perioperative environment’ was details these results. evident across the qualitative data, Comments made in relation to the except the section on ‘equipment With regard to composite scoring of theme of patient risks were both and environment’. Staff were more each of the items, those ranked one tangible, e.g. personal protective

e-32 Journal of Perioperative Nursing Volume 33 Number 4 Summer 2020 acorn.org.au Table 3: Results relative to relevance and importance within ACORN standards topic area (n = 113)

Relevance Importance Composite Topic area Item detail x SD x SD (R+I)/2 Rank Identify strategies to change the culture of the Staff and operating suite and enhance the safety of the 4.5 0.83 4.5 0.83 4.5 1 patient safety perioperative team Consider risk mitigation in the operating suite 4.4 0.88 4.4 0.89 4.4 2 Explore the safe use of patient handling equipment in 4.3 0.8 4.2 0.9 4.25 6 the operating suite Evaluate the use of, and outcomes associated with, 3.9 0.99 4 1.13 3.95 11 the new ACORN practice audit tools Determine how to protect the perioperative team 3.8 1.18 3.7 1.12 3.75 15 during the use of cytotoxic drugs intraoperatively Professional Identify barriers and enablers to ACORN guidelines / 4.3 0.82 4.2 0.86 4.25 7 practice standards implementation in perioperative settings Examine compliance with medication safety standards 4.2 0.85 4.1 1.04 4.15 9 and labelling of medications Investigate strategies to manage and provide safe patient care to surgical patients with cognitive 4 1.07 3.9 1.13 3.95 12 impairment Investigate the use of patient / family-centred 3.7 1.1 3.7 1.25 3.7 17 approaches in the perioperative context Explore the lived experience of new graduate nurses 3.7 1.17 3.5 1.17 3.6 18 when implementing the ACORN Standards in practice Sepsis and Examine the effectiveness of strategies to minimise or 4.4 0.84 4.4 0.84 4.4 3 clinical care prevent perioperative-acquired pressure injuries Identify the most effective types of head attire for use 3.4 1.41 3.2 1.4 3.3 19 in the perioperative setting Equipment and Identify the most effective method to minimise heat 4.4 0.83 4.3 0.86 4.35 4 environment loss in patients before, during and after surgery Examine the integration of instrument tracking with the Patient Information Management Standard 3.9 1.07 3.9 1.06 3.9 13 (electronic) Explore noise reduction methods in operating rooms 3.9 1.05 3.7 1.1 3.8 14 and patient care areas Explore non-technical skills, such as situational Management awareness, decision making, communication and 4.4 0.88 4.2 0.94 4.3 5 and staffing teamwork in operating suites Consider recognition and attitudes of perioperative 4.2 0.95 4.2 0.97 4.2 8 nurses to bullying behaviours Explore the effects of disruptive behaviour on patient 4.1 1.04 3.9 1.11 4 10 safety Examine the impact of different staffing models or 3.8 1.1 3.7 1.15 3.75 16 models of care on patient experience Examine the causes of obesity among perioperative 3 1.39 3 1.4 3 20 nurses

Journal of Perioperative Nursing Volume 33 Number 4 Summer 2020 acorn.org.au e-33 Table 4: Sub-themes and topics high-quality evidence about the prevention and treatment of pressure 36 Most frequently occurring topics [number of injuries is crucial , in particular in 37 Sub-themes comments] the perioperative environment . The findings are similar with regard to Safety Non-use / awareness of / lack of access to technology and use of equipment standards [7] in the operating suite38. One of the Plume and other fumes [2] challenges facing clinicians is how Fatigue [5] to implement research findings in 6 Wellness [3] clinical practice . Noise in operating rooms [2] Patient safety within the health care Tracking compliance [2] industry has emerged as a result of the evolving complexity in health Loan set processes [2] care systems and resulting increase Preventing SSIs (not attire-related) [5] in adverse patient outcomes39. It is Culture of the Negative culture and patient safety [3] reported that patient harm due to perioperative Aggression / bullying / negative behaviours [10] unsafe care is the fourteenth leading environment cause of the global disease burden40, with approximately half of these Operating room Hats [7] injuries considered preventable41. attire Foot covers [2] Hospital-acquired complications Education and Staff education / training / ongoing [6] (HAC) were reported for two per training Equipment-related training [2] cent of all hospitalisations in 2016–2017 which included 2.2 million Staffing Staffing ratios [4] elective and 352 000 emergency surgeries42. The cost of these failures likely to experience the impact to breaches’. [Respondent 108, is considerable with an estimated of a negative environment rather perioperative services director]. 15 per cent of hospital expenditure than the patient. However, several attributed to treating safety failures40. respondents noted that when staff Discussion This costs the Australian health care were intimidated they did not Three research topics were identified system an estimated $1 billion per speak up and patient safety was 43 as priorities in this study: patient year . compromised, as reported by one safety, management of risk in the respondent, ‘patients are not safe Issues relating to staff wellbeing operating room, and culture of when staff are distracted or feel were rated as being important and the perioperative environment. intimidated by others’. [Respondent relevant, this was also identified in Issues linked to safe patient care, 108, perioperative service director] the qualitative data, in particular including prevention of pressure bullying and disruptive behaviour. The most frequently reported injuries, safe use of patient handling In fact, one of the major themes comments highlighted bullying, equipment, minimising heat loss identified in the data related intimidation and aggressive and medication safety, were rated to culture in the perioperative behaviours across all of the topic high on both scales (relevance and environment. Although there are a areas. Several comments also importance), with education linked number of studies where bullying reflected the need for a change of to the use of equipment identified behaviour has been identified44–47 attitude by surgeons, senior nurses as a key theme. There is a plethora further research is required to and hospital administrators. These of evidence relating to maintaining identify the factors associated with 30–32 included ‘how to engage medical normothermia in surgical patients , culture in the unit with strategies staff to comply with processes that and also for evidence relating to developed so that this can be nursing staff introduce for staff and pressure injury prevention in the better managed. Awareness of the 33–35 patient safety’. [Respondent 50, nurse perioperative environment . importance of a poor safety and unit manager] and ‘professional However, in a recent meta-synthesis quality culture is paramount in respectful behaviours need to of Cochrane reviews the authors preventing adverse patient events, be reinforced with zero tolerance concluded that the generation of a concept not well researched48

e-34 Journal of Perioperative Nursing Volume 33 Number 4 Summer 2020 acorn.org.au but of extreme importance in an survey was conducted before this patients and themselves. Where it increasingly complex perioperative edition was pubished.] affected staff in particular, this was environment. linked to the negative culture of A key component of safety and the setting, with formal leadership The publication To err is human: quality in health care includes required to institutionalise evidence- Building a safer health system the Australian National Safety and based practice and initiate change62,63. suggests a comprehensive approach Quality Health Service Standards Responses from the perioperative to improving patient safety and (NSQHS Standards) which were nurses provide an indication of states that an organisational culture introduced in 2011 with the aim of the evidence that is required in that encourages learning from protecting patients from harm and clinical practice. While evidence- adverse events and near misses is improving the quality of health based practise is considered the required49. The importance of this service delivery58. As the largest gold standard, a number of barriers was confirmed in a systematic review component of the health workforce, prevent the application of best which identified the association nurses play a critical role in meeting practice standards64. It is clear between positive organisational these standards and improving that building research capacity is and workplace cultures and positive the quality of patient care59. The important, not only to demonstrate patient outcomes, such as reduced importance of this was evident with the positive impact of perioperative mortality rates and hospital acquired the inclusion of the icons from the nursing on patient outcomes but also infections and increased patient NSQHS Standards in 16th edition of to strengthen the evidence on which satisfaction50. the ACORN Standards, indicating standards for practice are based and how individual ACORN standards Similar topics that were rated lower enhance the professional standing of support the NSQHS Standards60. in the relevance and importance perioperative nurses24. As noted in 2018 by Williams et al., categories, such as noise in the well-developed, evidence-based operating room and instrument standards are not enough to change Limitations tracking, were identified in the practice as a number of barriers have Although the low response rate qualitative data. When searching been identified when perioperative reported in this study is a limitation, the literature, studies exploring nurses are required to introduce it should be noted that the noise in the operating room 51,52 or evidence into their practice24. While perioperative nurses who responded instrument tracking53 have been criticisms about the poor quality of to the survey were from a range published; however, these provide the research informing the standards of nursing roles, locations and limited evidence to inform clinical was noted24, these documents types of hospital settings. Valuable practice. Another example of a topic are only as good as the research information about the research where there is limited evidence in evidence used to inform them61. As priorities in perioperative nursing the literature was obesity among evidenced in the literature there has been identified, highlighting perioperative nurses54,55. Many of has been limited input of end-users areas of practice that require further these topics have been identified in identifying relevant research evidence to support practice. as leading health problems priorities; therefore, there remains globally, for example the growing an obligation to ensure research epidemic of obesity in Australia56,57; References activities align with the interests, therefore, there is an opportunity for 1. Spruce L. Back to basics: Implementing needs and values of perioperative perioperative nurses to undertake evidence-based practice. AORN J practice8. 2016;101(1):107–112. research to address these issues 2. Vetter MJ, Latimer B. Tactics for teaching and improve the safety of patients Implications for evidence-based practice: Enhancing active and wellbeing of health care leaning strategies with large class of professionals. 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