Competency of Perioperative Nurse

Mentoring and safety instruction are universally acknowledged to be significant components of clinical education (Masters, K., 2016). The value of mentorship has been thoroughly researched in various student demographics. Ajorpaz et al. highlighted the necessity to examine the efficiency of mentorship in the competence of operating room students in their 2016 study. According to the findings of the study, mentoring is an important supplement to ordinary training that includes faculty supervision. Students in operating room nursing who were given supplementary mentoring programs performed better than those who simply got teacher supervision. According to the findings, it is clear that mentoring is effective in the preparation of nursing students in practise (Ajorpaz et al, 2016). By examining five experimental and quasi experimental research articles addressing mentorship programs, Chen and Lou (2014) discovered that medical negligence and stress rates are reduced while professional identity and job satisfaction of recently registered nurses are improved through the implementation of mentorship programs (Chen et al., 2007; Chen, C-M. & Lou, M-F., 2014).

When the relationship between the staffs and the students are improved, the healthcare systems may improve, and the quality of care for patients can also be increased (Coe, R. & Gould, D., 2008; Tame, S.L., 2012). However, many operating room (OR) nurses are often abused by the physicians and the effects of such abuse is not already understood. The abuse is contributed to by three factors; the culture of the operating room, the position and experience of the nurse, and the perceived effects on the physical, psychological and social health of the nurses (Higgins, B.L. & Macintosh, J., 2010). The abuse together with other factors often discourages nurses and new staff members from seeking support from their supervisors and they ultimately gain little from the supervision (Moked & Drach-Zahavy, 2016).

Supervision outcomes and support-seeking behaviours can be improved by enhancing mentor-student encounter when nursing clinical supervision is being performed through creating supportive environments. High independent nursing students tend to seek less support as compared to low independent ones (Moked & Drach-Zahavy, 2016). According to personal evaluation, the students seeking less support see themselves as more professionally competent (Gardulf et al., 2016; Tilley, D.D.S., 2008) than those who seek more support. The relationship between professional competencies and support-seeking behaviours can be moderated by enhancing the mentor’s counter-dependent attachment style (Kieu et al., 2015; Lyon, P., 2004). Administrators can promote supervision processes in ways that ensure they are compatible with the independent learning style of students. However, the processes must be geared towards the prevention of the adverse implications of autonomic learning. Since the support-seeking of students can be hindered by mentors counter-dependent attachment style, it is important to consider attachment styles when mentors are being selected (Moked & Drach-Zahavy, 2016). To achieve significant results, studies show that the operating room should be designed as a clinical learning environment (Bernedt et al., 2015; Meyer, R., Van Schalkwyk, S.C. & Prakaschandra, R., 2016).

The professional competence of staff members can improve with the number of years of working experience together with academic training (Nicholson et al., 2013; Ortiz, J., 2016). During training and the first two to three years of work, the staff should be facilitated, directed and given feedbacks that are constructive by a mentor/preceptor so that the mentor can help the nurses gain competency (Gopee, 2011). When independence and support seeking has been nurtured among the nurses, hospitals can use more nurse anaesthetists and fewer physicians to minimize errors and increase efficiency and nurses’ competency (Marcus, R., 2006; Meeusen et al., 2010; Alfredsdottir, H. & Bjornsdottir, K., 2008).

McGarvey, H.E., Chambers, M.G.A. and Boore, J.R.P found that different contextual mechanisms affect the perioperative nurses’ performance (2004). Studies have highlighted that adequate support should be provided to perioperative nurses so that they can perform their roles especially in environments that are intensely stressful (Meretoja, Leino-Kilpi & Kaira, 2004; Arora et al., 2010b; Rajan, D., 2015). The strengthening of perioperative nursing practice and the ultimate improvement of patient care are strongly dependent on the promotion of a caring philosophy and a patient-focussed leadership (Sexton, Thomas & Helmereich, 2000).

Health systems around the world today emphasize the management of risk as a policy priority. Patient safety circles currently stress the importance of identifying and managing risk in order to minimize harm to patients (van Beuzekom et al., 2012). McDonald, Waring and Harrison found out that sophisticated risk discourses are useable in the operation theatre department in challenging the current orthodoxy in patient safety (2005). Particularly, doctors were found to use discourses that lay emphasis in the scientific nature of the measurement of risk and taking advantage of the fact that the probabilistic risk calculations are ambiguous.

Even though the objective risk identification and management is currently an accepted wisdom in the policy circles of patient safety, the conceptualization of risk among doctors and nurses still remain at odds with the widely accepted wisdom. Studies indicate that nurses currently focus on counting of swabs, ensuring sterile conditions are maintained and checking trays as their roles in managing risk (McDonald, R., Waring, J. & Harrison, S., 2005). However, instead of focussing on their own skills and individual performance with regard to their duties, they were more focussed on the processes and the immediate area of responsibility. For instance, many nurses would rather gossip about the surgeon’s laziness when they are on their own than speak out in the operating room whenever they see the surgeon putting the life of a patient at risk. Sometimes the staffs fear to report the adverse incidents when they feel the information may not be used or be used poorly (Catchpole, 2010). The study by McDonald, Waring and Harrison (2005) also revealed that nurses can follow erroneous directions without knowing. This can lead to a minimization in their confidence in practise and lack of knowledge on how to handle risks. Systems should be redesigned to promote error and injury reporting (Cutter, J. & Jordan, S., 2013).

Risks can be effectively managed if the nurses can learn to work in teams and communicate freely with the doctors and their supervisors (Alfredsdottir, H. & Bjornsdottir, K., 2008). Attitude surveys reveal positive attitudes to the behaviours that are associated with safety and teamwork (Flin et al., 2006). However, nurses and surgeons have different perceptions of views about leadership and teamwork and how it affects performance. The quality of communication and surgical leadership within the theatre are more favoured among consultant surgeons than trainees and theatre nurses (Flin et al., 2006). The lack of agreement in thought between surgeons and trainees often leave the operating room teams at risk of being stressed (Hull et al., 2011; Gillespie, et al., 2009).

The most likely teams to be stressed include assistant surgeons postoperatively and intraoperatively as well as the circulating staff preoperatively (Hull et al., 2011). Generally, stress has adverse effects on team performance in the operating room (Arora et al., 2010b). Patient safety in the operating room can be enhanced by interventions that are geared toward protecting teams against avoidable stress. However, the interventions must be developed with vivid and comprehensive understanding of how stress affects team performance and competency in nursing (Tilley, D.D.S., 2008). One method that has been found to be very effective in enhancing patient safety in the operating room and increasing the competency of perioperative nurses is the implementation of the revised WHO checklist (Fajemilehin et al., 2016). However, studies have revealed that providers are often not keen on implementing the checklist or even any standardized checklist (Erestam et al., 2017; Fajemilehin et al., 2016; Hurlbert, S.N. & Garrett, J., 2009).

The nature of the operation can also contribute to stress among perioperative nurses and other theatre staff. Operations like organ and tissue donation are potent stressors in the operating room. Some cultures may view organ and tissue donation as a taboo or immoral (Araujo & Massarollo, 2014; Kim, J.-R., Fisher, M.J. & Elliott, D., 2006). If nurses from such cultures are compelled to participate in such operations, many nurses would become stressed up or even depressed (Kent, R., 2002). One key solution to the problem is to eliminate all possible causes for failures in communication so that nurses can, among other things, freely communicate their attitudes about the type of operation and whether they would not mind participating.

Failures in communication in the operating room often lead to a common set of problems (Catchpole, 2010; Lingard et al., 2004). About 30 per cent of team exchanges have been found to constitute communication failures and a third of the failures lead to effects that adversely affect patient safety through raising cognitive load, increasing tension in the operating room and interrupting the operation routine (Lingard et al., 2004). Even though team training and improved team processes have been discovered to help in boosting team culture, performance, safety and clinical outcomes, there are still scarce opportunities for interprofessional learning (Gillespie, et al., 2009; Weaver, S.J., Dy, S.M. & Rosen, M.A., 2014).

The high-risk, high pressure environment in which perioperative practitioners work, without being given the benefits of stable team membership is a barrier to opportunities and momentum for collaborative improvements initiated by teams (Meretoja, Leino-Kilpi & Kaira, 2004). The best solution to the problem is to minimize the workplace pressures through communication (Kingdon, B. & Halvorsen, F., 2006) and actions like debriefing, safety briefing before surgery, and after action review, which can help in generating interprofessional improvement plans and creating a safety climate within the OR (Allard et al., 2011; Alves et al., 2017; DeFontes, J. & Surbida, S., 2004; Stephens et al., 2016). Nurses also need to participate in the definition of roles so that they gain clear directions for the future (McGarvey, H.E., Chambers, M.G.A. & Boore, J.R.P., 2000). Another important intervention is to use an invitational operating room teaching in which the preceptees are made to feel welcome and included in the operating room by the preceptors (Finger & Pape, 2002; Lewis, L. & McGowan, B., 2015).

Another issue that affects patient safety and sometimes leads to stress among nurses is the boundary conflict between theatre nurses and a new profession known as Operating Department Practitioner (ODP) whose roles are similar to those of theatre nurses (Timmons, S. & Tanner, J., 2004). However, nurses have been found not to be deeply concerned about demarcation issues. The more pressing issue is the ability of the professionals whose duties are to assist the surgeon to anticipate the needs of the surgeon beforehand and make provisions to eliminate risks (Mitchell et al., 2011). Novice scrub nurses take longer to anticipate the needs of the surgeons, increase the possibilities of making mistakes. Experienced nurses have scored higher performance scores in terms of cognitive non-technical skills than the novice nurses (Koh, Park & Wickens, 2014; Mitchell et al., 2011). The failures in non-technical skills have been found to lead to avoidable incidents during the operating procedures (Rutherford, Flin & Mitchell, 2012). There is need to offer non-technical skills training to both team and individual nurses in order to promote OR patient safety (Siu, Maran & Paterson-Brown, 2016; Mitchell, L & Flin, R., 2008).

Nurses fail to gain competency during their academic education due to lacking academic research at the time of clinical practice, failure to apply the theoretical aspects of the process of nursing into practice, and limited availability of professional educators who are knowledgeable (Sharghi et al., 2015; Pupkiewicz, J., Kitson, A. & Perry, J., 2015). Other factors include using traditional methods that are routine-oriented, and limited time for knowledge-based performance in association with the workload for the nurse. In order to improve qualified nurses’ education, there need to be efforts of reducing the separation between theoretical and practical knowledge both in the educational and the work environments (Sharghi et al., 2015; Stephens et al., 2016). Schools of nursing should also be integrated into higher education so that the nursing students can be exposed to the nursing practice as early as possible (Burke, L.M., 2006). In China, for example, managers have been reducing occupational stress for nurses by reducing the workload for the nurses (Zhou, H. & Gong, Y.-H., 2015). One strategy that has been successful in reducing workload is employing more nurses. Nurses should also be trained in skills for problem solving and their active coping strategies fortified (Zhou, H. & Gong, Y.-H., 2015). Further, nurses staffing should take into account night shifts so that the stressors associated with the shortage of nurses during the night can be eliminated (Arora et al, 2010a; Newhouse et al, 2005).

In perioperative nursing, psychological stress is a very complex issue that has been reported to have potentially adverse effects. Studies have shown that perioperative nurses experience stress due to factors like interpersonal conflict, workload, equipment availability and organisational issues (Santamaria, N. & O’Sullivan, S., 1998). Interpersonal conflict has been regarded as the leading stressor. There is also a significant correlation between nurses’ psychological stress and the lifestyle construct especially in particular tough situations of interpersonal conflict. Interventions that are based on individual psychology (IP) can help nurses in dealing better with interpersonal conflict especially in the environment of perioperative practice. Their stress responses in interpersonal conflicts that are frequently encountered can also be reduced (Santamaria, N. & O’Sullivan, S., 1998).

Through a systematic literature review, it was discovered that there are various factors that affect perioperative nurse competency and subsequently their psychological wellbeing and patient safety. To improve the competency of perioperative nurses, competency and non-technical skills education should be promoted in all institutions that offer nursing education. Risks and stressors in the operating room can be enhanced by promoting a learning and safety environment in the operating theatre. The study also revealed that nurses who are offered mentoring and preceptor supervision tend to become more independent but still feel free to seek support where necessary. Such nurses were found to be more confident and competent in their duties.


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