Prerequisites for infection prevention interventions during the intraoperative phase from the perspective of operating room nurses, An integrative review

Prerequisites for infection prevention interventions during the intraoperative phase from the perspective of operating room nurses, An integrative review | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Research Article Prerequisites for infection prevention interventions during the intraoperative phase from the perspective of operating room nurses, An integrative review Ida Markström, Kristofer Bjerså, Margareta Bachrach- Lindström, and 2 more This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-3082832/v1 This work is licensed under a CC BY 4.0 License Status: Posted Version 1 posted You are reading this latest preprint version Abstract Background Surgical site infections pose a significant threat to patient safety, causing morbidity and mortality. Preventing surgical site infections through infection prevention interventions during surgery is crucial in limiting the risk of contamination from environmental microorganisms or skin flora. In many countries, operating room nurses are responsible for the aseptic environment and the performing of preventive interventions during the intraoperative phase. For patient safety, optimal prerequisites should be present for the operating room nurses’ performance of infection prevention interventions. This integrative review was conducted to explore the prerequisites for operating room nurses to effectively carry out infection prevention interventions during the intraoperative phase. Method Whittemore and Knafl´s review method guided this integrative review. The search strategy includes multiple academic databases, backward and forward chaining, and targeted internet searches. The constant comparative method was used to analyse and synthesise data from 17 studies. Results This review identified several key factors that affect operating room nurses' ability to perform safe infection prevention interventions. These factors included intrapersonal prerequisites of the operating room nurses, interpersonal prerequisites within the operating room team, external conditions, and both facilitating prerequisites and barriers to implementing evidence-based practice. The intrapersonal category emerges from the subcategories: have control, planning ahead, competency, and occupational stress. The interpersonal category originates from the subcategories: cooperative behaviour and respect. The conditions category emerges from the subcategories: management and communication systems. The evidence-based practice category includes prerequisites for the use of scientific evidence. Conclusions This study highlights the need to improve the prerequisites to effectively execute safe preventive infection interventions. The team's lack of commitment to preventing surgical site infections raises concerns for patient safety and leaves operating room nurses feeling disrespected. Operating room nurses should assume leadership responsibilities and be supported by management, with access to necessary prerequisites such as information, education, and sufficient time for preparation and implementation. Regular feedback on infection rates and complications is crucial. The study highlights the significance of well-staffed and familiar teams and the urgency of zero tolerance for abusive behaviour. Resilience is essential for operating room nurses' well-being and optimal patient care. antisepsis infection control review nurse operating room patient safety perioperative postoperative complications prevention surgical site infections Figures Figure 1 1. Background 1.1 Problem identification Patients are always at risk during surgery and are particularly at risk for surgical site infections. These infections are hospital-acquired infections that occur after surgery at the incision site or in deeper tissues where the surgery took place ( 1 , 2 ). Surgical site infections pose a significant threat to patient safety and cause patient suffering in the form of physical disability, additional surgical procedures, reduced quality of life, morbidity, and mortality ( 3 – 7 ). More than 13 million surgical procedures are performed worldwide every year ( 8 ). The annual incidence of surgical site infections in the United States is approximately 1%, with approximately 8000 deaths directly related ( 9 ). In 2017, the European union countries, reported rates were around 1.5% from a total of approximately 649,000 surgical procedures ( 10 ). In developing countries, the numbers are higher, with over 30% of surgical patients developing surgical site infections each year ( 11 ). Surgical site infections result in significantly increased clinical workloads and economic burdens ( 3 , 12 ). In the United states, it was the costliest of the hospital acquired infections, with an estimated annual cost of $ 3.3 billion, extending length of the hospital stay by 9.7 days ( 2 , 13 ). Surgical wounds are at a high risk of contamination from pathogenic microorganisms derived from the patient's own skin or from the surrounding environment ( 14 – 16 ). The development of surgical site infections depends on bacterial load, bacterial virulence and patient’s ability to resist infection ( 17 ). There are numerous factors associated with causing surgical site infection. The patient's physical health, the type of surgery and the duration of the surgical procedure, can be used to predict risks of surgical site infections ( 18 , 19 ). By adopting a team-based approach during the perioperative phase (which includes the time before, during, and after surgery), it is possible to prevent up to 50% of these infections ( 20 , 21 ). There are evidence-based guidelines available to prevent surgical site infections. These guidelines include recommendations for preventive practices such as antiseptic prophylaxis, prevention of hypothermia, antimicrobial prophylaxis, glucose control, oxygenation, and skin preparation ( 16 , 22 , 23 ). During the intraoperative phase, which spans from the admission of the patient to the operating room until the transportation of the patient to the recovery area after the surgical procedure, the surgical wound is at great risk of contamination ( 17 , 24 ). The optimal operating room environment should be aseptic, and the equipment used should be sterile, meaning it should be free from any living organisms ( 25 ). Infection prevention interventions are implemented to limit the risk of contamination from environmental microorganisms or skin flora ( 25 , 26 ). There are international differences, but in many countries the operating room nurse has the aseptic responsibility to perform infection prevention interventions during the intraoperative phase. This includes identifying the risk of infections, preparing, and covering the skin, and maintaining a safe aseptic environment ( 25 , 27 , 28 ). Other nursing roles that may have aseptic responsibilities in the intraoperative phase include perioperative nurses, surgical nurses, and scrub nurses ( 24 ). The operation room is a high-risk environment in which different professional groups with different specialisations, foci, and training must work together in sometimes stressful situations ( 29 ). It is known that conditions in the operating room affect the surgical team's performance, which may result in negative consequences for the patient ( 30 – 32 ). An earlier study explored operating room nurses' experiences with infection-preventive skin preparation and found that several factors within the team, the environment, and the organisation negatively impacted patient safety ( 33 ). Patients have the right to equitable, efficient, and safe healthcare, and operating room nurses are obligated to perform safe infection prevention interventions. The prevention of surgical site infections is major focus for global healthcare and to our knowledge, there is no knowledge about the prerequisites necessary for operating room nurses to carry out infection preventive interventions during the intraoperative phase. Hence, the objectives of this study were to explore prerequisites for operating room nurses to carry out infection prevention interventions during the intraoperative phase. Infection prevention during surgery is essential for improving patient outcomes, reducing healthcare costs, and ensuring safe and effective surgical care. This review will identify potential risk areas for surgical site infections, with the goal of increasing patient safety and improving infection prevention. 2. Methods This integrative review was carried out in five stages described by Whittemore & Knafl ( 34 , 35 ); problem identification, literature research, data evaluation, data analysis, and presentation. 2.1 Literature search The integrative review search methods described by Whittemore & Knafl ( 34 ) guided the literature search process. A search strategy was organised using searches of academic databases, manual screening of reference lists (backward chaining), and citation searches via Google Scholar (forward chaining) and internet searches. With the assistance of librarians, computer-assisted searches with both thesaurus terms and keywords in four academic databases were performed (specific search strategies are outlined in Table 1 ). The search started in PubMed, followed by searches in the Cumulative Index of Nursing and Allied Health Literature (CINAHL, EBSCO), and Embase. Free-text keyword searches were employed in Web of Science’s Core Collection. The search terms used were terms related to patient safety and operating room nursing. No time restrictions were applied. Table 1 Overview of the database searches Database Main search Limitations Pubmed 2022-04-12 (patient safety OR patient harm) AND (perioperative nurse OR perioperative nursing OR operating room nurse OR operating room nursing OR operating theatre nursing OR operating theatre nurse) 1 English Cinahl 2022-04-12 (patient safety OR patient harm) AND (perioperative nurse OR perioperative nursing OR operating room nurse OR operating room nursing OR operating theatre nursing) 2 English Embase 2022-04-12 (patient safety OR patient harm) AND (perioperative nurse OR perioperative nursing OR operating room nurse OR operating room nursing OR operating theatre nursing) 2 English Web of Science Core collection 2022-04-12 (patient safety OR patient harm) AND (perioperative nurse OR perioperative nursing OR operating room nurse OR operating room nursing OR operating theatre nursing) 3 English ( 1 All fields, 2 Default, 3 Topic search) The initial database searches were performed on April 12, 2022, yielded 7471 studies, and were exported to Endnote© (version X9). A flow diagram of the selection process is presented in Fig. 1 ( 36 ). -Please insert Fig. 1 here- Duplicates (n = 2748) were removed, and inclusion and exclusion criteria were established (Table 2 ). The remaining studies (n = 4723) were divided among the five authors and screened by title and, if necessary, by abstract. During the initial title screening, the overall inclusion criterion was applied to ensure that the selected articles matched the objectives of the integrative review. Table 2 Inclusion and exclusion criteria for studies Inclusion criteria: • Focus on patient safety in the operating room • Focus on operating room nurses or synonyms for ‘nurse with aseptic responsibility (scrub, perioperative, surgical, etc.) • Studies evaluating experiences of infection prevention interventions • Experiences during the intraoperative phase Exclusion criteria: • Reviews, guidelines, theses, abstracts, letters, and unscientific articles • Studies that do not allow extraction of findings from operating room nurses For validation, the first author reviewed the titles of the excluded studies, and a few were brought up for a second review and discussion in the research group. The title screening phase resulted in 581 unique studies. Next, using the same inclusion criteria, the authors switched articles and performed abstract reading; an additional 336 were excluded. The remaining 245 studies were split among the five authors and read in full using all inclusion and exclusion criteria. Only studies that could indicate nurses' experiences with aseptic responsibilities were included in the analysis. All five authors discussed the studies until an additional 236 articles were excluded, finally agreeing on nine studies. Additional manual screening of reference lists (backward chaining), and citation searches via Google Scholar (forward chaining) of the nine articles was performed. Furthermore, from April 2022 to November 2022, the first author received weekly updates from PubMed for new articles in the search area. The first author also ran weekly targeted web searches through www.google.com using the combination of the words operating room nurse and patient safety during the same period. After further discussion in the research group, the additional searches generated eight more unique studies. This resulted in a final inclusion of 17 studies in the integrative review (Fig. 1 ). 2.2 Data evaluation The data evaluation stage aims to assess the quality of the studies by identifying their strengths and weaknesses, by assessing whether the results of the included studies are unbiased and transparent and could be included in the integrative review ( 34 ). The Critical Appraisal Skills programme for cohort and qualitative studies was chosen because it suits a variety of research designs and is widely used in Integrative reviews ( 37 , 38 ). The appraisal forms have 10 and 14 questions, respectively (see supplementary material Table 1). Each question may be answered by three alternatives: yes, can´t tell/not applicable, or no. To enable systematic quality checking and comparability, we have chosen to add numerical values to each answer; yes = 2, can't say/not applicable = 1 and no = 0. For qualitative studies, the maximum quality score was 20, whereas 15–16 was considered moderate, and below 15 was considered low quality. For quantitative studies, the maximum score was 28, whereas 22–23 was considered moderate, and below 21 was considered low quality. All five authors performed the assessments independently. Due to co-authorship, one of the authors did not evaluate Wistrand et al. ( 39 ) and Wistrand et al. ( 40 ). The assessments resulted in eight high qualitative studies,( 41 – 48 ) and one high quality quantitative study ( 40 ). We found two low quality qualitative studies,( 49 , 50 ) and one low quality quantitative study,( 39 ), four qualitative studies of moderate quality,( 51 – 54 ) and one quantitative study of moderate quality ( 55 ). All authors discussed the assessment, and no studies were excluded because they all could contribute to the overall results and were published in academic peer-reviewed journals. However, their place in the evidence hierarchy was considered during data analysis. 2.3 Data analysis The constant comparative method was used for analysis since it is suitable for various research designs and facilitates structured data analysis ( 34 , 56 , 57 ). The primary data found in the included articles was displayed, compared, and synthesised. Raw data such as author, year, country, design, study aim, sample population, data collection, analysis, and key findings were extracted and put into a data collection form by the first author (Table 3 ). All five authors read, discussed, and approved the extraction. Table 3 Summary of reviewed studies Author (year), Country Research design Purpose Setting and sample characteristics Data collection methods/key measurements Analyse method Major findings Aholaakko (2011), Finland Explorative interview study To explore aseptic practise-related stress among surgery nurses Setting: One surgery department of Helsinki University Central Hospital. Sample: 31 intraoperative surgery nurses* *= The nurses varied their roles so that in every other operation they worked as a ‘scrub nurse’. Stimulated -recall interviews 31 operations were videotaped and used as stimuli. A membership categorization device analysis by Baker …as novis surgical nurses was afraid of not knowing what to do, they want to perform as good as more experienced colleagues, stressed when they need to do instruments counts and have environmental control at the same time Time stress (need to focus on the next surgery) Need to control persons with “aseptic looseness”. Persons with limitations on taking feedback or following recommendations for aseptic practise …stress was present when a hot-tempered surgeon; fussy co-worker; either nurse or surgeon with limitations on taking feedback or following recommendations for aseptic practise participated in the team Patient-related stress in aseptic practise was visible during operations, for example as a need to document the obesity of the patient as a potential risk for infection A young nurse was worried about harming an old patient’s thin skin or had problems with patients’ anatomical variances Power-related feedback as being afraid to give feedback about aseptic practise to the surgeon, afraid to make them angry, surgical field being a battlefield …stress was felt as positive when a surgery nurse was an Aseptic Practise specialist being in a “dream surgery team” A nurse has to be independent and, sometimes, quite headstrong to have the right to work properly” Alfredsdottir and Bjornsdottir (2008), Iceland Explorative interview study To identify what threatens and enhances patient safety and how operating room nurses see their role in ensuring safety Setting: OR-nurses at one university hospital in Iceland. Sample: I14 OR nurses* *=8 OR nurses in individual interviews and 2 focus group. (Two OR nurses participated in both individual and focus groups) Individual & focus group interviews A study in two stages, stage two is included in this integrative review. Interpretive content analysis All participants described how prevention is always at the core of their work They also described how they had to know the background of the patient, and their vulnerability and fragility that might increase risk during the operation They rely on information from the patients’ records, particularly from the anaesthesia team A number of participants said that in some situations they do not have all the information required preoperatively, especially in cases of specific patient needs …better preoperative information would ensure patient-centred nursing, continuity of care, and better and more efficient preparation for the surgical operation The teams are often unequally staffed; some are under-staffed and often need support from other teams. Participants felt that this needed to be attended to by managers Participants described how imbalance in staffing, which may be either under- or over-staffing, may lead to unsystematic preparation or distraction The work processes are timed and, while the surgical procedure cannot be rushed, the nurses sense pressure to reduce time for preparation and time between operations Bastami, Imani et al. (2022), Iran Phenomenological study To explain the lived experiences of operating room nurses experiences with patient cares for laparotomy surgeries Setting: A public educational hospital, Hamedan. Sample: 10 OR nurses In-depth and semi-structured interviews Analytical phenomenological method Aseptic technique observance in the operating room is a fundamental factor in providing indirect care for patients under surgical operation “I always gloves and gown changed. Because leakage into the peritoneal cavity can be a source of generalized peritoneal sepsis” “I always wear two gloves before beginning a surgical operation. For dressing the wound, I take off the upper gloves so that the dressing does not get dirty” According to the participants’ experiences, inadequate sterilization of the skin and drape of the surgical site was one of the leading causes of hospital infections after the surgery “One of our colleagues preps the surgical site within less than 1 min, fills the gallipot with 7.5% betadine, but never uses it. I have noted several times, but he never pays attention and does not care about the patient’s life” Björn and Lindberg-Boström (2008), Sweden Descriptive study with Phenomenographic approach To describe the theatre nurses’ work from their own perspective. Setting: OR nurses from two hospitals in Sweden. Sample: 15 OR nurses Interviews with open-ended questions Phenomenographic technique Theatre nurses achieve control of the situation by advanced planning and being ‘one step ahead’ The most important thing for a nurse is to be prepared for the operation The lack of respect for their practice that they sometimes experienced from colleagues in other disciplines and which had a negative impact on teamwork Holmes, Vifladt et al. (2020), Norway Descriptive interview study To explore Norwegian operating room nurses’ perceptions of how team skills in the inter-professional operating room team influence perioperative nursing in relation to patient safety. Setting: Operating departments at three general hospitals and one university hospital in the south-east of Norway. Sample: 10 operating room nurses Semi-structed Interviews Inductive content analysis …the OR nurses’ perception that the performance of perioperative nursing is better when there are good team skills …OR nurses strive to do their tasks in a good way, even though this might be time-consuming and tiring: “My standard is the same, independent of who the patient is, or who I’m working together with. But it’s easier to achieve this if communication is good” The OR nurses perceived constructive criticism, willingness to learn, planning and a good tone as resulting in better performance of perioperative nursing The participants perceived that poor communication or situation monitoring, along with experiencing a lack of mutual support or leadership, can lead to intraoperative events such as faulty positioning or draping, lacking equipment, or forgetting a catheter or warming blanket Unnecessary communication, noise, loss of concentration, stress, insecurity and irritation have a negative influence on the performance of perioperative nursing Good communication makes it easier for OR nurses to speak up about risks to patient safety. They perceived that adverse event such as hypothermia, injury due to positioning, infection and extensive blood loss might occur partly because of poor team skills Poor communication, for example lack of information, inappropriate or unnecessary remarks, poor leadership and situation monitoring, or having to take on others’ tasks, can result in delays because they lose focus on their own task “You lose some focus when you have to watch what is going on around you at the same time” “If you aren’t good at leading the OR team, it can result in misunderstandings, which can have serious consequences, complications, for the patient” “in big operations it is good when the surgeon comes in early to see everything is okay. To help find equipment, hold up the leg for skin disinfection … and at least offer to help” Poor team skills such as misunderstandings, interruptions and not being able to trust others to do their job properly can create stress, which again can increase the risk of making mistakes Kaldheim and Slettebø (2016), Norway Explorative interview study To acquire knowledge about what theatre nurses, perceive as important factors in collaboration with other team members to see what factors are needed to strengthen interdisciplinary cooperation. Setting: Four Norwegian operational units Sample: 8 OR nurses Semi–structured interviews Constant comparative inductive analysis The theatre nurses want to be accepted as having skills and duties that are equal to the other members in the team They want to be seen and heard by the others in the team as people with tasks that are meaningful They often experience working situations where there is not always so much tolerance for having to wait for each other, and that their task must be done “quickly and invisibly” The participants want others to understand the importance of their job and to recognise that it also requires time When team members have knowledge and understanding of each other’s work, it is also easier to help each other The participants describe how a surgeon may help them to open and cover sterile equipment preoperatively, while he/she waits to be ready for the operation It may be the way in which things are said, or someone raising their voice and shouting. It affects the concentration and focus of the participants in the situation, and this affects the quality of the performance of theatre nursing There are some situations like that where, for me at least, there will be poorer cooperation when someone gets scolded. For then you will be a little preoccupied in your head that there is a bad atmosphere here. In addition, I lose a little of my concentration The leader should have insight into the team members’ tasks and communicate the need for resources upward in the organisation Lingard, Garwood et al. (2004), Canada Explorative validation study To determine to what extent documented tension patterns are transferable to other institutional contexts. Setting: Two small academic hospitals in in Canada. Sample 1: 22 OR nurses, (5 anaesthesiologists, 10 trainees, 6 surgeons) Sample; phase 2 10 surgeons (and fluctuating team members) Data were collected in two phases: Phase 1: 8 focus group, 8 individual interviews Phase 2: Field observations Modified grounded theory approach …issues of aseptic technique and patient safety influenced team communication. Nurses were almost always participants in these communication exchanges, perhaps reflecting their professional responsibility for aseptic technique For instance: Senior resident enters OR not scrubbed, stands inches from the sterile field. Circulating nurse turns towards resident, watches intently, frowns disapprovingly. With only 6 of 28 observed instances (21%) involving higher tension levels, the theme of safety and sterility was not a prominent catalyst for tension Nordström and Wihlborg (2019), Sweden Phenomenographic interview study To describe the work experiences of nurse anaesthetists and OR nurses in the OR. Setting: One university hospital and one regional hospital in Sweden. Sample: 6 OR nurses (6 anaesthetic nurses) Interviews Phenomenographic analysis An important aspect was to be acknowledged as integral members of the OR team and the recognition that every profession in the OR is a valuable part of this team Another aspect of responsibility is that all professionals must be given sufficient time to conduct their specific individual tasks They expressed a desire to be well prepared and have enough time to perform their work to the best of their ability Students and new colleagues should be given extra time to perform their tasks. When a new colleague attends, you have to tell everybody to slow down a bit so he or she has a chance [to perform their part] Nyberg, Olofsson et al. (2021), Sweden Explorative interview study To explore aspects of patient safety practice during joint replacement surgery through assessment of operating room nurses experiences. Setting: Three hospitals in Sweden; one university, one public general and one private orthopaedic hospital. Sample: 21 OR nurses Semi structured interviews Inductive qualitative content analysis Stated their need for a reliable preoperative plan to ensure a safe procedure. By planning and preparing well for the procedure, they attempted to reduce the time for surgical procedure Before preparing for the procedure, they often needed to confirm the information from a computerised surgical planning system with the orthopaedic surgeon, due to occurrence of failure in updating the plan. This need to confirm the plan was perceived as unsatisfying and experienced as time- consuming For some participants, the main source of patientrelated information was derived from the surgical planning system and the anaesthesia preoperative assessment They did not find time to get information from the main health records and were thereby not routinely accessing information There was no systematic feedback on results or complications. For example, some participants emphasised that they wanted to know the infection rates for their specific department OR management sent information about new routines and incidents by email, and these were sometimes perceived to not reach the appropriate OR personnel Established safety controls and compliance with aseptic principles were stated as important aspects for safety practice within the team Compliance with aseptic principles was considered to vary among different professions within the team. The ORNs were expecting all team members to perform responsibly, and when this was not the case, it became a strain in the workplace for them In situations where two ORNs collaborated during surgery, they had opportunities to support and learn from each other, and thereby improve their work They kept guarding sterility throughout the entire surgical procedure by keeping an eye on the activities of other team members, which sometimes could be challenging Participants noted that the prerequisites for work in an aseptic environment were present National guidelines for preventing PJIs were established, and there was most often compliance with these One example given was a guideline to control the traffic and avoid disturbance of the ventilation by opening the doors and trying to minimise the number of persons in the OR Participants experienced that compliance with guidelines varied within the team. For example, some orthopaedic surgeons followed the guidelines more strictly than others. With an interesting surgical case, minimising the amount of personnel in the OR was disregarded by some surgeons The ORNs also emphasised a need to improve staff behaviour regarding adherence to the aseptic principles When they insisted on observing aseptic protocols, it sometimes was considered a disturbance of the flow, affecting both the surgical procedure and the whole day operation schedule When notifying others on breaks of aseptic principles, some participants perceived that they were seen as annoying …Even if people might think you're irritating, I think you still get some kind of respect in that you have competence and can see that this is important. Even if you are considered awkward, you are trusted as the person who also is competent and good, good for the group and for the patient Although the ORNs were well aware that many factors could have led to an infection, they felt accountable for it if a patient acquired a surgical site infection or a periprosthetic joint infection Prati and Pietrantoni (2014), Italy Descriptive cross-sectional (pilot) study To assess attitudes about teamwork and safety among Italian surgeons and operating room nurses. Setting: One hospital in the centre of Italy Sample: 48 OR nurses (55 surgeons) Operating Room Management Attitudes Questionnaire (ORMAQ) Parametric statistics The majority of the OR nurses agreed to the statement: It bothers me when others do not respect my professional capabilities (94% agreed) More than half of the OR nurses did not agree to the statement that team members frequently disregard rules or guidelines (e.g., hand washing, treatment protocols/clinical pathways, sterile field) developed for our Operating Theatre (69% disagreed) Qvistgaard et al. (2019), Sweden Reflective Lifeworld Research approach How OR nurses experience intraoperative prevention of SSIs. Setting: Seven hospitals in Sweden Sample: 15 OR nurses Interviews Phenomenological analysis …further competencies such as experience and courage are needed to ensure prevention Prevention of SSIs depends on an open and honest atmosphere within the team, a team that allows different professionals to contribute with their unique competencies ...the team members should adhere to the guidelines regarding OR hygiene “Everybody has their own responsibility inside the OR, but my job is to tell you when you are too close, when you have to change gloves, or when you need to adjust your surgical gown. You are trying to have an overview of everything that happens inside the OR and simultaneously keep the focus on what is going on during the surgical procedure” The absence of structured feedback makes it difficult when the profession seeks arguments for strengthening routines related to preventing SSIs. Therefore, measures intended to combat this invisible threat are difficult to evaluate and analyse. This lack of evidence for the effectiveness of routines results in insecurity and doubt connected to SSIs prevention measures “Sterility is the alpha and omega to me; here is where my occupational pride is at stake and I cannot look the other way” Awareness of risks related to SSIs is carried out by individuals who have confidence in each other and dare to confront human shortcomings Confident relations and resolute communication within the team generate favourable conditions for preventing SSIs The invisible threat of microorganisms can be made visible to others if OR nurses use their profound knowledge to explain the connection between bacterial load and the risk of SSIs a lack of trust in one’s colleagues creates anxiety among the team, a milieu that will not benefit the patient: “You really need your team and it’s important that everybody understands why we do certain things, not just doing it because I say so” Friction among team members is evident when one or several team members are unwilling to understand other professionals’ responsibilities and competencies Some people are more or less frightened of some surgeons and then you become nervous and that leads to insecurity and mistakes. For example, if a surgeon is intimidating, I might make mistakes, get nervous and take the surgical towel that I had for cleaning instruments and put it in an open wound during hip replacement Confronting colleagues irrespective of their position requires a security in one’s own competence and a security in the team’s willingness to hear potentially uncomfortable feedback, competencies that develop with experience Effective leadership helps team members develop confidence in organizational structures and offers stability for the team members. Managing both team collaboration and organisation are intertwined and clearly related to intraoperative prevention of SSIs Traditionally, the head surgeon is the team leader and this person’s effectiveness as a leader ensures the effectiveness of the preventive work. Both formal and informal leaders dictate the terms of the preventive work; if they aim for the same goal, it is possible to reach mutual strategies OR nurses often feel their contributions are minimised. The balance between the legitimacy of OR nurses and the authority of the traditional hierarchy, which places surgeons at the top, is fragile Prevention of SSIs often end up being a secondary priority, a lack of commitment that often leaves OR nurses feeling ignored “You can get so tired of yourself and you feel like a disc that repeats itself over and over again, but you can’t give up and capitulate to what you believe is correct. Who will take an interest in SSI prevention if not me, no one would care about that” OR nurses reside in their responsibility to ensure that team members follow hygienic guidelines inside the OR Sandelin and Gustafsson (2015), Sweden Descriptive interview study To describe operating theatre nurses’ experiences of teamwork within the surgical team in regard to achieving patient safety. Setting: Four hospitals in Sweden; two urban and two hospitals in rural regions. Sample: 16 OR nurses Interviews Content analysis A brief meeting (with the patient before surgery) facilitated OTNs to be better prepared for safe nursing care Interdependent collaboration with surgeons was reached when OTNs experienced respect as equal co-workers and were involved and engaged as key partners, and spoken to with respect for their professional skills OTNs were totally dependent on nurse assistant (NAs) willingness to collaborate. The collaboration of the OTNs and NA was characterized by leadership and the NA was perceived as the OTNs’ ‘right hand’ OTNs believed that friendly leadership was necessary in the collaboration as this would generate a willingness to follow OTNs’ instructions efficiently the nursing care-plan was based on OTNs’ personal experience, general routines and a brief reading of each patient’s medical record Sometimes surgeons were unable to control their tantrums with consequences of other team-members’ knowledge and skills tended to decrease because of the strained atmosphere In order to be able to trust unfamiliar or inexperienced NAs, OTNs interrogated them about nursing knowledge and skills. This was necessary for the planning and the performance of nursing care, and involved guiding in a polite and friendly way to do the right thing at the right Sandelin, Gustafsson et al. (2019), Sweden Descriptive interview study To describe operating theatre nurses’ experience of preconditions for safe intraoperative nursing care and teamwork. Setting: Four hospitals in Sweden; two urban and two hospitals in rural regions. Sample: 16 OR-nurses Interviews (reanalysed data) Content analysis …operating theatre nurses (OTN) met patients preoperatively for a conversation about their health status and needs, as well as details about the surgical intervention. In these cases, OTNs expressed that they were well prepared with adequate information from the primary source for decision-making of care activities for safe intraoperative nursing care OTNs’ described frequent experiences of obtaining only brief, incomplete and fragmented information about the patients’ health situations and their upcoming surgical interventions The documentation in the computerised systems was not complete, due to restrictions from codes and measures in the systems when not informed, they had to phone the surgeon in orderto be properly prepared for the intervention they preferably wanted to be prepared for each patient's operation the day before For the most part, because they were moved around between different surgeries in their daily work, OTNs would not read the patient's record until the patient was confirmed and transported to the OT department. This meant that they did not have a chance to be completely prepared for each patient's surgery “Also, even when an operation was delayed because of an anaesthesia procedure, OTNs felt they were the ones to blame. Sometimes it takes time for the anaesthesia personnel, when the patient has a complex health situation, and I feel stressed doing the skin disinfection and the sterile draping …and the surgeons enter and wonder what you are doing and why it has taken such a long time” OTNs explained they needed to have high standards of personal professional skills and knowledge to be able to offer patients safe perioperative nursing care They also depicted their responsibility for the hygiene and aseptic care environment as well as, security controls of the sterile surgical equipment and the patient's well-being and safety. OTNs’ best experience of safe and efficient work occurred in situations where two colleague OTNs collaborated during surgery OTNs described the importance for ensuring patient safety of nurse leadership holding clear standards, routines and operational goals. When first-line managers were invisible and uncommitted, the OT department was described as lacking standards and routines Silén-Lipponen (2005), Finland, United Kingdom & Unites states of America Critical incident study OR nurses’ experiences about potential errors and error prevention in operating room Setting: OR departments in Finland, UK and USA. Part of larger international research project Sample: 30 OR nurses Finnish (n = 10), American (n = 10) British (n = 10) Audio-taped interviews Qualitative content analysis The need to manage multiple, simultaneous demands while providing high-quality care imposed a continuous pressure on nurses “You know, people cannot work or even think if they are constantly worried about their own or others’ mistakes” Arguments during operations could lead to overheated feelings and, thus, jeopardize patients’ safety by causing errors. Therefore, nurses forced themselves to remain undisturbed and to keep up sustained working Confidence about the individual team members’ skills made advanced preparation Teams familiar with their members could pool their strengths, anticipate each other’s needs (even from gestures), exchange roles across professional boundaries and, thus, minimize the occurrence of errors Contact with careless or risky behaviour: “The instrument was gas-sterilized but had not been aerated. I told him [the surgeon] that you cannot use it because of what it causes to human tissues is the same as a microwave oven. Still, the surgeon insisted on having it. Then the situation was taken out of my hands, and I had to write a case report about serious misbehaviour that compromised the safety of a human being” Timmons and Tanner (2005), United Kingdom Ethnographic study To explore the emotional labour in an operating theatre nurses context Setting: Five hospitals in UK Sample: 12 OR nurses (8 other professions) Observations n = 20 & individual interviews n = 20 Not known …it was their responsibility to ‘look after’ the surgeons rather like an air hostess or a party hostess Not upsetting surgeons describes actions which nurses refrained from undertaking to prevent antagonizing surgeons …nurses might have tolerated poor practice rather than antagonize surgeons even though the poor practice was to the detriment of unconscious patients The surgeon walks into the theatre. He is carrying his coffee mug and eating a roll. This contravenes theatre infection control policies. None of the nurses say anything to him Surgeon comes into theatre, he is not wearing a hat. This contravenes the theatre dress code and presents a risk of infection. The nurses, including Nurse W, don’t say anything. Another surgeon comes in, looks at the surgeon with no hat and says ‘What, no hat, is this a new rule? ’ In the following example, the interviewer asked a nurse why she poured ether over some swabs for a surgeon? (Ether, a hazardous substance, is banned from theatre departments): He likes using [ether]. We have to get pharmacy to supply it especially for him. Yes, I know we shouldn’t be using it The nurses would accommodate surgeons’ demands even if they did not agree with them: The instruments had been set up and we had to wait about 30 min for the patient. When the patient came in and they were about to start operating, the surgeon asked the Sister if these were the same instruments? She said ‘Yes, but they are all right’. The surgeon said ‘I want fresh instruments’. The nurse got new instrument trays out. Later, the nurse said to me ‘I didn’t need to change them but I wasn’t going to argue with him’ Wistrand, Falk-Brynhildsen et al. (2018), Sweden Descriptive cross-sectional study To describe the daily interventions Swedish operating room nurses perform to prevent SSIs following national guidelines Setting: OR-nurses from 64 hospitals in Sweden. Sample: N = 890 OR- nurses Web-based questionnaire Descriptive statistics The majority of the interventions recommended by the national guidelines were implemented in daily work and that the interventions were performed fairly consistently nationally When guidelines were lacking, variation in the intervention used increased, for example, the application of adhesive plastic drapes Most, 41.1% (n = 366), often let the skin dry before draping; and to enhance adherence of the drapes to the patient’s skin, 34% (n = 303) of the nurses often wiped the skin dry in the site where the drapes should adhere using sterile paper towels Most of the nurses responded that they had learned to perform patient skin disinfection from their supervisors (another OR nurse) or at the clinical practice during in-service education (48.9%; n = 435), while 41.7% n = 371) learned the technique from the educator at a university. The remaining 9.4% of the nurses stated either that they had learned it from colleagues or the Handbook for Healthcare Workers or that they did not remember Sterile gowns for single use were employed by 83.8% (746/890) of the nurses The reasons for changing the outer gloves differed, but the most dominant reasons were puncture of the glove or the wearing of the outer glove for a long time The majority of the nurses reported that they performed the pre-operative disinfection of the patient for two to five minutes Wistrand, Falk-Brynhildsen et al. (2021), Sweden Descriptive cross-sectional study To explore interventions that Swedish operating room nurses considered important for the prevention of bacterial contamination and surgical site infections. Sample: N = 890 OR- nurses Web-based questionnaire with an open-ended question From part II, analysis of the open-ended question. Summative content analysis and descriptive statistics Infection control included 57.7% of the total number of codes (n = 2033), it was considered the most important way for the nurses to prevent bacterial contamination and SSI Skin disinfection is the most important intervention in order to prevent bacterial contamination and surgical site infection Aseptic technique was maintained during surgery by keeping the sterile goods sterile, removing the draping after the dressing was applied, supervising other persons in the surgical team to ensure that they did not contaminate anything in the sterile field, and quickly replacing any contaminated item with a new, sterile one Along with this, the nurses described additional interventions that they performed in order to uphold an aseptic technique: the use of antibacterial sutures, avoiding touching implants, a thorough preoperative hand disinfection of their own hands including the checking of other team members’ hand disinfection, and cleaning the sterile goods during surgery in order to avoid bacterial growth The use of incision drapes to protect the surgical area and transparent plastic film to cover open wounds was considered important It was important that the draping was employed correctly, and that it should stay in place throughout the procedure Important aspects included choosing a dressing suitable for that specific surgery, applying the dressing in a sterile manner, and applying the dressing closely and tightly against the skin ...the importance of choosing a dressing that was gentle and appropriate for sensitive skin, and that would not cause blisters or eczema … a lack of an instrument in the OR, the personnel in the OR should use the phone to ask someone outside the OR to bring the missing instrument instead of opening the doors important for the hygiene level in the OR to be satisfactory and the doors of the OR to be kept closed; or, at least, opened only when absolutely necessary during preparation for surgery and the surgery itself “Use the phone in the OR as your means of communication [with staff outside of the OR], do not run in and out. Plan your work and make sure that the equipment you might need is in the OR, use reach-through cabinets as much as possible” The nurses described a calm environment, few people, and no opening of doors as important factors in order to minimize bacterial air contamination Aseptic technique was also considered important. This was described in many ways, for example in terms of making sure to change gloves with holes or gloves that were damaged in some way The nurses believed that it was important for all personnel working in the OR to be dressed appropriately in tightly woven clothes or clean air suits, including using a mask and helmet, with sterile gowns and gloves for the personnel actively working with or around the surgical area… The nurses stated that they felt it best to set up and cover the sterile goods before the patient arrived at the OR if possible, and that it was important for the preparation to be done in a sterile manner Connected to preparation, such as checking that the instruments were sterilized before taking them out of their packaging The nurses stated that it was important for basic hygiene to be upheld by all members of the OR staff “The importance of sterility throughout the surgery, and being responsible for ensuring that everyone in the OR follows the hygiene regulations” “Being well informed regarding the patient by reading their medical chart” One nurse stated that it was important to have “knowledge of postoperative wound infections in order to be able to prepare oneself properly” Two of the nurses stated that they needed to be given the proper amount of time to prepare the skin disinfection of the surgical area, in order to allow them to perform their work well and without stress -Please insert Table 3 here- The analysis process began with the first author conducting an open coding of the extracted data, which were then reviewed and approved by the entire research group. A first draft was created by three of the authors (an operating room nurse, a registered nurse, and a critical care nurse), all with experience with qualitative data and two with previous experience with the analysis method. All were aware of the risk of personal judgement when researching one’s own field of practice, and this risk was repeatedly and critically discussed ( 58 ). The coded data were compared individually to find patterns, similarities, and connections, and to form subcategories. After the initial draft was approved, the research team synthesised the results within each sub-category. This process led to the creation of an integrated summary and the development of main categories by the research group ( 57 ). For an example of the analysis process, see Table 4 . Table 4 Examples of the analysis process Meaning units Code Subcategory Category …as being afraid to give feedback about aseptic practise to the surgeon, afraid to make them angry, surgical field being a battlefield. Being afraid to give feedback Cooperative behaviour Interpersonal There was no systematic feedback on results or complications. For example, some participants emphasised that they wanted to know the infection rates for their specific department. Need for feedback Communication systems Conditions 3. Results A total of 17 articles were included in the analysis and comprised studies from the following countries: Canada (n = 1), Finland (n = 1), Iceland (n = 1), Iran (n = 1), Italy (n = 1), Norway (n = 2), Sweden (n = 8), the United Kingdom (UK) (n = 1), and an article with findings from the UK, Finland, and the US (n = 1). Out of the total, 14 studies employed qualitative methods, while three studies had quantitative methods. Demographics are presented in Table 3 . The analysis resulted in four categories; intrapersonal, interpersonal, evidence-based practice, and conditions. The main categories emerged from the eight subcategories; have control, planning ahead, competency, occupational stress, cooperative behaviour, respect, management, and communication systems. 3.1. Intrapersonal The intrapersonal category includes prerequisites among operating room nurses and regarded beliefs, perceptions, emotions, and personal characteristics concerning the professional responsibility of prevention interventions during the intraoperative phase. The intrapersonal category emerges from the subcategories; have control, planning ahead, competency, and occupational stress. 3.1.1. Have control Prevention was an essential part of their professional responsibility ( 47 ), and infection prevention interventions was considered the most important way to prevent surgical site infections ( 40 , 54 ). To maintain an aseptic environment, they strive to have control over the operating room, the equipment, and the personal actions of other professionals within team ( 40 , 42 , 44 , 46 , 49 – 52 , 54 ). They felt responsible if the patient acquired infection ( 44 ) and felt obliged to assess and document risks of surgical site infections ( 51 ). They actively worked to maintain control of the aseptic environment by implementing infection prevention interventions, including the replacement of non-sterile equipment, glove changes, proper dressing application, and ensuring the secure placement of the drape ( 39 , 40 , 50 ). The aspiration was to have control over the equipment, ensuring its proper setup and coverage before the patient's arrival ( 40 ). Skin disinfection was considered the most important intraoperative infection preventive intervention, and draping was essential ( 40 , 50 ). Incision drapes to protect the surgical site and plastic drapes to cover open wounds were also considered important ( 40 ). 3.1.2. Planning ahead Being able to plan ahead was an important prerequisite ( 40 , 41 , 43 – 47 ). The ability to be prepared meant being one step ahead in the surgical procedure ( 41 ). Operating room nurses require adequate time for preparation, which is crucial, as they often face time constraints while performing their duties ( 40 , 43 , 44 , 46 , 51 ). A precise preoperative plan makes preparation easier and reduces the patient's time in the operating room, which can decrease the risk of surgical site infections ( 40 , 44 ) A desire was expressed to review the patient's medical chart or preoperative plan prior to the procedure, ensuring that all necessary information and preparations were in place ( 40 , 45 , 51 ). Knowledge of patients' medical histories provide a higher level of awareness of risk factors such as vulnerability and fragility, setting the stage for adjusted infection preventive interventions ( 44 , 45 , 47 ). A preoperative conversation with the patient was highly advantageous, as they found it to be beneficial in ensuring the provision of safe care ( 45 ). 3.1.3. Competency The professional competence of operating room nurses was prerequisite. Competence, as well as experience were described as essential skills for the performance of infection prevention interventions ( 40 , 47 , 54 ). Two studies rated competence as the most important factor ( 46 , 51 ). Within the team, operating room nurses had the most competence in infection prevention and took charge of educating other professionals ( 42 , 45 , 47 , 51 , 54 ). Competency was a prerequisite for the ability to direct actions for an aseptic environment ( 51 , 52 , 54 ). They believed that having the necessary skills and knowledge, along with a friendly leadership style could foster respect among team members and increase their willingness to comply with hygiene rules ( 44 , 45 ). The ability to direct infection prevention actions improved with experience ( 54 ). 3.1.4. Occupational stress Occupational stress was present, affected the prerequisites for preventive infection interventions, and contributed to feelings of an inability to cope with work demands ( 46 , 47 , 51 , 52 ). Operating room nurses endeavoured to provide safe and equitable care ( 52 ). However, the lack of time was stated as one of the major sources of occupational stress, and they often experienced time pressure in their clinical duties ( 44 , 46 , 51 ). Stressors arose when they felt obligated to minimise the time allocated for mandatory tasks during preparation and surgery ( 46 , 47 , 51 , 52 ). Stress also arose when they felt the need to have ‘split vision’, such as planning the next surgery while protecting sterility and performing infection prevention interventions ( 48 , 51 , 52 ). Stress also arose when team members failed to follow hygiene rules or disregarded feedback on their behaviour ( 44 , 48 , 51 , 52 , 54 ). Patient-related factors, such as poor preoperative preparations or physical challenges were experienced as stressful, especially for inexperienced operating room nurses ( 51 ). New operating room nurses were more worried about not knowing what to do ( 51 ). 3.2. Interpersonal The Interpersonal category contains prerequisites for infection prevention interventions that were influenced by the interaction of two or more people. Interpersonal prerequisites related to the operating room team included composition, competencies, the ability to cooperate, and respect for the operating room nurse's area of ​​responsibility. The interpersonal category was based on the subcategories: cooperative behaviour and respect. 3.2.1. Cooperative behaviour Cooperative behaviour was related to operating room nurses and surgeons, nurse assistants, or anaesthetic nurses. All team members needed to understand the importance of infection prevention and follow hygiene rules ( 40 , 54 ). Operating room nurses emphasised the value of a well-functioning team ( 45 , 48 , 51 – 54 ). Positive relationships among team members were found to facilitate infection prevention interventions and encouraged operating room nurses to speak up about errors and risks when necessary ( 51 , 52 , 54 ). Opportunities for mutual support and collaboration across professional boundaries were created when operating room nurses trusted the competencies and responsibilities of other team members ( 48 , 52 – 54 ). Collaboration between two operating room nurses during the intraoperative phase was found to be an enabling prerequisite ( 44 , 46 ). When performing preventive infection interventions, operating room nurses were dependent on the nurse assistants' willingness to cooperate ( 45 ). Additionally, cooperative behaviour, where the surgeon was willing to assist with infection preventive interventions, was highly valued ( 52 , 53 ). On the other hand, operating room nurses described conditions when cooperative behaviour was ineffective and unsafe. The necessary preoperative information from the operating surgeon was often lacking, and operating room nurses sometimes had to double-check information with the surgeon ( 44 , 46 , 47 , 52 ). Tensions in the team, unnecessary disturbances and poor communication skills were other conditions that negatively influenced infection prevention interventions ( 45 , 52 – 54 ). A lack of trust, communication, or an understanding of each other's responsibilities could lead to risky events such as ineffective infection prevention interventions ( 48 , 52 – 54 ). Bad tempered surgeons during the intraoperative phase could make them nervous and generate mistakes ( 48 , 52 – 54 ). When assessing the reasons for tensions in the operating room, safety and sterility were not prominent concerns ( 42 ). For reasons of patient safety, they endeavoured to remain focused and not respond to any distractions or engage with any instances of bad behaviour ( 48 ). Fearful of conflicts, they sometimes avoided informing the surgeon of poor aseptic practices ( 42 , 49 , 51 ). In one study, the operating room nurses described needing to ensure that surgeon has a smooth experience during surgery ( 49 ). 3.2.2. Respect Interpersonal requirements included a desire for other team members to respect their area of ​​expertise. Operating room nurses want to be treated as equal team members with valuable duties that take time ( 41 , 43 , 45 , 46 , 53 , 55 ). They perceived that infection preventive interventions were considered less valuable by other team members, who did not prioritize dedicating time to these interventions over other surgical tasks ( 41 , 46 , 53 – 55 ). Team members found it bothersome when operating room nurses alerted them to inadequate aseptic behaviour or initiated aseptic measures ( 44 ). 3.3. Evidence Based Practice The Evidence-Based Practice category contains prerequisites to integrate current evidence with clinical expertise in operating room nurses’ work on infection prevention during the intraoperative phase. This category includes conflicting findings. In several studies operating room nurses were of the opinion that most infection prevention interventions recommended in guidelines were implemented and followed during the daily work ( 39 , 44 , 55 ). On the other hand, there were several examples where guidelines were not followed by other team members or by the operating room nurses themselves ( 42 , 44 , 48 – 51 , 54 ). Adherence to guidelines varied between professionals in the team and between different operating room nurses ( 44 , 50 ). Not all infection preventive interventions had scientific evidence backing them up, and interventions with limited scientific evidence were, practised in various ways to a greater extent ( 39 ). A study reported that interventions were performed based on the operating room nurse's experience, routines, or emanated from the medical court ( 45 ). In one study, most operating room nurses followed the recommended time for skin disinfection and wore double sterile gloves ( 39 ). Although there is evidence supporting recommended practices for skin disinfection, studies found that some not adhere to them ( 39 , 50 ). Most of them acquired the skill of performing skin disinfection by learning from colleagues during their clinical education ( 39 ). The use of evidence-based interventions and the adherence to guidelines was impacted by the surgeon. Surgeons had final decision-making power and could decide on infection prevention interventions ( 48 , 49 , 54 ). Operating room nurses accommodate surgeons' specific requests, including deviations from guidelines and manufacturer recommendations ( 48 , 49 ). 3.4. Conditions Several studies reported prerequisites from outside the operating room nurses and the team. This category included prerequisites from the physical context in which operating room nurses practise infection prevention interventions. The category was based on the two subcategories: management and communication systems. 3.4.1. Management The environment provided prerequisites for infection prevention interventions. Operating room nurses required the environment to be calm during both the preparation and surgical procedure ( 40 ). Most often, they felt that there were good prerequisites for an aseptic environment ( 44 , 55 ). They stressed the need for all members of the team to have access to appropriate personal equipment such as surgical suits, gloves, helmets, and masks ( 40 ). Changes to timetables and team composition posed challenges in preparing for surgeries ( 46 , 47 ). Time constraints schedules did not include time to access patients’ medical records and the available preoperative information was overly brief ( 44 ). Operating room nurses believed that management should allocate sufficient time for preparation and infection prevention interventions ( 40 , 43 , 44 , 47 ). Management needs to have insight into the situations faced by operating room nurses and communicate their resource needs to the organisation ( 47 , 53 ). They recognise good management as a crucial support for infection prevention interventions ( 52 , 54 ), whereas poor management can lead to unstable routines and serve as a barrier to effective infection prevention ( 46 , 52 ). 3.4.2. Communication systems Well-functioning communication systems were a necessary prerequisite concerning infection prevention interventions ( 40 , 44 , 47 , 54 ). Of the included studies, three described operating room nurses’ access to insufficient and too-brief information from the anaesthesia assessment or from the operating room planning system ( 44 , 46 , 47 ). Feedback systems on surgical site infection rates or complications were requested to assess the effectiveness of infection prevention interventions and to gain insights to the efficiency of routines ( 40 , 44 ). The lack of feedback systems for surgical site infections was highlighted as barrier in two studies, as was not knowing the impact of performed interventions ( 44 , 54 ). Also, information about new practices and complications did not reach the right personnel ( 44 ). 4. Discussion To ensure the safety of vulnerable surgical patients, optimal prerequisites for the performance of infection prevention interventions must be present. This integrative review identified several key factors that affect operating room nurses' ability to perform safe infection prevention interventions. These factors included intrapersonal prerequisites within individual operating room nurses, interpersonal prerequisites within the team, external conditions, and both facilitating prerequisites and barriers to implementing evidence-based practice. Included studies show prevention was a high priority, and operating room nurses guarded the environment to protect the patient. This control is comparable to the attributes of patient advocacy, where healthcare professionals make sure that patients receive the best possible care and that their rights and interests are respected and protected ( 59 ). The operating room nurse plays an essential role in advocating for the patient's safety during surgical procedures. This striving for control is also similar to the concept of nursing vigilance; where nurses are meant to be scientifically, intellectually, and experientially aware of the situation, to assess the risks, and be prepared to minimise and respond to risks ( 60 ). As identified in this review, competence is crucial, not only for practising nursing vigilance but also for successfully implementing infection prevention interventions. Operating room nurses emphasised their distinctive role and extensive knowledge regarding aseptic and infection prevention interventions within the team. This unique theoretical and clinical competence has been described as essential to ensuring patient safety during surgery ( 61 ). Given this unique competence, operating room nurses are ideally positioned to lead infection prevention efforts within the team for patient safety and, therefore, must be given the necessary respect, time, and resources for this duty. As previously studied, operating room nurses have linked competence to knowledge, good communication skills, and teamwork ( 62 ). This review emphasises the importance of teamwork as a prerequisite for infection prevention, which is consistent with previous research on infection prevention in general ( 28 , 15 ). It is crucial for all team members to follow infection prevention guidelines and take appropriate actions. A synergistic effect can be achieved in the ideal team, where each individual contributes specific knowledge and competence to enhancing overall performance. Trust in the skills of other team members and good communication were prerequisites for infection prevention interventions. Previous studies have shown that inadequate information sharing during the intraoperative phase increases the risk of complications or patient mortality ( 63 ). It has been suggested that operating room teams with consistent members improve quality of care, reduce conflicts, and contribute to a flatter team hierarchy ( 64 , 65 ). The extensive utilisation of temporary staff across several European nations raises concerns regarding patient safety, as it may have implications for effective communication, coordination, and adherence to hygiene rules and routines ( 66 ). Thus, from the perspective of patient safety, it is desirable to have more permanent teams. This review revealed that operating room nurses perceived a lack of respect for their area of responsibility, including team members who did not follow hygiene rules, and negative attitudes from surgeons with bad tempers. Disruptive behaviour in the operating room has been reported in previous studies ( 67 , 68 ). A study revealed that at least once per month, over 20% of operating room nurses reported experiencing recurring incidents of verbal abuse from physicians ( 69 ). To manage this, they have developed coping mechanisms, such as remaining silent after experiencing verbal abuse, to maintain a working relationship with specific surgeons ( 70 , 71 ). Surgeons' disruptive behaviour has been shown to have a negative impact on patient safety by causing a loss of focus, increasing the risk of errors, reducing productivity, and potentially leading to staff turnover ( 72 , 73 ). These findings should serve as a wake-up call for managers. Operating room nurses should feel empowered to report such behaviour and be confident that action will be taken to address it. Furthermore, our findings addressed a hierarchical issue where the surgeon has ultimate decision-making power over the responsibilities of operating room nurses. Similar dilemmas were described for midwives, who lacked authority to make crucial decisions relating to births and faced ethical dilemmas because of hierarchical pressure from physicians and management ( 73 ). Even if surgeons have the formal responsibility of the surgery, they must follow established regulations and guidelines to ensure the safety and effectiveness of the procedure. For reasons of patient safety, operating room nurses must stop playing the role of ‘hostess’, as was described in this review, and not act solely as a surgeon's assistant ( 74 ). They must stop fulfilling requests from surgeons that do not comply with evidence and guidelines. Another skill required might be the ability to challenge authorities. Indeed, for patient safety, operating room nurses must meet the expectations within their area of responsibility and thoroughly follow established evidence-based practices. Operating room nurses claimed weak scientific evidence caused variation in routines. In fact, tradition-based infection preventive interventions are practised ( 33 , 75 ). Developing more evidence on infection prevention interventions can support them in their role as leaders of infection prevention interventions and contribute to patient safety. This review highlights the need for supportive conditions to ensure safe infection prevention interventions. Time constraints and lacking information and feedback from management were reported as negative prerequisites. An earlier study examined the reasons why operating room nurses decided to remain in their workplace. It identified positive prerequisites, such as supportive leadership, personal stability, and opportunities for personal and organizational growth, which are consistent with the findings of this review ( 76 ). Operating room nurses were often experienced stress and productivity demands. The concept of nurse resilience has gained increasing attention as a potential solution for enhance nurses well-being. Nurse resilience involves the ability of nurses to positively adapt to stress and adversity, incorporating both external resources and personal characteristics, which can vary with context and life circumstances ( 77 ). The essential attributes that contribute to nursing resilience include social support from colleagues, managers, friends, and families, as well as self-belief, work-life balance, self-care, humour, optimism, realistic assessment of challenges, and the establishment of attainable goal ( 77 ). This review revealed that novice operating room nurses encountered higher levels of stress and uncertainty when carrying out infection prevention interventions. With the right support, younger and less experienced can also experience resilience and growth in their profession, as one study highlighted that factors such as age, experience, and education have limited impact on the resilience of operating room nurses ( 78 ). In order to maintain their resilience, operating room nurses need to be able to identify and utilise their personal resources, receive support from management, and be provided with working conditions that promote resilience. If management is not attentive to these needs, it may lead to a shortage of nurses and reduced patient safety. This study emphasises the importance of ongoing research on infection prevention interventions to enhance patient safety and reduce practice variability. Improving the prerequisites for infection prevention interventions in clinical care decreases the risk of surgical site infections, improves patient safety, and increases resilience. 4.1. Strengths and limitations This integrative review follows the methodological recommendations of Whittemore & Knalf ( 34 ), and the preferred reporting items for systematic reviews ( 36 ). Studies were reviewed and assessed using critical appraisal tools. To ensure the credibility of the results, this review follows the stages of the constant comparative method. Additionally, all five authors of this review analysed and discussed the results together in order to prevent the authors from making any subjective interpretations ( 79 ). Several methodological limitations are worth considering in this integrative review. This integrative review includes studies from countries in Europe, as well as Canada and Iran, and the responsibilities of operating room nurses may differ between these. Thus, all the included studies provided insights into the operating room nurses’ aseptic responsibility and infection prevention interventions. Only 9 of the 17 included studies (53%) came from the initial database searches. This is a known problem due to indexing issues and inconsistent search terminology, especially in qualitative studies, which often require screening large numbers of studies and the use of multiple search strategies ( 34 , 80 ). A comprehensive literature search should include at least two or three search strategies ( 81 ). This review included five search strategies. Risk of publication bias was present, as only studies published in English were selected, and included the risk of missing out of important results. Initially, narrower search approaches were attempted, but these did not yield studies that aligned with the objectives of the study. In discussions with librarians, the broader data search strategy was chosen. However, it is important for the accuracy of the results of the integrative review that the literature research process is clearly and transparently documented and comprehensible ( 34 ). 5. Conclusions In conclusion, the study highlights the need to improve the prerequisites to effectively execute safe preventive infection interventions. The lack of commitment by the team to preventing surgical site infections is a cause for concern, as it left operating room nurses feeling disrespected and raised concerns for patient safety. Operating room nurses must be willing to shoulder the responsibility of leading and must be supported by management as leaders of infection preventive interventions, as well as provided with necessary prerequisites such as readily accessible information, further education, and sufficient time for preparation and implementation. Regular feedback on surgical site infection rates or complications is essential. This study emphasises the importance of well-staffed and familiar teams and underscores the need for zero tolerance for abusive behaviour, which has been overlooked for far too long. Finally, resilience is essential to maintain operating room nurses own well-being and provide the best possible safe care to patients. These recommendations, if implemented, will help improve the prevention of surgical site infections and promote patient safety in the operating room. Declarations 6.1. Ethics approval and consent to participate Not applicable 6.2. Consent for publication Not applicable. 6.3. Availability of data and materials Data is available upon reasonable request. All requests relating to data should be addressed to [email protected] 6.4. Competing interests The authors declare that they have no competing interest. 6.5. Funding This study was funded by the County Council of Region Östergötland, Sweden. 6.6. Authors’ contributions The authorship of this study was a collaborative effort involving IM, KB, GHF, MBL, and KFB. All authors actively contributed to the planning, goal setting, study design, and completion of this integrative review. Following the initial planning phase, the screening of studies after data searches was conducted through collaborative discussions by all authors. GHF, MBL, and IM carried out the initial analysis, while subsequent discussions involving KB and KFB were held. IM assumed the lead role in writing the manuscript and throughout the writing process, with each author providing feedback and making valuable contributions to the manuscript. The final version of the manuscript has been thoroughly reviewed and approved by all authors. 6.7. Acknowledgements We would like to thank the librarians Joakim Westerlund and Magdalena Öström at the Medical library, Linköping University, Sweden, for their support with the literature search. 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The preventable proportion of healthcare-associated infections 2005–2016: Systematic review and meta-analysis. Infection Control & Hospital Epidemiology. 2018;39(11):1277-95; doi: 10.1017/ice.2018.183 Keenan JE, Speicher PJ, Thacker JKM, Walter M, Kuchibhatla M, Mantyh CR. The Preventive Surgical Site Infection Bundle in Colorectal Surgery. JAMA Surgery. 2014;149(10):1045; doi: 10.1001/jamasurg.2014.346. National Institute for Health and Care Excellence. Surgical site infections:preventions and treatment, . NICE guideline 2019 [cited 2023 April 12]. https://www.nice.org.uk/guidance/ng125 Accessed 23 April 2023. Benze C, Spruce L, Groah L. Perioperative nursing: scope and standards of practice. Denver: AORN Inc; 2021. Rothrock JC. Alexander's Care of the Patient in Surgery-E-Book: Elsevier Health Sciences; 2018. Dumville JC, Norman G, Westby MJ, Blazeby J, McFarlane E, Welton NJ, et al. 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Thousand Oaks: Sage Publications; 1998. Page MJ, McKenzie JE, Bossuyt PM, Boutron I, Hoffmann TC, Mulrow CD, et al. The PRISMA 2020 statement: an updated guideline for reporting systematic reviews. BMJ. 2021:n71; doi: 10.1136/bmj.n71. Critical Appraisal Skills Programme. CASP Quallitative Checklist. 2018. https://casp-uk.net/casp-tools-checklists/. Accessed 20 May, 2022. Critical Appraisal Skills Programme. CASP Cohort Checklist.2018. [Available from: https://casp-uk.net/casp-tools-checklists/. Accessed 20 May, 2022. Wistrand C, Falk-Brynhildsen K, Nilsson U. National Survey of Operating Room Nurses' Aseptic Techniques and Interventions for Patient Preparation to Reduce Surgical Site Infections. Surg Infect (Larchmt). 2018;19(4):438-45; doi: 10.1089/sur.2017.286. Wistrand C, Falk-Brynhildsen K, Sundqvist AS. Important interventions in the operating room to prevent bacterial contamination and surgical site infections. Am J Infect Control. 2021; doi: doi: 10.1016/j.ajic.2021.12.021. Björn C, Lindberg Boström E. Theatre nurses understanding of their work: a phenomenographic study at a hospital theatre. Journal of Advanced Perioperative Care. 2008;3(4):149-55; doi: 10.1002%2Fnop2.424. Lingard L, Garwood S, Poenaru D. Tensions influencing operating room team function: does institutional context make a difference? Medical Education. 2004;38(7):691-9; doi: 10.1111/j.1365-2929.2004.01844.x. Nordström A, Wihlborg M. A Phenomenographic Study of Swedish Nurse Anesthetists' and OR Nurses' Work Experiences. Aorn j. 2019;109(2):217-26; doi: 10.1002/aorn.12582. Nyberg A, Olofsson B, Otten V, Haney M, Fagerdahl AM. Patient safety during joint replacement surgery: experiences of operating room nurses. BMJ Open Qual. 2021;10(4); doi: 10.1177/0107408315591337. Sandelin A, Gustafsson BÅ. Operating theatre nurses’ experiences of teamwork for safe surgery. Nordic Journal of Nursing Research. 2015;35(3):179-85; doi: 10.1177/0107408315591337. Sandelin A, Gustafsson BÅ, Kalman S. Prerequisites for safe intraoperative nursing care and teamwork—Operating theatre nurses' perspectives: A qualitative interview study. Journal of Clinical Nursing (John Wiley & Sons, Inc). 2019;28(13/14):2635-43; doi: 10.1111/jocn.14850 Alfredsdottir H, Bjornsdottir K. Nursing and patient safety in the operating room. Journal of Advanced Nursing. 2008;61(1):29-37; doi: 10.1111/j.1365-2648.2007.04462.x. Silén-Lipponen M, Tossavainen K, Turunen H, Smith A. Potential errors and their prevention in operating room teamwork as experienced by Finnish, British and American nurses. International Journal of Nursing Practice (Wiley-Blackwell). 2005;11(1):21-32; doi: 10.1111/j.1440-172X.2005.00494.x. Timmons S, Tanner J. Operating theatre nurses: Emotional labour and the hostess role. International Journal of Nursing Practice. 2005;11(2):85-91; doi: 10.1111/j.1440-172X.2005.00507.x. Bastami M, Imani B, Koosha M. Operating room nurses’ experience about patient cares for laparotomy surgeries: A phenomenological study. Journal of Family Medicine and Primary Care. 2022;11(4):1282-7; doi: 10.4103/jfmpc.jfmpc_1085_21. Aholaakko T-K. Reducing surgical nurses' aseptic practice-related stress. Journal of Clinical Nursing. 2011;20(23-24):3339-50; doi: 10.1111/j.1365-2702.2011.03844.x. Holmes T, Vifladt A, Ballangrud R. A qualitative study of how inter-professional teamwork influences perioperative nursing. Nurs Open. 2020;7(2):571-80; doi: 10.1111/j.1365-2702.2011.03844.x. Kaldheim HKA, Slettebø Å. Respecting as a basic teamwork process in the operating theatre - A qualitative study of theatre nurses who work in interdisciplinary surgical teams of what they see as important factors in this collaboration. Nordisk sygeplejeforskning. 2016;6(1):49-64; doi: 10.18261. Qvistgaard M, Lovebo J, Almerud-Österberg S. Intraoperative prevention of Surgical Site Infections as experienced by operating room nurses. International Journal of Qualitative Studies on Health & Well-Being. 2019;14(1): 1-12; doi: 10.1080/17482631.2019.1632109. Prati G, Pietrantoni L. Attitudes to teamwork and safety among Italian surgeons and operating room nurses. Work (Reading, Mass). 2014;49(4):669-77; doi: 10.3233/WOR-131702. Glaser BG, Strauss AL. The Discovery of Grounded Theory. 2017. New York: Routledge. Glaser BG. The constant comparative method of qualitative analysis. Social problems. 1965;12(4):436-45. Patton MQ. Qualitative research & evaluation methods. 3. ed. 2002. London: SAGE. Abbasinia M, Ahmadi F, Kazemnejad A. Patient advocacy in nursing: A concept analysis. Nursing ethics. 2020;27(1):141-51; doi: 10.1177/0969733019832950. Meyer G, Lavin MA. Vigilance: the essence of nursing. Online Journal of Issues in Nursing. 2005;10(3):38-51. http://nursingworld.org/ojin/topic22/tpc22_6.htm. Accessed 10 May 2023. Von Vogelsang AC, Swenne CL, Gustafsson B, Falk Brynhildsen K. Operating theatre nurse specialist competence to ensure patient safety in the operating theatre: A discursive paper. Nurs Open. 2020;7(2):495-502; doi: 10.1002/nop2.424. Gillespie BM, Chaboyer W, Wallis M, Chang HyA, Werder H. Operating theatre nurses’ perceptions of competence: a focus group study. Journal of advanced nursing. 2009;65(5):1019-28; doi: 10.1111/j.1365-2648.2008.04955.x. Mazzocco K, Petitti DB, Fong KT, Bonacum D, Brookey J, Graham S, et al. Surgical team behaviors and patient outcomes. The American Journal of Surgery. 2009;197(5):678-85; doi: 10.1016/j.amjsurg.2008.03.002. Lingard L, Regehr G, Espin S, Devito I, Whyte S, Buller D, et al. Perceptions of Operating Room Tension across Professions: Building Generalizable Evidence and Educational Resources. Acad Med. 2005;80(10):S75-S9; doi: 10.1097/00001888-200510001-00021. Makary MA, Sexton JB, Freischlag JA, Holzmueller CG, Millman EA, Rowen L, et al. Operating Room Teamwork among Physicians and Nurses: Teamwork in the Eye of the Beholder. Journal of the American College of Surgeons. 2006;202(5):746-52; doi: 10.1016/j.jamcollsurg.2006.01.017. De Cuyper N, Piccoli B, Fontinha R, De Witte H. Job insecurity, employability and satisfaction among temporary and permanent employees in post-crisis Europe. Economic and Industrial Democracy. 2019;40(2):173-92; doi: 10.1177/0143831X18804655. Rosenstein AH, O’Daniel M. A Survey of the Impact of Disruptive Behaviors and Communication Defects on Patient Safety. The Joint Commission Journal on Quality and Patient Safety. 2008;34(8):464-71; doi: 10.1016/s1553-7250(08)34058-6. Michael R, Jenkins HJ. The impact of work-related trauma on the well-being of perioperative nurses. Collegian. 2001;8(2):36-40; doi: 10.1016/S1322-7696(08)60008-6. Saridi M, Toska A, Latsou D, Giannakouli A, Geitona M. Verbal abuse in the operating room: a survey of three general hospitals in the Peloponnese Region. Cureus. 2021;13(9); doi: 10.7759/cureus.18098. Gillespie BM, Kermode S. How do perioperative nurses cope with stress? Contemporary Nurse. 2004;16(1-2):20-9; doi: 10.5172/conu.16.1-2.20. Cochran A, Elder WB. Effects of disruptive surgeon behavior in the operating room. The American Journal of Surgery. 2015;209(1):65-70; doi: 10.1016/j.amjsurg.2014.09.017. Lögde A, Rudolfsson G, Broberg RR, Rask-Andersen A, Wålinder R, Arakelian E. I am quitting my job. Specialist nurses in perioperative context and their experiences of the process and reasons to quit their job. Int J Qual Health Care. 2018;30(4):313-20; doi: 10.1093/intqhc/mzy023. Türken H, Çalım Sİ. Ethical dilemmas experienced by midwives working in the delivery room. Nursing Ethics. 2022;29(5):1231-43; doi: 10.1177/09697330221081952. Blomberg A-C, Bisholt B, Nilsson J, Lindwall L. Making the invisible visible – operating theatre nurses’ perceptions of caring in perioperative practice. Scandinavian Journal of Caring Sciences. 2015;29(2):361-8; doi: 10.1111/scs.12172. Markström I, Bjerså K. Diversities in perceived knowledge and practice of preoperative skin preparation in Swedish orthopaedic surgery. Journal of perioperative practice. 2015;25(5):101-6; doi: 10.1016/j.jopan.2018.06.095. Arakelian E, Rudolfsson G, Rask-Andersen A, Runeson-Broberg R, Wålinder R. I Stay-Swedish Specialist Nurses in the Perioperative Context and Their Reasons to Stay at Their Workplace. J Perianesth Nurs. 2019;34(3):633-44; doi: 10.1016/j.jopan.2018.06.095. Cooper AL, Brown JA, Rees CS, Leslie GD. Nurse resilience: A concept analysis. International Journal of Mental Health Nursing. 2020;29(4):553-75; doi: 10.1111/inm.12721. Gillespie BM, Chaboyer W, Wallis M. The influence of personal characteristics on the resilience of operating room nurses: A predictor study. International journal of nursing studies. 2009;46(7):968-76 ; doi: 10.1016/j.ijnurstu.2007.08.006. Polit DF, Beck CT. Nursing Research: generating and assessing evidence for nursing practice. Eleventh edition ed. Philadelphia: Wolters Kluwer; 2021. Shaw RL, Booth A, Sutton AJ, Miller T, Smith JA, Young B, et al. Finding qualitative research: an evaluation of search strategies. BMC Medical Research Methodology. 2004;4(1); doi: 10.1186/1471-2288-4-5. Conn VS, Isaramalai S-A, Rath S, Jantarakupt P, Wadhawan R, Dash Y. Beyond MEDLINE for Literature Searches. Journal of Nursing Scholarship. 2003;35(2):177-82. Additional Declarations No competing interests reported. Supplementary Files Additionalfile1.docx Cite Share Download PDF Status: Posted Version 1 posted You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. As a division of Research Square Company, we’re committed to making research communication faster, fairer, and more useful. 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Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-3082832","acceptedTermsAndConditions":true,"allowDirectSubmit":true,"archivedVersions":[],"articleType":"Research Article","associatedPublications":[],"authors":[{"id":214272544,"identity":"56bff0e6-4212-4dd1-98b6-8fc568f2369c","order_by":0,"name":"Ida Markström","email":"data:image/png;base64,iVBORw0KGgoAAAANSUhEUgAAAZAAAAAyAQMAAABI0h/eAAAABlBMVEX///8AAABVwtN+AAAACXBIWXMAAA7EAAAOxAGVKw4bAAAA3klEQVRIiWNgGAWjYBACNoYEMG0A4VZY8JCghQ1EnZEgrIUBRQtjmwRhDXzsyQ+YbtTcM5af3/vw0c15EjIGB9gfPsDrMJ5nBsw5x4rNDI6xGxvnbpPgMTjAY2yAV4tEAlALW4KNARsbmzRUCxte57FJpH9gzvmXYCPfBtIyB6SF/fkP/FpyDJhz2xLMGI6BtDSAtDCY4dMB9MubgsO5fQnGBsfSmI1zjknwSB7mMcbrMPn29I2Pc74lGM5vPsb4OKfGxp7vePvDD3itAYIDqFxmQupHwSgYBaNgFBAEALW2PRQpdrlPAAAAAElFTkSuQmCC","orcid":"","institution":"Department of Health, Medicine and Caring Sciences, Division of Nursing Sciences and Reproductive Health, Linköping University","correspondingAuthor":true,"prefix":"","firstName":"Ida","middleName":"","lastName":"Markström","suffix":""},{"id":214272545,"identity":"cc3c6946-b5d3-4dd4-b07e-e8fcdfcd0b7b","order_by":1,"name":"Kristofer Bjerså","email":"","orcid":"","institution":"Department of Surgery, Clinical Sciences, Sahlgrenska Academy, University of Gothenburg","correspondingAuthor":false,"prefix":"","firstName":"Kristofer","middleName":"","lastName":"Bjerså","suffix":""},{"id":214272546,"identity":"acfa25a1-04f8-4cf1-b989-63448715c0d1","order_by":2,"name":"Margareta Bachrach- Lindström","email":"","orcid":"","institution":"Department of Health, Medicine and Caring Sciences, Division of Nursing Sciences and Reproductive Health, Linköping University","correspondingAuthor":false,"prefix":"","firstName":"Margareta","middleName":"Bachrach-","lastName":"Lindström","suffix":""},{"id":214272547,"identity":"ab48e07d-017d-4b97-acd4-971283b8326c","order_by":3,"name":"Gunilla Hollman Frisman","email":"","orcid":"","institution":"Department of Health, Medicine and Caring Sciences, Division of Nursing Sciences and Reproductive Health, Linköping University","correspondingAuthor":false,"prefix":"","firstName":"Gunilla","middleName":"Hollman","lastName":"Frisman","suffix":""},{"id":214272548,"identity":"57a1382b-4126-486b-bc78-a396a19a8234","order_by":4,"name":"Karin Falk-Brynhildsen","email":"","orcid":"","institution":"Faculty of Medicine and Health. School of Health Sciences, Örebro University,","correspondingAuthor":false,"prefix":"","firstName":"Karin","middleName":"","lastName":"Falk-Brynhildsen","suffix":""}],"badges":[],"createdAt":"2023-06-19 13:29:31","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-3082832/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-3082832/v1","draftVersion":[],"editorialEvents":[],"editorialNote":"","failedWorkflow":false,"files":[{"id":39468394,"identity":"040b7619-1b36-4f1e-a180-0cfe0678562c","added_by":"auto","created_at":"2023-07-03 14:16:10","extension":"jpeg","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":869545,"visible":true,"origin":"","legend":"\u003cp\u003ePRISMA 2020 flow diagram for new systematic reviews\u003c/p\u003e","description":"","filename":"floatimage1.jpeg","url":"https://assets-eu.researchsquare.com/files/rs-3082832/v1/3b2d795f4b2486e676c2d30a.jpeg"},{"id":55264688,"identity":"87926876-1450-48a3-9e88-8c8dc1de64fc","added_by":"auto","created_at":"2024-04-25 01:46:44","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":1976055,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-3082832/v1/742380f6-8b54-4688-b114-02cbebc44e85.pdf"},{"id":39468393,"identity":"21008253-d28c-4388-bf37-3a19169250a3","added_by":"auto","created_at":"2023-07-03 14:16:10","extension":"docx","order_by":1,"title":"","display":"","copyAsset":false,"role":"supplement","size":65198,"visible":true,"origin":"","legend":"","description":"","filename":"Additionalfile1.docx","url":"https://assets-eu.researchsquare.com/files/rs-3082832/v1/7235569b48fc7c3fd1403c29.docx"}],"financialInterests":"No competing interests reported.","formattedTitle":"Prerequisites for infection prevention interventions during the intraoperative phase from the perspective of operating room nurses, An integrative review","fulltext":[{"header":"1. Background","content":"\u003cdiv id=\"Sec2\" class=\"Section2\"\u003e \u003ch2\u003e1.1 Problem identification\u003c/h2\u003e \u003cp\u003ePatients are always at risk during surgery and are particularly at risk for surgical site infections. These infections are hospital-acquired infections that occur after surgery at the incision site or in deeper tissues where the surgery took place (\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e, \u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e). Surgical site infections pose a significant threat to patient safety and cause patient suffering in the form of physical disability, additional surgical procedures, reduced quality of life, morbidity, and mortality (\u003cspan additionalcitationids=\"CR4 CR5 CR6\" citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eMore than 13\u0026nbsp;million surgical procedures are performed worldwide every year (\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e). The annual incidence of surgical site infections in the United States is approximately 1%, with approximately 8000 deaths directly related (\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e). In 2017, the European union countries, reported rates were around 1.5% from a total of approximately 649,000 surgical procedures (\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e). In developing countries, the numbers are higher, with over 30% of surgical patients developing surgical site infections each year (\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e). Surgical site infections result in significantly increased clinical workloads and economic burdens (\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e, \u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e). In the United states, it was the costliest of the hospital acquired infections, with an estimated annual cost of \u003cspan\u003e$\u003c/span\u003e3.3\u0026nbsp;billion, extending length of the hospital stay by 9.7 days (\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e, \u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eSurgical wounds are at a high risk of contamination from pathogenic microorganisms derived from the patient's own skin or from the surrounding environment (\u003cspan additionalcitationids=\"CR15\" citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e). The development of surgical site infections depends on bacterial load, bacterial virulence and patient\u0026rsquo;s ability to resist infection (\u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e). There are numerous factors associated with causing surgical site infection. The patient's physical health, the type of surgery and the duration of the surgical procedure, can be used to predict risks of surgical site infections (\u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e, \u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e). By adopting a team-based approach during the perioperative phase (which includes the time before, during, and after surgery), it is possible to prevent up to 50% of these infections (\u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e, \u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e). There are evidence-based guidelines available to prevent surgical site infections. These guidelines include recommendations for preventive practices such as antiseptic prophylaxis, prevention of hypothermia, antimicrobial prophylaxis, glucose control, oxygenation, and skin preparation (\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e, \u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e, \u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e23\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eDuring the intraoperative phase, which spans from the admission of the patient to the operating room until the transportation of the patient to the recovery area after the surgical procedure, the surgical wound is at great risk of contamination (\u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e, \u003cspan citationid=\"CR24\" class=\"CitationRef\"\u003e24\u003c/span\u003e). The optimal operating room environment should be aseptic, and the equipment used should be sterile, meaning it should be free from any living organisms (\u003cspan citationid=\"CR25\" class=\"CitationRef\"\u003e25\u003c/span\u003e). Infection prevention interventions are implemented to limit the risk of contamination from environmental microorganisms or skin flora (\u003cspan citationid=\"CR25\" class=\"CitationRef\"\u003e25\u003c/span\u003e, \u003cspan citationid=\"CR26\" class=\"CitationRef\"\u003e26\u003c/span\u003e). There are international differences, but in many countries the operating room nurse has the aseptic responsibility to perform infection prevention interventions during the intraoperative phase. This includes identifying the risk of infections, preparing, and covering the skin, and maintaining a safe aseptic environment (\u003cspan citationid=\"CR25\" class=\"CitationRef\"\u003e25\u003c/span\u003e, \u003cspan citationid=\"CR27\" class=\"CitationRef\"\u003e27\u003c/span\u003e, \u003cspan citationid=\"CR28\" class=\"CitationRef\"\u003e28\u003c/span\u003e). Other nursing roles that may have aseptic responsibilities in the intraoperative phase include perioperative nurses, surgical nurses, and scrub nurses (\u003cspan citationid=\"CR24\" class=\"CitationRef\"\u003e24\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eThe operation room is a high-risk environment in which different professional groups with different specialisations, foci, and training must work together in sometimes stressful situations (\u003cspan citationid=\"CR29\" class=\"CitationRef\"\u003e29\u003c/span\u003e). It is known that conditions in the operating room affect the surgical team's performance, which may result in negative consequences for the patient (\u003cspan additionalcitationids=\"CR31\" citationid=\"CR30\" class=\"CitationRef\"\u003e30\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR32\" class=\"CitationRef\"\u003e32\u003c/span\u003e). An earlier study explored operating room nurses' experiences with infection-preventive skin preparation and found that several factors within the team, the environment, and the organisation negatively impacted patient safety (\u003cspan citationid=\"CR33\" class=\"CitationRef\"\u003e33\u003c/span\u003e). Patients have the right to equitable, efficient, and safe healthcare, and operating room nurses are obligated to perform safe infection prevention interventions. The prevention of surgical site infections is major focus for global healthcare and to our knowledge, there is no knowledge about the prerequisites necessary for operating room nurses to carry out infection preventive interventions during the intraoperative phase. Hence, the objectives of this study were to explore prerequisites for operating room nurses to carry out infection prevention interventions during the intraoperative phase. Infection prevention during surgery is essential for improving patient outcomes, reducing healthcare costs, and ensuring safe and effective surgical care. This review will identify potential risk areas for surgical site infections, with the goal of increasing patient safety and improving infection prevention.\u003c/p\u003e \u003c/div\u003e"},{"header":"2. Methods","content":"\u003cp\u003eThis integrative review was carried out in five stages described by Whittemore \u0026amp; Knafl (\u003cspan citationid=\"CR34\" class=\"CitationRef\"\u003e34\u003c/span\u003e, \u003cspan citationid=\"CR35\" class=\"CitationRef\"\u003e35\u003c/span\u003e); problem identification, literature research, data evaluation, data analysis, and presentation.\u003c/p\u003e \u003cdiv id=\"Sec4\" class=\"Section2\"\u003e \u003ch2\u003e2.1 Literature search\u003c/h2\u003e \u003cp\u003eThe integrative review search methods described by Whittemore \u0026amp; Knafl (\u003cspan citationid=\"CR34\" class=\"CitationRef\"\u003e34\u003c/span\u003e) guided the literature search process. A search strategy was organised using searches of academic databases, manual screening of reference lists (backward chaining), and citation searches via Google Scholar (forward chaining) and internet searches.\u003c/p\u003e \u003cp\u003eWith the assistance of librarians, computer-assisted searches with both thesaurus terms and keywords in four academic databases were performed (specific search strategies are outlined in Table\u0026nbsp;\u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e1\u003c/span\u003e). The search started in PubMed, followed by searches in the Cumulative Index of Nursing and Allied Health Literature (CINAHL, EBSCO), and Embase. Free-text keyword searches were employed in Web of Science\u0026rsquo;s Core Collection. The search terms used were terms related to patient safety and operating room nursing. No time restrictions were applied.\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab1\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 1\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eOverview of the database searches\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"3\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eDatabase\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eMain search\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003eLimitations\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePubmed\u003c/p\u003e \u003cp\u003e2022-04-12\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e(patient safety OR patient harm) AND (perioperative nurse OR perioperative nursing OR operating room nurse OR operating room nursing OR operating theatre nursing OR operating theatre nurse)\u003csup\u003e1\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eEnglish\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eCinahl\u003c/p\u003e \u003cp\u003e2022-04-12\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e(patient safety OR patient harm) AND (perioperative nurse OR perioperative nursing OR operating room nurse OR operating room nursing OR operating theatre nursing)\u003csup\u003e2\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eEnglish\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eEmbase\u003c/p\u003e \u003cp\u003e2022-04-12\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e(patient safety OR patient harm) AND (perioperative nurse OR perioperative nursing OR operating room nurse OR operating room nursing OR operating theatre nursing)\u003csup\u003e2\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eEnglish\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eWeb of Science Core collection\u003c/p\u003e \u003cp\u003e2022-04-12\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e(patient safety OR patient harm) AND (perioperative nurse OR perioperative nursing OR operating room nurse OR operating room nursing OR operating theatre nursing)\u003csup\u003e3\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eEnglish\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003ctfoot\u003e \u003ctr\u003e\u003ctd colspan=\"3\"\u003e(\u003csup\u003e1\u003c/sup\u003e All fields, \u003csup\u003e2\u003c/sup\u003eDefault, \u003csup\u003e3\u003c/sup\u003eTopic search)\u003c/td\u003e\u003c/tr\u003e \u003c/tfoot\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003eThe initial database searches were performed on April 12, 2022, yielded 7471 studies, and were exported to Endnote\u0026copy; (version X9). A flow diagram of the selection process is presented in Fig.\u0026nbsp;\u003cspan refid=\"Fig1\" class=\"InternalRef\"\u003e1\u003c/span\u003e (\u003cspan citationid=\"CR36\" class=\"CitationRef\"\u003e36\u003c/span\u003e).\u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003cp\u003e-Please insert Fig.\u0026nbsp;\u003cspan refid=\"Fig1\" class=\"InternalRef\"\u003e1\u003c/span\u003e here-\u003c/p\u003e \u003cp\u003eDuplicates (n\u0026thinsp;=\u0026thinsp;2748) were removed, and inclusion and exclusion criteria were established (Table\u0026nbsp;\u003cspan refid=\"Tab2\" class=\"InternalRef\"\u003e2\u003c/span\u003e). The remaining studies (n\u0026thinsp;=\u0026thinsp;4723) were divided among the five authors and screened by title and, if necessary, by abstract. During the initial title screening, the overall inclusion criterion was applied to ensure that the selected articles matched the objectives of the integrative review.\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab2\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 2\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eInclusion and exclusion criteria for studies\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"1\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eInclusion criteria:\u003c/p\u003e \u003cp\u003e\u0026bull; Focus on patient safety in the operating room\u003c/p\u003e \u003cp\u003e\u0026bull; Focus on operating room nurses or synonyms for \u0026lsquo;nurse with aseptic responsibility (scrub, perioperative, surgical, etc.)\u003c/p\u003e \u003cp\u003e\u0026bull; Studies evaluating experiences of infection prevention interventions\u003c/p\u003e \u003cp\u003e\u0026bull; Experiences during the intraoperative phase\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eExclusion criteria:\u003c/p\u003e \u003cp\u003e\u0026bull; Reviews, guidelines, theses, abstracts, letters, and unscientific articles\u003c/p\u003e \u003cp\u003e\u0026bull; Studies that do not allow extraction of findings from operating room nurses\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003eFor validation, the first author reviewed the titles of the excluded studies, and a few were brought up for a second review and discussion in the research group. The title screening phase resulted in 581 unique studies. Next, using the same inclusion criteria, the authors switched articles and performed abstract reading; an additional 336 were excluded. The remaining 245 studies were split among the five authors and read in full using all inclusion and exclusion criteria. Only studies that could indicate nurses' experiences with aseptic responsibilities were included in the analysis. All five authors discussed the studies until an additional 236 articles were excluded, finally agreeing on nine studies. Additional manual screening of reference lists (backward chaining), and citation searches via Google Scholar (forward chaining) of the nine articles was performed. Furthermore, from April 2022 to November 2022, the first author received weekly updates from PubMed for new articles in the search area. The first author also ran weekly targeted web searches through \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e\u003ca href=\"http://www.google.com\" target=\"_blank\"\u003ewww.google.com\u003c/a\u003e\u003c/span\u003e\u003cspan address=\"http://www.google.com\" targettype=\"URL\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e using the combination of the words operating room nurse and patient safety during the same period. After further discussion in the research group, the additional searches generated eight more unique studies. This resulted in a final inclusion of 17 studies in the integrative review (Fig.\u0026nbsp;\u003cspan refid=\"Fig1\" class=\"InternalRef\"\u003e1\u003c/span\u003e).\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec5\" class=\"Section2\"\u003e \u003ch2\u003e2.2 Data evaluation\u003c/h2\u003e \u003cp\u003eThe data evaluation stage aims to assess the quality of the studies by identifying their strengths and weaknesses, by assessing whether the results of the included studies are unbiased and transparent and could be included in the integrative review (\u003cspan citationid=\"CR34\" class=\"CitationRef\"\u003e34\u003c/span\u003e). The Critical Appraisal Skills programme for cohort and qualitative studies was chosen because it suits a variety of research designs and is widely used in Integrative reviews (\u003cspan citationid=\"CR37\" class=\"CitationRef\"\u003e37\u003c/span\u003e, \u003cspan citationid=\"CR38\" class=\"CitationRef\"\u003e38\u003c/span\u003e). The appraisal forms have 10 and 14 questions, respectively (see supplementary material Table\u0026nbsp;1). Each question may be answered by three alternatives: yes, can\u0026acute;t tell/not applicable, or no. To enable systematic quality checking and comparability, we have chosen to add numerical values to each answer; yes\u0026thinsp;=\u0026thinsp;2, can't say/not applicable\u0026thinsp;=\u0026thinsp;1 and no\u0026thinsp;=\u0026thinsp;0. For qualitative studies, the maximum quality score was 20, whereas 15\u0026ndash;16 was considered moderate, and below 15 was considered low quality. For quantitative studies, the maximum score was 28, whereas 22\u0026ndash;23 was considered moderate, and below 21 was considered low quality. All five authors performed the assessments independently. Due to co-authorship, one of the authors did not evaluate Wistrand et al. (\u003cspan citationid=\"CR39\" class=\"CitationRef\"\u003e39\u003c/span\u003e) and Wistrand et al. (\u003cspan citationid=\"CR40\" class=\"CitationRef\"\u003e40\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eThe assessments resulted in eight high qualitative studies,(\u003cspan additionalcitationids=\"CR42 CR43 CR44 CR45 CR46 CR47\" citationid=\"CR41\" class=\"CitationRef\"\u003e41\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR48\" class=\"CitationRef\"\u003e48\u003c/span\u003e) and one high quality quantitative study (\u003cspan citationid=\"CR40\" class=\"CitationRef\"\u003e40\u003c/span\u003e). We found two low quality qualitative studies,(\u003cspan citationid=\"CR49\" class=\"CitationRef\"\u003e49\u003c/span\u003e, \u003cspan citationid=\"CR50\" class=\"CitationRef\"\u003e50\u003c/span\u003e) and one low quality quantitative study,(\u003cspan citationid=\"CR39\" class=\"CitationRef\"\u003e39\u003c/span\u003e), four qualitative studies of moderate quality,(\u003cspan additionalcitationids=\"CR52 CR53\" citationid=\"CR51\" class=\"CitationRef\"\u003e51\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR54\" class=\"CitationRef\"\u003e54\u003c/span\u003e) and one quantitative study of moderate quality (\u003cspan citationid=\"CR55\" class=\"CitationRef\"\u003e55\u003c/span\u003e). All authors discussed the assessment, and no studies were excluded because they all could contribute to the overall results and were published in academic peer-reviewed journals. However, their place in the evidence hierarchy was considered during data analysis.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec6\" class=\"Section2\"\u003e \u003ch2\u003e2.3 Data analysis\u003c/h2\u003e \u003cp\u003eThe constant comparative method was used for analysis since it is suitable for various research designs and facilitates structured data analysis (\u003cspan citationid=\"CR34\" class=\"CitationRef\"\u003e34\u003c/span\u003e, \u003cspan citationid=\"CR56\" class=\"CitationRef\"\u003e56\u003c/span\u003e, \u003cspan citationid=\"CR57\" class=\"CitationRef\"\u003e57\u003c/span\u003e). The primary data found in the included articles was displayed, compared, and synthesised. Raw data such as author, year, country, design, study aim, sample population, data collection, analysis, and key findings were extracted and put into a data collection form by the first author (Table\u0026nbsp;\u003cspan refid=\"Tab3\" class=\"InternalRef\"\u003e3\u003c/span\u003e). All five authors read, discussed, and approved the extraction.\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab3\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 3\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eSummary of reviewed studies\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"7\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c6\" colnum=\"6\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c7\" colnum=\"7\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eAuthor (year), Country\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eResearch design\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003ePurpose\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003eSetting and sample characteristics\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c5\"\u003e \u003cp\u003eData collection methods/key measurements\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c6\"\u003e \u003cp\u003eAnalyse method\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c7\"\u003e \u003cp\u003eMajor findings\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eAholaakko (2011),\u003c/p\u003e \u003cp\u003eFinland\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eExplorative interview study\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eTo explore aseptic practise-related stress among surgery nurses\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eSetting:\u003c/p\u003e \u003cp\u003eOne surgery department of Helsinki University Central Hospital.\u003c/p\u003e \u003cp\u003eSample:\u003c/p\u003e \u003cp\u003e31 intraoperative surgery nurses*\u003c/p\u003e \u003cp\u003e*= The nurses varied their roles so that in every other operation they worked as a \u0026lsquo;scrub nurse\u0026rsquo;.\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eStimulated -recall interviews\u003c/p\u003e \u003cp\u003e31 operations were videotaped and used as stimuli.\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003eA membership categorization device analysis by Baker\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e\u0026hellip;as novis surgical nurses was afraid of not knowing what to do, they want to perform as good as more experienced colleagues, stressed when they need to do instruments counts and have environmental control at the same time\u003c/p\u003e \u003cp\u003eTime stress (need to focus on the next surgery)\u003c/p\u003e \u003cp\u003eNeed to control persons with \u0026ldquo;aseptic looseness\u0026rdquo;. Persons with limitations on taking feedback or following recommendations for aseptic practise\u003c/p\u003e \u003cp\u003e\u0026hellip;stress was present when a hot-tempered surgeon; fussy co-worker; either nurse or surgeon with limitations on taking feedback or following recommendations for aseptic practise participated in the team\u003c/p\u003e \u003cp\u003ePatient-related stress in aseptic practise was visible during operations, for example as a need to document the obesity of the patient as a potential risk for infection\u003c/p\u003e \u003cp\u003eA young nurse was worried about harming an old patient\u0026rsquo;s thin skin or had problems with patients\u0026rsquo; anatomical variances\u003c/p\u003e \u003cp\u003ePower-related feedback as being afraid to give feedback about aseptic practise to the surgeon, afraid to make them angry, surgical field being a battlefield\u003c/p\u003e \u003cp\u003e\u0026hellip;stress was felt as positive when a surgery nurse was an Aseptic Practise specialist being in a \u0026ldquo;dream surgery team\u0026rdquo;\u003c/p\u003e \u003cp\u003eA nurse has to be independent and, sometimes, quite headstrong to have the right to work properly\u0026rdquo;\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eAlfredsdottir and Bjornsdottir (2008),\u003c/p\u003e \u003cp\u003eIceland\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eExplorative interview study\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eTo identify what threatens and\u003c/p\u003e \u003cp\u003eenhances patient safety and how operating room nurses see\u003c/p\u003e \u003cp\u003etheir role in ensuring safety\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eSetting:\u003c/p\u003e \u003cp\u003eOR-nurses at one university hospital in Iceland.\u003c/p\u003e \u003cp\u003eSample:\u003c/p\u003e \u003cp\u003eI14 OR nurses*\u003c/p\u003e \u003cp\u003e*=8 OR nurses in individual interviews and 2 focus group.\u003c/p\u003e \u003cp\u003e(Two OR nurses participated in both individual and focus groups)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eIndividual \u0026amp; focus group interviews\u003c/p\u003e \u003cp\u003eA study in two stages, stage two is included in this integrative review.\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003eInterpretive content analysis\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003eAll participants described how prevention is always at the core of their work\u003c/p\u003e \u003cp\u003eThey also described how they had to know the background of the patient, and their vulnerability and fragility that might increase risk during the operation\u003c/p\u003e \u003cp\u003eThey rely on information from the patients\u0026rsquo; records, particularly from the anaesthesia team\u003c/p\u003e \u003cp\u003eA number of participants said that in some situations they do not have all the information required preoperatively, especially in cases of specific patient needs\u003c/p\u003e \u003cp\u003e\u0026hellip;better preoperative information would ensure patient-centred nursing, continuity of care, and better and more efficient preparation for the surgical operation\u003c/p\u003e \u003cp\u003eThe teams are often unequally staffed; some are under-staffed and often need support from other teams. Participants felt that this needed to be attended to by managers\u003c/p\u003e \u003cp\u003eParticipants described how imbalance in staffing, which may be either under- or over-staffing, may lead to unsystematic preparation or distraction\u003c/p\u003e \u003cp\u003eThe work processes are timed and, while the surgical procedure cannot be rushed, the nurses sense pressure to reduce time for preparation and time between operations\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eBastami, Imani et al. (2022),\u003c/p\u003e \u003cp\u003eIran\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003ePhenomenological study\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eTo explain the lived experiences of operating room nurses experiences with patient cares for laparotomy surgeries\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eSetting:\u003c/p\u003e \u003cp\u003eA public educational hospital, Hamedan.\u003c/p\u003e \u003cp\u003eSample:\u003c/p\u003e \u003cp\u003e10 OR nurses\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eIn-depth and semi-structured interviews\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003eAnalytical phenomenological method\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003eAseptic technique observance in the operating room is a fundamental factor in providing indirect care for patients under surgical operation\u003c/p\u003e \u003cp\u003e\u0026ldquo;I always gloves and gown changed. Because leakage into the peritoneal cavity can be a source of generalized peritoneal sepsis\u0026rdquo;\u003c/p\u003e \u003cp\u003e\u0026ldquo;I always wear two gloves before beginning a surgical operation. For dressing the wound, I take off the upper gloves so that the dressing does not get dirty\u0026rdquo;\u003c/p\u003e \u003cp\u003eAccording to the participants\u0026rsquo; experiences, inadequate sterilization of the skin and drape of the surgical site was one of the leading causes of hospital infections after the surgery\u003c/p\u003e \u003cp\u003e\u0026ldquo;One of our colleagues preps the surgical site within less than 1 min, fills the gallipot with 7.5% betadine, but never uses it. I have noted several times, but he never pays attention and does not care about the patient\u0026rsquo;s life\u0026rdquo;\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eBj\u0026ouml;rn and Lindberg-Bostr\u0026ouml;m (2008),\u003c/p\u003e \u003cp\u003eSweden\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eDescriptive study with Phenomenographic approach\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eTo describe the theatre nurses\u0026rsquo; work from their own perspective.\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eSetting:\u003c/p\u003e \u003cp\u003eOR nurses from two hospitals in Sweden.\u003c/p\u003e \u003cp\u003eSample:\u003c/p\u003e \u003cp\u003e15 OR nurses\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eInterviews with open-ended questions\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003ePhenomenographic technique\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003eTheatre nurses achieve control of the situation by advanced planning and being \u0026lsquo;one step ahead\u0026rsquo;\u003c/p\u003e \u003cp\u003eThe most important thing for a nurse is to be prepared for the operation\u003c/p\u003e \u003cp\u003eThe lack of respect for their practice that they sometimes experienced from colleagues in other disciplines and which had a negative impact on teamwork\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eHolmes, Vifladt et al. (2020),\u003c/p\u003e \u003cp\u003eNorway\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eDescriptive interview study\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eTo explore Norwegian operating room nurses\u0026rsquo; perceptions of how team skills in the inter-professional operating room team influence perioperative nursing in relation to patient safety.\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eSetting:\u003c/p\u003e \u003cp\u003eOperating departments at three general hospitals and one university hospital in the south-east of Norway.\u003c/p\u003e \u003cp\u003eSample:\u003c/p\u003e \u003cp\u003e10 operating room nurses\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eSemi-structed Interviews\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003eInductive content analysis\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e\u0026hellip;the OR nurses\u0026rsquo; perception that the\u003c/p\u003e \u003cp\u003eperformance of perioperative nursing is better when there are good team skills\u003c/p\u003e \u003cp\u003e\u0026hellip;OR nurses strive to do their tasks in a good way, even though this might be time-consuming and tiring: \u0026ldquo;My standard is the same, independent of who the patient is, or who I\u0026rsquo;m working together with. But it\u0026rsquo;s easier to achieve this if communication is good\u0026rdquo;\u003c/p\u003e \u003cp\u003eThe OR nurses perceived constructive criticism, willingness to learn, planning and a good tone as resulting in better performance of perioperative nursing\u003c/p\u003e \u003cp\u003eThe participants perceived that poor communication or situation monitoring, along with experiencing a lack of mutual support or leadership, can lead to intraoperative events such as faulty positioning or draping, lacking equipment, or forgetting a catheter or warming blanket\u003c/p\u003e \u003cp\u003eUnnecessary communication, noise, loss of concentration, stress, insecurity and irritation have a negative\u003c/p\u003e \u003cp\u003einfluence on the performance of perioperative nursing\u003c/p\u003e \u003cp\u003eGood communication makes it easier for OR nurses to speak up about risks to patient safety. They perceived that adverse event such as hypothermia, injury due to positioning, infection and extensive blood loss might occur partly because of poor team skills\u003c/p\u003e \u003cp\u003ePoor communication, for example lack of\u003c/p\u003e \u003cp\u003einformation, inappropriate or unnecessary remarks, poor leadership and situation monitoring, or having to take on others\u0026rsquo; tasks, can result in delays because they lose focus on their own task\u003c/p\u003e \u003cp\u003e\u0026ldquo;You lose some focus when you have to watch what is going on around you at the same time\u0026rdquo;\u003c/p\u003e \u003cp\u003e\u0026ldquo;If you aren\u0026rsquo;t good at leading the OR team, it can result in misunderstandings, which can have serious consequences, complications, for the patient\u0026rdquo;\u003c/p\u003e \u003cp\u003e\u0026ldquo;in big operations it is good when the surgeon comes in early to see everything is okay. To help find equipment, hold up the leg for skin disinfection \u0026hellip; and at least offer to help\u0026rdquo;\u003c/p\u003e \u003cp\u003ePoor team skills such as misunderstandings, interruptions and not being able to trust others to do their job properly can create stress, which again can increase the risk of making mistakes\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eKaldheim and Sletteb\u0026oslash; (2016),\u003c/p\u003e \u003cp\u003eNorway\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eExplorative interview study\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eTo acquire knowledge about what theatre nurses, perceive as important factors in collaboration with other team members to see what factors are needed to strengthen interdisciplinary cooperation.\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eSetting:\u003c/p\u003e \u003cp\u003eFour Norwegian operational units\u003c/p\u003e \u003cp\u003eSample:\u003c/p\u003e \u003cp\u003e8 OR nurses\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eSemi\u0026ndash;structured interviews\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003eConstant comparative inductive analysis\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003eThe theatre nurses want to be accepted as having skills and duties that are equal to the other members in the team\u003c/p\u003e \u003cp\u003eThey want to be seen and heard by the others in the team as people with tasks that are meaningful\u003c/p\u003e \u003cp\u003eThey often experience working situations where there is not always so much tolerance for having to wait for each other, and that their task must be done \u0026ldquo;quickly and invisibly\u0026rdquo;\u003c/p\u003e \u003cp\u003eThe participants want others to understand the importance of their job and to recognise that it also requires time\u003c/p\u003e \u003cp\u003eWhen team members have knowledge and understanding of each other\u0026rsquo;s work, it is also easier to help each other\u003c/p\u003e \u003cp\u003eThe participants describe how a surgeon may help them to open and cover sterile equipment preoperatively, while he/she waits to be ready for the operation\u003c/p\u003e \u003cp\u003eIt may be the way in which things are said, or someone raising their voice and shouting. It affects the concentration and focus of the participants in the situation, and this affects the quality of the performance of theatre nursing\u003c/p\u003e \u003cp\u003eThere are some situations like that where, for me at least, there will be poorer cooperation when someone gets scolded. For then you will be a little preoccupied in your head that there is a bad atmosphere here. In addition, I lose a little of my concentration\u003c/p\u003e \u003cp\u003eThe leader should have insight into the team members\u0026rsquo; tasks and communicate the need for resources upward in the organisation\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eLingard, Garwood et al. (2004),\u003c/p\u003e \u003cp\u003eCanada\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eExplorative validation study\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eTo determine to what extent documented tension patterns are transferable to other institutional contexts.\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eSetting:\u003c/p\u003e \u003cp\u003eTwo small academic hospitals in in Canada.\u003c/p\u003e \u003cp\u003eSample 1:\u003c/p\u003e \u003cp\u003e22 OR nurses,\u003c/p\u003e \u003cp\u003e(5 anaesthesiologists,\u003c/p\u003e \u003cp\u003e10 trainees,\u003c/p\u003e \u003cp\u003e6 surgeons)\u003c/p\u003e \u003cp\u003eSample; phase 2\u003c/p\u003e \u003cp\u003e10 surgeons\u003c/p\u003e \u003cp\u003e(and fluctuating team members)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eData were collected in two phases:\u003c/p\u003e \u003cp\u003ePhase 1:\u003c/p\u003e \u003cp\u003e8 focus group,\u003c/p\u003e \u003cp\u003e8 individual interviews\u003c/p\u003e \u003cp\u003ePhase 2:\u003c/p\u003e \u003cp\u003eField observations\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003eModified grounded theory approach\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e\u0026hellip;issues of aseptic technique and patient safety influenced team communication. Nurses were almost always participants in these communication exchanges, perhaps reflecting their professional responsibility for aseptic technique\u003c/p\u003e \u003cp\u003eFor instance: Senior resident enters OR not scrubbed, stands inches from the sterile field. Circulating nurse turns towards resident, watches intently, frowns disapprovingly.\u003c/p\u003e \u003cp\u003eWith only 6 of 28 observed instances (21%) involving higher tension levels, the theme of safety and sterility was not a prominent catalyst for tension\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eNordstr\u0026ouml;m and Wihlborg (2019),\u003c/p\u003e \u003cp\u003eSweden\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003ePhenomenographic interview study\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eTo describe the work experiences of nurse anaesthetists and OR nurses in the OR.\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eSetting:\u003c/p\u003e \u003cp\u003eOne university hospital and one regional hospital in Sweden.\u003c/p\u003e \u003cp\u003eSample:\u003c/p\u003e \u003cp\u003e6 OR nurses\u003c/p\u003e \u003cp\u003e(6 anaesthetic nurses)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eInterviews\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003ePhenomenographic analysis\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003eAn important aspect was to be acknowledged as integral members of the OR team and the recognition that every profession in the OR is a valuable part of this team\u003c/p\u003e \u003cp\u003eAnother aspect of responsibility is that all professionals must be given sufficient time to conduct their specific individual tasks\u003c/p\u003e \u003cp\u003eThey expressed a desire to be well prepared and have enough time to perform their work to the best of their ability\u003c/p\u003e \u003cp\u003eStudents and new colleagues should be given extra time to perform their tasks. When a new colleague attends, you have to tell everybody to slow down a bit so he or she has a chance [to perform their part]\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eNyberg, Olofsson et al. (2021),\u003c/p\u003e \u003cp\u003eSweden\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eExplorative interview study\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eTo explore aspects of patient safety practice during joint replacement surgery through assessment of operating room nurses experiences.\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eSetting:\u003c/p\u003e \u003cp\u003eThree hospitals in Sweden; one university, one public general and one private orthopaedic hospital.\u003c/p\u003e \u003cp\u003eSample:\u003c/p\u003e \u003cp\u003e21 OR nurses\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eSemi structured interviews\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003eInductive qualitative content analysis\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003eStated their need for a reliable preoperative plan to ensure a safe procedure. By planning and preparing well for the procedure, they attempted to reduce the time for surgical procedure\u003c/p\u003e \u003cp\u003eBefore preparing for the procedure, they often needed to confirm the information from a computerised surgical planning system with the orthopaedic surgeon, due to occurrence of failure in updating the plan. This need to confirm the plan was perceived as unsatisfying and experienced as time- consuming\u003c/p\u003e \u003cp\u003eFor some participants, the main source of patientrelated information was derived from the surgical planning system and the anaesthesia preoperative assessment\u003c/p\u003e \u003cp\u003eThey did not find time to get information from the main health records and were thereby not routinely accessing information\u003c/p\u003e \u003cp\u003eThere was no systematic feedback on results or complications. For example, some participants emphasised that they wanted to know the infection rates for their specific department\u003c/p\u003e \u003cp\u003eOR management sent information about new routines and incidents by email, and these were sometimes perceived to not reach the appropriate OR personnel\u003c/p\u003e \u003cp\u003eEstablished safety controls and compliance with aseptic principles were stated as important aspects for safety practice within the team\u003c/p\u003e \u003cp\u003eCompliance with aseptic principles was considered to vary among different professions within the team. The ORNs were expecting all team members to perform responsibly, and when this was not the case, it became a strain in the workplace for them\u003c/p\u003e \u003cp\u003eIn situations where two ORNs collaborated during surgery, they had opportunities to support and learn from each other, and thereby improve their work\u003c/p\u003e \u003cp\u003eThey kept guarding sterility throughout the entire surgical procedure by keeping an eye on the activities of other team members, which sometimes could be challenging\u003c/p\u003e \u003cp\u003eParticipants noted that the prerequisites for work in an aseptic environment were present\u003c/p\u003e \u003cp\u003eNational guidelines for preventing PJIs were established, and there was most often compliance with these\u003c/p\u003e \u003cp\u003eOne example given was a guideline to control the traffic and avoid disturbance of the ventilation by opening the doors and trying to minimise the number of persons in the OR\u003c/p\u003e \u003cp\u003eParticipants experienced that compliance with guidelines varied within the team. For example, some orthopaedic surgeons followed the guidelines more strictly than others. With an interesting surgical case, minimising the amount of personnel in the OR was disregarded by some surgeons\u003c/p\u003e \u003cp\u003eThe ORNs also emphasised a need to improve staff behaviour regarding adherence to the aseptic principles\u003c/p\u003e \u003cp\u003eWhen they insisted on observing aseptic protocols, it sometimes was considered a disturbance of the flow, affecting both the surgical procedure and the whole day operation schedule\u003c/p\u003e \u003cp\u003eWhen notifying others on breaks of aseptic principles, some participants perceived that they were seen as annoying\u003c/p\u003e \u003cp\u003e\u0026hellip;Even if people might think you're irritating, I think you still get some kind of respect in that you have competence and can see that this is important. Even if you are considered awkward, you are trusted as the person who also is competent and good, good for the group and for the patient\u003c/p\u003e \u003cp\u003eAlthough the ORNs were well aware that many factors could have led to an infection, they felt accountable for it if a patient acquired a surgical site infection or a periprosthetic joint infection\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePrati and Pietrantoni (2014),\u003c/p\u003e \u003cp\u003eItaly\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eDescriptive cross-sectional (pilot) study\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eTo assess attitudes about teamwork and safety among Italian surgeons and operating room nurses.\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eSetting:\u003c/p\u003e \u003cp\u003eOne hospital in the centre of Italy\u003c/p\u003e \u003cp\u003eSample:\u003c/p\u003e \u003cp\u003e48 OR nurses\u003c/p\u003e \u003cp\u003e(55 surgeons)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eOperating Room Management Attitudes Questionnaire\u003c/p\u003e \u003cp\u003e(ORMAQ)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003eParametric statistics\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003eThe majority of the OR nurses agreed to the statement: It bothers me when others do not respect my professional capabilities (94% agreed)\u003c/p\u003e \u003cp\u003eMore than half of the OR nurses did not agree to the statement that team members frequently disregard rules or guidelines (e.g., hand washing, treatment protocols/clinical pathways, sterile field) developed for our Operating Theatre (69% disagreed)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eQvistgaard et al. (2019),\u003c/p\u003e \u003cp\u003eSweden\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eReflective Lifeworld Research approach\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eHow OR nurses experience intraoperative prevention of SSIs.\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eSetting:\u003c/p\u003e \u003cp\u003eSeven hospitals in Sweden\u003c/p\u003e \u003cp\u003eSample:\u003c/p\u003e \u003cp\u003e15 OR nurses\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eInterviews\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003ePhenomenological analysis\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e\u0026hellip;further competencies such as experience and courage are needed to ensure prevention\u003c/p\u003e \u003cp\u003ePrevention of SSIs depends on an open and honest atmosphere within the team, a team that allows different professionals to contribute with their unique competencies\u003c/p\u003e \u003cp\u003e...the team members should adhere to the guidelines regarding OR hygiene\u003c/p\u003e \u003cp\u003e\u0026ldquo;Everybody has their own responsibility inside the OR, but my job is to tell you when you are too close, when you have to change gloves, or when you need to adjust your surgical gown. You are trying to have an overview of everything that happens inside the OR and simultaneously keep the focus on what is going on during the surgical procedure\u0026rdquo;\u003c/p\u003e \u003cp\u003eThe absence of structured feedback makes it difficult when the profession seeks arguments for strengthening routines related to preventing SSIs. Therefore, measures intended to combat this invisible threat are difficult to evaluate and analyse. This lack of evidence for the effectiveness of routines results in insecurity and doubt connected to SSIs prevention measures\u003c/p\u003e \u003cp\u003e\u003cem\u003e\u0026ldquo;Sterility is the alpha and omega to me; here is where my occupational pride is at stake and I cannot look the other way\u0026rdquo;\u003c/em\u003e\u003c/p\u003e \u003cp\u003eAwareness of risks related to SSIs is carried out by individuals who have confidence in each other and dare to confront human shortcomings\u003c/p\u003e \u003cp\u003eConfident relations and resolute communication within the team generate favourable conditions for preventing SSIs\u003c/p\u003e \u003cp\u003eThe invisible threat of microorganisms can be made visible to others if OR nurses use their profound knowledge to explain the connection between bacterial load and the risk of SSIs\u003c/p\u003e \u003cp\u003ea lack of trust in one\u0026rsquo;s colleagues creates anxiety among the team, a milieu that will not benefit the patient: \u0026ldquo;You really need your team and it\u0026rsquo;s important that everybody understands why we do certain things, not just doing it because I say so\u0026rdquo;\u003c/p\u003e \u003cp\u003eFriction among team members is evident when one or several team members are unwilling to understand other professionals\u0026rsquo; responsibilities and competencies\u003c/p\u003e \u003cp\u003eSome people are more or less frightened of some surgeons and then you become nervous and that leads to insecurity and mistakes. For example, if a surgeon is intimidating, I might make mistakes, get nervous and take the surgical towel that I had for cleaning instruments and put it in an open wound during hip replacement\u003c/p\u003e \u003cp\u003eConfronting colleagues irrespective of their position requires a security in one\u0026rsquo;s own competence and a security in the team\u0026rsquo;s willingness to hear potentially uncomfortable feedback, competencies that develop with experience\u003c/p\u003e \u003cp\u003eEffective leadership helps team members develop confidence in organizational structures and offers stability for the team members. Managing both team collaboration and organisation are intertwined and clearly related to intraoperative prevention of SSIs\u003c/p\u003e \u003cp\u003eTraditionally, the head surgeon is the team leader and this person\u0026rsquo;s effectiveness as a leader ensures the effectiveness of the preventive work. Both formal and informal leaders dictate the terms of the preventive work; if they aim for the same goal, it is possible to reach mutual strategies\u003c/p\u003e \u003cp\u003eOR nurses often feel their contributions are minimised. The balance between the legitimacy of OR nurses and the authority of the traditional hierarchy, which places surgeons at the top, is fragile\u003c/p\u003e \u003cp\u003ePrevention of SSIs often end up being a secondary priority, a lack of commitment that often leaves OR nurses feeling ignored\u003c/p\u003e \u003cp\u003e\u0026ldquo;You can get so tired of yourself and you feel like a disc that repeats itself over and over again, but you can\u0026rsquo;t give up and capitulate to what you believe is correct. Who will take an interest in SSI prevention if not me, no one would care about that\u0026rdquo;\u003c/p\u003e \u003cp\u003eOR nurses reside in their responsibility to ensure that team members follow hygienic guidelines inside the OR\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eSandelin and Gustafsson (2015),\u003c/p\u003e \u003cp\u003eSweden\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eDescriptive interview study\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eTo describe operating theatre nurses\u0026rsquo; experiences of teamwork within the surgical team in regard to achieving patient safety.\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eSetting:\u003c/p\u003e \u003cp\u003eFour hospitals in Sweden; two urban and two hospitals in rural regions.\u003c/p\u003e \u003cp\u003eSample:\u003c/p\u003e \u003cp\u003e16 OR nurses\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eInterviews\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003eContent analysis\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003eA brief meeting (with the patient before surgery) facilitated OTNs to be better prepared for safe nursing care\u003c/p\u003e \u003cp\u003eInterdependent collaboration with surgeons was reached when OTNs experienced respect as equal co-workers and were involved and engaged as key partners, and spoken to with respect for their professional skills\u003c/p\u003e \u003cp\u003eOTNs were totally dependent on nurse assistant (NAs) willingness to collaborate. The collaboration of the OTNs and NA was characterized by leadership and the NA was perceived as the OTNs\u0026rsquo; \u0026lsquo;right hand\u0026rsquo;\u003c/p\u003e \u003cp\u003eOTNs believed that friendly leadership was necessary in the collaboration as this would generate a willingness to follow OTNs\u0026rsquo; instructions efficiently\u003c/p\u003e \u003cp\u003ethe nursing care-plan was based on OTNs\u0026rsquo; personal experience, general routines and a brief reading of each patient\u0026rsquo;s medical record\u003c/p\u003e \u003cp\u003eSometimes surgeons were unable to control their tantrums with consequences of other team-members\u0026rsquo; knowledge and skills tended to decrease because of the strained atmosphere\u003c/p\u003e \u003cp\u003eIn order to be able to trust unfamiliar or inexperienced\u003c/p\u003e \u003cp\u003eNAs, OTNs interrogated them about nursing knowledge and skills. This was necessary for the planning and the performance of nursing care, and involved guiding in a polite and friendly way to do the right thing at the right\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eSandelin, Gustafsson et al. (2019), Sweden\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eDescriptive interview study\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eTo describe operating theatre nurses\u0026rsquo; experience of preconditions for safe intraoperative nursing care and teamwork.\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eSetting:\u003c/p\u003e \u003cp\u003eFour hospitals in Sweden; two urban and two hospitals in rural regions.\u003c/p\u003e \u003cp\u003eSample:\u003c/p\u003e \u003cp\u003e16 OR-nurses\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eInterviews\u003c/p\u003e \u003cp\u003e(reanalysed data)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003eContent analysis\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e\u0026hellip;operating theatre nurses (OTN) met patients preoperatively for a conversation about their health status and needs, as well as details about the surgical intervention. In these cases, OTNs expressed that they were well prepared with adequate information from the primary source for decision-making of care activities for safe intraoperative nursing care\u003c/p\u003e \u003cp\u003eOTNs\u0026rsquo; described frequent experiences of obtaining only brief, incomplete and fragmented information about the patients\u0026rsquo; health situations and their upcoming surgical interventions\u003c/p\u003e \u003cp\u003eThe documentation in the computerised systems was not complete, due to restrictions from codes and measures in the systems\u003c/p\u003e \u003cp\u003ewhen not informed, they had to phone the surgeon in orderto be properly prepared for the intervention\u003c/p\u003e \u003cp\u003ethey preferably wanted to be prepared for each patient's operation the day before\u003c/p\u003e \u003cp\u003eFor the most part, because they were moved around between different surgeries in their daily work, OTNs would not read the patient's record until the patient was confirmed and transported to the OT department. This meant that they did not have a chance to be completely prepared for each patient's surgery\u003c/p\u003e \u003cp\u003e\u0026ldquo;Also, even when an operation was delayed because of an anaesthesia procedure, OTNs felt they were the ones to blame. Sometimes it takes time for the anaesthesia personnel, when the patient has a complex health situation, and I feel stressed doing the skin disinfection and the sterile draping \u0026hellip;and the surgeons enter and wonder what you are doing and why it has taken such a long time\u0026rdquo;\u003c/p\u003e \u003cp\u003eOTNs explained they needed to have high standards of personal professional skills and knowledge to be able to offer patients safe perioperative nursing care\u003c/p\u003e \u003cp\u003eThey also depicted their responsibility for the hygiene and aseptic care environment as well as, security controls of the sterile surgical equipment and the patient's well-being and safety.\u003c/p\u003e \u003cp\u003eOTNs\u0026rsquo; best experience of safe and efficient work occurred in situations where two colleague OTNs collaborated during surgery\u003c/p\u003e \u003cp\u003eOTNs described the importance for ensuring patient safety of nurse leadership holding clear standards, routines and operational goals. When first-line managers were invisible and uncommitted, the OT department was described as lacking standards and routines\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eSil\u0026eacute;n-Lipponen (2005),\u003c/p\u003e \u003cp\u003eFinland, United Kingdom \u0026amp; Unites states of America\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eCritical incident study\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eOR nurses\u0026rsquo;\u003c/p\u003e \u003cp\u003eexperiences about potential errors and error prevention in operating room\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eSetting:\u003c/p\u003e \u003cp\u003eOR departments in Finland, UK and USA.\u003c/p\u003e \u003cp\u003ePart of larger international research project\u003c/p\u003e \u003cp\u003eSample:\u003c/p\u003e \u003cp\u003e30 OR nurses\u003c/p\u003e \u003cp\u003eFinnish (n\u0026thinsp;=\u0026thinsp;10),\u003c/p\u003e \u003cp\u003eAmerican (n\u0026thinsp;=\u0026thinsp;10)\u003c/p\u003e \u003cp\u003eBritish (n\u0026thinsp;=\u0026thinsp;10)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eAudio-taped interviews\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003eQualitative content analysis\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003eThe need to manage multiple, simultaneous demands while providing high-quality care imposed a continuous pressure on nurses\u003c/p\u003e \u003cp\u003e\u0026ldquo;You know, people cannot work or even think if they are constantly worried about their own or others\u0026rsquo; mistakes\u0026rdquo;\u003c/p\u003e \u003cp\u003eArguments during operations could lead to overheated feelings and, thus, jeopardize patients\u0026rsquo; safety by causing errors. Therefore, nurses forced themselves to remain undisturbed and to keep up sustained working\u003c/p\u003e \u003cp\u003eConfidence about the individual team members\u0026rsquo; skills made advanced preparation\u003c/p\u003e \u003cp\u003eTeams familiar with their members could pool their strengths, anticipate each other\u0026rsquo;s needs (even from gestures), exchange roles across professional boundaries and, thus, minimize the occurrence of errors\u003c/p\u003e \u003cp\u003eContact with careless or risky behaviour: \u0026ldquo;The instrument was gas-sterilized but had not been aerated. I told him [the surgeon] that you cannot use it because of what it causes to human tissues is the same as a microwave oven. Still, the surgeon insisted on having it. Then the situation was taken out of my hands, and I had to write a case report about serious misbehaviour that compromised the safety of a human being\u0026rdquo;\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eTimmons and Tanner (2005),\u003c/p\u003e \u003cp\u003eUnited Kingdom\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eEthnographic study\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eTo explore the emotional labour in an operating theatre nurses context\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eSetting:\u003c/p\u003e \u003cp\u003eFive hospitals in UK\u003c/p\u003e \u003cp\u003eSample:\u003c/p\u003e \u003cp\u003e12 OR nurses\u003c/p\u003e \u003cp\u003e(8 other professions)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eObservations n\u0026thinsp;=\u0026thinsp;20\u003c/p\u003e \u003cp\u003e\u0026amp; individual interviews n\u0026thinsp;=\u0026thinsp;20\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003eNot known\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e\u0026hellip;it was their responsibility to \u0026lsquo;look after\u0026rsquo; the surgeons rather like an air hostess or a party hostess\u003c/p\u003e \u003cp\u003eNot upsetting surgeons describes actions which nurses\u003c/p\u003e \u003cp\u003erefrained from undertaking to prevent antagonizing surgeons\u003c/p\u003e \u003cp\u003e\u0026hellip;nurses might have tolerated poor practice rather than antagonize surgeons even though the poor practice was to the detriment of unconscious patients\u003c/p\u003e \u003cp\u003eThe surgeon walks into the theatre. He is carrying his coffee mug and eating a roll. This contravenes theatre infection control policies. None of the nurses say anything to him\u003c/p\u003e \u003cp\u003eSurgeon comes into theatre, he is not wearing a hat. This contravenes the theatre dress code and presents a risk of infection. The nurses, including Nurse W, don\u0026rsquo;t say anything. Another surgeon comes in, looks at the surgeon with no hat and says \u0026lsquo;What, no hat, is this a new rule?\u003cem\u003e\u0026rsquo;\u003c/em\u003e\u003c/p\u003e \u003cp\u003eIn the following example, the interviewer asked a nurse why she poured ether over some swabs for a surgeon? (Ether, a hazardous substance, is banned from theatre departments): He likes using [ether]. We have to get pharmacy to supply it especially for him. Yes, I know we shouldn\u0026rsquo;t be using it\u003c/p\u003e \u003cp\u003eThe nurses would accommodate surgeons\u0026rsquo; demands even if they did not agree with them: The instruments had been set up and we had to wait about 30 min for the patient. When the patient came in and they were about to start operating, the surgeon asked the Sister if these were the same instruments? She said \u0026lsquo;Yes, but they are all right\u0026rsquo;. The surgeon said \u0026lsquo;I want fresh instruments\u0026rsquo;. The nurse got new instrument trays out. Later, the nurse said to me \u0026lsquo;I didn\u0026rsquo;t need to change them but I wasn\u0026rsquo;t going to argue with him\u0026rsquo;\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eWistrand, Falk-Brynhildsen et al. (2018),\u003c/p\u003e \u003cp\u003eSweden\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eDescriptive cross-sectional study\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eTo describe the daily interventions Swedish operating room nurses perform to prevent SSIs following national guidelines\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eSetting:\u003c/p\u003e \u003cp\u003eOR-nurses from 64 hospitals in Sweden.\u003c/p\u003e \u003cp\u003eSample:\u003c/p\u003e \u003cp\u003eN\u0026thinsp;=\u0026thinsp;890 OR- nurses\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eWeb-based questionnaire\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003eDescriptive statistics\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003eThe majority of the interventions recommended by the national guidelines were implemented in daily work and that the interventions were performed fairly consistently nationally\u003c/p\u003e \u003cp\u003eWhen guidelines were lacking, variation in the intervention used increased, for example, the application of adhesive plastic drapes\u003c/p\u003e \u003cp\u003eMost, 41.1% (n\u0026thinsp;=\u0026thinsp;366), often let the skin dry before draping; and to enhance adherence of the drapes to the patient\u0026rsquo;s skin, 34% (n\u0026thinsp;=\u0026thinsp;303) of the nurses often wiped the skin dry in the site where the drapes should adhere using sterile paper towels\u003c/p\u003e \u003cp\u003eMost of the nurses responded that they had learned to perform patient skin disinfection from their supervisors (another OR nurse) or at the clinical practice during in-service education (48.9%; n\u0026thinsp;=\u0026thinsp;435), while 41.7% n\u0026thinsp;=\u0026thinsp;371) learned the technique from the educator at a university. The remaining 9.4% of the nurses stated either that they had learned it from colleagues or the Handbook for Healthcare Workers or that they did not remember\u003c/p\u003e \u003cp\u003eSterile gowns for single use were employed by 83.8%\u003c/p\u003e \u003cp\u003e(746/890) of the nurses\u003c/p\u003e \u003cp\u003eThe reasons for changing the outer gloves differed, but the most dominant reasons were puncture of the glove or the wearing of the outer glove for a long time\u003c/p\u003e \u003cp\u003eThe majority of the nurses reported that they performed the pre-operative disinfection of the patient for two to five minutes\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eWistrand, Falk-Brynhildsen et al. (2021),\u003c/p\u003e \u003cp\u003eSweden\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eDescriptive cross-sectional study\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eTo explore interventions that Swedish operating room nurses considered important for the prevention of bacterial contamination and surgical site infections.\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eSample:\u003c/p\u003e \u003cp\u003eN\u0026thinsp;=\u0026thinsp;890 OR- nurses\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eWeb-based questionnaire\u003c/p\u003e \u003cp\u003ewith an open-ended question\u003c/p\u003e \u003cp\u003eFrom part II, analysis of the open-ended question.\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003eSummative content analysis and descriptive statistics\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003eInfection control included 57.7% of the total number of codes (n\u0026thinsp;=\u0026thinsp;2033), it was considered the most important way for the nurses to prevent bacterial contamination and SSI\u003c/p\u003e \u003cp\u003eSkin disinfection is the most important intervention in order to prevent bacterial contamination and surgical site infection\u003c/p\u003e \u003cp\u003eAseptic technique was maintained during surgery by keeping the sterile goods sterile, removing the draping after the dressing was applied, supervising other persons in the surgical team to ensure that they did not contaminate anything in the sterile field, and quickly replacing any contaminated item with a new, sterile one\u003c/p\u003e \u003cp\u003eAlong with this, the nurses described additional interventions that they performed in order to uphold an aseptic technique: the use of antibacterial sutures, avoiding touching implants, a thorough preoperative hand disinfection of their own hands including the checking of other team members\u0026rsquo; hand disinfection, and cleaning the sterile goods during surgery in order to avoid bacterial growth\u003c/p\u003e \u003cp\u003eThe use of incision drapes to protect the surgical area and transparent plastic film to cover open wounds was considered important\u003c/p\u003e \u003cp\u003eIt was important that the draping was employed correctly, and that it should stay in place throughout the procedure\u003c/p\u003e \u003cp\u003eImportant aspects included choosing a dressing suitable for that specific surgery, applying the dressing in a sterile manner, and applying the dressing closely and tightly against the skin\u003c/p\u003e \u003cp\u003e...the importance of choosing a dressing that was gentle and appropriate for sensitive skin, and that would not cause blisters or eczema\u003c/p\u003e \u003cp\u003e\u0026hellip; a lack of an instrument in the OR, the personnel in the OR should use the phone to ask someone outside the OR to bring the missing instrument instead of opening the doors\u003c/p\u003e \u003cp\u003eimportant for the hygiene level in the OR to be satisfactory and the doors of the OR to be kept closed; or, at least, opened only when absolutely necessary during preparation for surgery and the surgery itself\u003c/p\u003e \u003cp\u003e\u0026ldquo;Use the phone in the OR as your means of communication [with staff outside of the OR], do not run in and out. Plan your work and make sure that the equipment you might need is in the OR, use reach-through cabinets as much as possible\u0026rdquo;\u003c/p\u003e \u003cp\u003eThe nurses described a calm environment, few people, and no opening of doors as important factors in order to minimize bacterial air contamination\u003c/p\u003e \u003cp\u003eAseptic technique was also considered important. This was described in many ways, for example in terms of making sure to change gloves with holes or gloves that were damaged in some way\u003c/p\u003e \u003cp\u003eThe nurses believed that it was important for all personnel working in the OR to be dressed appropriately in tightly woven clothes or clean air suits, including using a mask and helmet, with sterile gowns and gloves for the personnel actively working with or around the surgical area\u0026hellip;\u003c/p\u003e \u003cp\u003eThe nurses stated that they felt it best to set up and cover the sterile goods before the patient arrived at the OR if possible, and that it was important for the preparation to be done in a sterile manner\u003c/p\u003e \u003cp\u003eConnected to preparation, such as checking that the instruments were sterilized before taking them out of their packaging\u003c/p\u003e \u003cp\u003eThe nurses stated that it was important for basic hygiene to be upheld by all members of the OR staff\u003c/p\u003e \u003cp\u003e\u0026ldquo;The importance of sterility throughout the surgery, and being responsible for ensuring that everyone in the OR follows the hygiene regulations\u0026rdquo;\u003c/p\u003e \u003cp\u003e\u0026ldquo;Being well informed regarding the patient by reading their medical chart\u0026rdquo;\u003c/p\u003e\u003cp\u003eOne nurse stated that it was important to have \u0026ldquo;knowledge of postoperative wound infections in order to be able to prepare oneself properly\u0026rdquo;\u003c/p\u003e\u003cp\u003eTwo of the nurses stated that they needed to be given the proper amount of time to prepare the skin disinfection of the surgical area, in order to allow them to perform their work well and without stress\u003c/p\u003e\u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003e-Please insert Table\u0026nbsp;\u003cspan refid=\"Tab3\" class=\"InternalRef\"\u003e3\u003c/span\u003e here-\u003c/p\u003e \u003cp\u003eThe analysis process began with the first author conducting an open coding of the extracted data, which were then reviewed and approved by the entire research group. A first draft was created by three of the authors (an operating room nurse, a registered nurse, and a critical care nurse), all with experience with qualitative data and two with previous experience with the analysis method. All were aware of the risk of personal judgement when researching one\u0026rsquo;s own field of practice, and this risk was repeatedly and critically discussed (\u003cspan citationid=\"CR58\" class=\"CitationRef\"\u003e58\u003c/span\u003e). The coded data were compared individually to find patterns, similarities, and connections, and to form subcategories. After the initial draft was approved, the research team synthesised the results within each sub-category. This process led to the creation of an integrated summary and the development of main categories by the research group (\u003cspan citationid=\"CR57\" class=\"CitationRef\"\u003e57\u003c/span\u003e). For an example of the analysis process, see Table\u0026nbsp;\u003cspan refid=\"Tab4\" class=\"InternalRef\"\u003e4\u003c/span\u003e.\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab4\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 4\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eExamples of the analysis process\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"4\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eMeaning units\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eCode\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003eSubcategory\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003eCategory\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u0026hellip;as being afraid to give feedback about aseptic practise to the surgeon, afraid to make them angry, surgical field being a battlefield.\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eBeing afraid to give feedback\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eCooperative behaviour\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eInterpersonal\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eThere was no systematic feedback on results or complications. For example, some participants emphasised that they wanted to know the infection rates for their specific department.\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eNeed for feedback\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eCommunication systems\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eConditions\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003c/div\u003e"},{"header":"3. Results","content":"\u003cp\u003eA total of 17 articles were included in the analysis and comprised studies from the following countries: Canada (n\u0026thinsp;=\u0026thinsp;1), Finland (n\u0026thinsp;=\u0026thinsp;1), Iceland (n\u0026thinsp;=\u0026thinsp;1), Iran (n\u0026thinsp;=\u0026thinsp;1), Italy (n\u0026thinsp;=\u0026thinsp;1), Norway (n\u0026thinsp;=\u0026thinsp;2), Sweden (n\u0026thinsp;=\u0026thinsp;8), the United Kingdom (UK) (n\u0026thinsp;=\u0026thinsp;1), and an article with findings from the UK, Finland, and the US (n\u0026thinsp;=\u0026thinsp;1). Out of the total, 14 studies employed qualitative methods, while three studies had quantitative methods. Demographics are presented in Table\u0026nbsp;\u003cspan refid=\"Tab3\" class=\"InternalRef\"\u003e3\u003c/span\u003e. The analysis resulted in four categories; intrapersonal, interpersonal, evidence-based practice, and conditions. The main categories emerged from the eight subcategories; have control, planning ahead, competency, occupational stress, cooperative behaviour, respect, management, and communication systems.\u003c/p\u003e \u003cdiv id=\"Sec8\" class=\"Section2\"\u003e \u003ch2\u003e3.1. Intrapersonal\u003c/h2\u003e \u003cp\u003eThe intrapersonal category includes prerequisites among operating room nurses and regarded beliefs, perceptions, emotions, and personal characteristics concerning the professional responsibility of prevention interventions during the intraoperative phase. The intrapersonal category emerges from the subcategories; have control, planning ahead, competency, and occupational stress.\u003c/p\u003e \u003cdiv id=\"Sec9\" class=\"Section3\"\u003e \u003ch2\u003e3.1.1. Have control\u003c/h2\u003e \u003cp\u003ePrevention was an essential part of their professional responsibility (\u003cspan citationid=\"CR47\" class=\"CitationRef\"\u003e47\u003c/span\u003e), and infection prevention interventions was considered the most important way to prevent surgical site infections (\u003cspan citationid=\"CR40\" class=\"CitationRef\"\u003e40\u003c/span\u003e, \u003cspan citationid=\"CR54\" class=\"CitationRef\"\u003e54\u003c/span\u003e). To maintain an aseptic environment, they strive to have control over the operating room, the equipment, and the personal actions of other professionals within team (\u003cspan citationid=\"CR40\" class=\"CitationRef\"\u003e40\u003c/span\u003e, \u003cspan citationid=\"CR42\" class=\"CitationRef\"\u003e42\u003c/span\u003e, \u003cspan citationid=\"CR44\" class=\"CitationRef\"\u003e44\u003c/span\u003e, \u003cspan citationid=\"CR46\" class=\"CitationRef\"\u003e46\u003c/span\u003e, \u003cspan additionalcitationids=\"CR50 CR51\" citationid=\"CR49\" class=\"CitationRef\"\u003e49\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR52\" class=\"CitationRef\"\u003e52\u003c/span\u003e, \u003cspan citationid=\"CR54\" class=\"CitationRef\"\u003e54\u003c/span\u003e). They felt responsible if the patient acquired infection (\u003cspan citationid=\"CR44\" class=\"CitationRef\"\u003e44\u003c/span\u003e) and felt obliged to assess and document risks of surgical site infections (\u003cspan citationid=\"CR51\" class=\"CitationRef\"\u003e51\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eThey actively worked to maintain control of the aseptic environment by implementing infection prevention interventions, including the replacement of non-sterile equipment, glove changes, proper dressing application, and ensuring the secure placement of the drape (\u003cspan citationid=\"CR39\" class=\"CitationRef\"\u003e39\u003c/span\u003e, \u003cspan citationid=\"CR40\" class=\"CitationRef\"\u003e40\u003c/span\u003e, \u003cspan citationid=\"CR50\" class=\"CitationRef\"\u003e50\u003c/span\u003e). The aspiration was to have control over the equipment, ensuring its proper setup and coverage before the patient's arrival (\u003cspan citationid=\"CR40\" class=\"CitationRef\"\u003e40\u003c/span\u003e). Skin disinfection was considered the most important intraoperative infection preventive intervention, and draping was essential (\u003cspan citationid=\"CR40\" class=\"CitationRef\"\u003e40\u003c/span\u003e, \u003cspan citationid=\"CR50\" class=\"CitationRef\"\u003e50\u003c/span\u003e). Incision drapes to protect the surgical site and plastic drapes to cover open wounds were also considered important (\u003cspan citationid=\"CR40\" class=\"CitationRef\"\u003e40\u003c/span\u003e).\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec10\" class=\"Section3\"\u003e \u003ch2\u003e3.1.2. Planning ahead\u003c/h2\u003e \u003cp\u003eBeing able to plan ahead was an important prerequisite (\u003cspan citationid=\"CR40\" class=\"CitationRef\"\u003e40\u003c/span\u003e, \u003cspan citationid=\"CR41\" class=\"CitationRef\"\u003e41\u003c/span\u003e, \u003cspan additionalcitationids=\"CR44 CR45 CR46\" citationid=\"CR43\" class=\"CitationRef\"\u003e43\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR47\" class=\"CitationRef\"\u003e47\u003c/span\u003e). The ability to be prepared meant being one step ahead in the surgical procedure (\u003cspan citationid=\"CR41\" class=\"CitationRef\"\u003e41\u003c/span\u003e). Operating room nurses require adequate time for preparation, which is crucial, as they often face time constraints while performing their duties (\u003cspan citationid=\"CR40\" class=\"CitationRef\"\u003e40\u003c/span\u003e, \u003cspan citationid=\"CR43\" class=\"CitationRef\"\u003e43\u003c/span\u003e, \u003cspan citationid=\"CR44\" class=\"CitationRef\"\u003e44\u003c/span\u003e, \u003cspan citationid=\"CR46\" class=\"CitationRef\"\u003e46\u003c/span\u003e, \u003cspan citationid=\"CR51\" class=\"CitationRef\"\u003e51\u003c/span\u003e). A precise preoperative plan makes preparation easier and reduces the patient's time in the operating room, which can decrease the risk of surgical site infections (\u003cspan citationid=\"CR40\" class=\"CitationRef\"\u003e40\u003c/span\u003e, \u003cspan citationid=\"CR44\" class=\"CitationRef\"\u003e44\u003c/span\u003e) A desire was expressed to review the patient's medical chart or preoperative plan prior to the procedure, ensuring that all necessary information and preparations were in place (\u003cspan citationid=\"CR40\" class=\"CitationRef\"\u003e40\u003c/span\u003e, \u003cspan citationid=\"CR45\" class=\"CitationRef\"\u003e45\u003c/span\u003e, \u003cspan citationid=\"CR51\" class=\"CitationRef\"\u003e51\u003c/span\u003e). Knowledge of patients' medical histories provide a higher level of awareness of risk factors such as vulnerability and fragility, setting the stage for adjusted infection preventive interventions (\u003cspan citationid=\"CR44\" class=\"CitationRef\"\u003e44\u003c/span\u003e, \u003cspan citationid=\"CR45\" class=\"CitationRef\"\u003e45\u003c/span\u003e, \u003cspan citationid=\"CR47\" class=\"CitationRef\"\u003e47\u003c/span\u003e). A preoperative conversation with the patient was highly advantageous, as they found it to be beneficial in ensuring the provision of safe care (\u003cspan citationid=\"CR45\" class=\"CitationRef\"\u003e45\u003c/span\u003e).\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec11\" class=\"Section3\"\u003e \u003ch2\u003e3.1.3. Competency\u003c/h2\u003e \u003cp\u003eThe professional competence of operating room nurses was prerequisite. Competence, as well as experience were described as essential skills for the performance of infection prevention interventions (\u003cspan citationid=\"CR40\" class=\"CitationRef\"\u003e40\u003c/span\u003e, \u003cspan citationid=\"CR47\" class=\"CitationRef\"\u003e47\u003c/span\u003e, \u003cspan citationid=\"CR54\" class=\"CitationRef\"\u003e54\u003c/span\u003e). Two studies rated competence as the most important factor (\u003cspan citationid=\"CR46\" class=\"CitationRef\"\u003e46\u003c/span\u003e, \u003cspan citationid=\"CR51\" class=\"CitationRef\"\u003e51\u003c/span\u003e). Within the team, operating room nurses had the most competence in infection prevention and took charge of educating other professionals (\u003cspan citationid=\"CR42\" class=\"CitationRef\"\u003e42\u003c/span\u003e, \u003cspan citationid=\"CR45\" class=\"CitationRef\"\u003e45\u003c/span\u003e, \u003cspan citationid=\"CR47\" class=\"CitationRef\"\u003e47\u003c/span\u003e, \u003cspan citationid=\"CR51\" class=\"CitationRef\"\u003e51\u003c/span\u003e, \u003cspan citationid=\"CR54\" class=\"CitationRef\"\u003e54\u003c/span\u003e). Competency was a prerequisite for the ability to direct actions for an aseptic environment (\u003cspan citationid=\"CR51\" class=\"CitationRef\"\u003e51\u003c/span\u003e, \u003cspan citationid=\"CR52\" class=\"CitationRef\"\u003e52\u003c/span\u003e, \u003cspan citationid=\"CR54\" class=\"CitationRef\"\u003e54\u003c/span\u003e). They believed that having the necessary skills and knowledge, along with a friendly leadership style could foster respect among team members and increase their willingness to comply with hygiene rules (\u003cspan citationid=\"CR44\" class=\"CitationRef\"\u003e44\u003c/span\u003e, \u003cspan citationid=\"CR45\" class=\"CitationRef\"\u003e45\u003c/span\u003e). The ability to direct infection prevention actions improved with experience (\u003cspan citationid=\"CR54\" class=\"CitationRef\"\u003e54\u003c/span\u003e).\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec12\" class=\"Section3\"\u003e \u003ch2\u003e3.1.4. Occupational stress\u003c/h2\u003e \u003cp\u003eOccupational stress was present, affected the prerequisites for preventive infection interventions, and contributed to feelings of an inability to cope with work demands (\u003cspan citationid=\"CR46\" class=\"CitationRef\"\u003e46\u003c/span\u003e, \u003cspan citationid=\"CR47\" class=\"CitationRef\"\u003e47\u003c/span\u003e, \u003cspan citationid=\"CR51\" class=\"CitationRef\"\u003e51\u003c/span\u003e, \u003cspan citationid=\"CR52\" class=\"CitationRef\"\u003e52\u003c/span\u003e). Operating room nurses endeavoured to provide safe and equitable care (\u003cspan citationid=\"CR52\" class=\"CitationRef\"\u003e52\u003c/span\u003e). However, the lack of time was stated as one of the major sources of occupational stress, and they often experienced time pressure in their clinical duties (\u003cspan citationid=\"CR44\" class=\"CitationRef\"\u003e44\u003c/span\u003e, \u003cspan citationid=\"CR46\" class=\"CitationRef\"\u003e46\u003c/span\u003e, \u003cspan citationid=\"CR51\" class=\"CitationRef\"\u003e51\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eStressors arose when they felt obligated to minimise the time allocated for mandatory tasks during preparation and surgery (\u003cspan citationid=\"CR46\" class=\"CitationRef\"\u003e46\u003c/span\u003e, \u003cspan citationid=\"CR47\" class=\"CitationRef\"\u003e47\u003c/span\u003e, \u003cspan citationid=\"CR51\" class=\"CitationRef\"\u003e51\u003c/span\u003e, \u003cspan citationid=\"CR52\" class=\"CitationRef\"\u003e52\u003c/span\u003e). Stress also arose when they felt the need to have \u0026lsquo;split vision\u0026rsquo;, such as planning the next surgery while protecting sterility and performing infection prevention interventions (\u003cspan citationid=\"CR48\" class=\"CitationRef\"\u003e48\u003c/span\u003e, \u003cspan citationid=\"CR51\" class=\"CitationRef\"\u003e51\u003c/span\u003e, \u003cspan citationid=\"CR52\" class=\"CitationRef\"\u003e52\u003c/span\u003e). Stress also arose when team members failed to follow hygiene rules or disregarded feedback on their behaviour (\u003cspan citationid=\"CR44\" class=\"CitationRef\"\u003e44\u003c/span\u003e, \u003cspan citationid=\"CR48\" class=\"CitationRef\"\u003e48\u003c/span\u003e, \u003cspan citationid=\"CR51\" class=\"CitationRef\"\u003e51\u003c/span\u003e, \u003cspan citationid=\"CR52\" class=\"CitationRef\"\u003e52\u003c/span\u003e, \u003cspan citationid=\"CR54\" class=\"CitationRef\"\u003e54\u003c/span\u003e). Patient-related factors, such as poor preoperative preparations or physical challenges were experienced as stressful, especially for inexperienced operating room nurses (\u003cspan citationid=\"CR51\" class=\"CitationRef\"\u003e51\u003c/span\u003e). New operating room nurses were more worried about not knowing what to do (\u003cspan citationid=\"CR51\" class=\"CitationRef\"\u003e51\u003c/span\u003e).\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv id=\"Sec13\" class=\"Section2\"\u003e \u003ch2\u003e3.2. Interpersonal\u003c/h2\u003e \u003cp\u003eThe Interpersonal category contains prerequisites for infection prevention interventions that were influenced by the interaction of two or more people. Interpersonal prerequisites related to the operating room team included composition, competencies, the ability to cooperate, and respect for the operating room nurse's area of ​​responsibility. The interpersonal category was based on the subcategories: cooperative behaviour and respect.\u003c/p\u003e \u003cdiv id=\"Sec14\" class=\"Section3\"\u003e \u003ch2\u003e3.2.1. Cooperative behaviour\u003c/h2\u003e \u003cp\u003eCooperative behaviour was related to operating room nurses and surgeons, nurse assistants, or anaesthetic nurses. All team members needed to understand the importance of infection prevention and follow hygiene rules (\u003cspan citationid=\"CR40\" class=\"CitationRef\"\u003e40\u003c/span\u003e, \u003cspan citationid=\"CR54\" class=\"CitationRef\"\u003e54\u003c/span\u003e). Operating room nurses emphasised the value of a well-functioning team (\u003cspan citationid=\"CR45\" class=\"CitationRef\"\u003e45\u003c/span\u003e, \u003cspan citationid=\"CR48\" class=\"CitationRef\"\u003e48\u003c/span\u003e, \u003cspan additionalcitationids=\"CR52 CR53\" citationid=\"CR51\" class=\"CitationRef\"\u003e51\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR54\" class=\"CitationRef\"\u003e54\u003c/span\u003e). Positive relationships among team members were found to facilitate infection prevention interventions and encouraged operating room nurses to speak up about errors and risks when necessary (\u003cspan citationid=\"CR51\" class=\"CitationRef\"\u003e51\u003c/span\u003e, \u003cspan citationid=\"CR52\" class=\"CitationRef\"\u003e52\u003c/span\u003e, \u003cspan citationid=\"CR54\" class=\"CitationRef\"\u003e54\u003c/span\u003e). Opportunities for mutual support and collaboration across professional boundaries were created when operating room nurses trusted the competencies and responsibilities of other team members (\u003cspan citationid=\"CR48\" class=\"CitationRef\"\u003e48\u003c/span\u003e, \u003cspan additionalcitationids=\"CR53\" citationid=\"CR52\" class=\"CitationRef\"\u003e52\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR54\" class=\"CitationRef\"\u003e54\u003c/span\u003e). Collaboration between two operating room nurses during the intraoperative phase was found to be an enabling prerequisite (\u003cspan citationid=\"CR44\" class=\"CitationRef\"\u003e44\u003c/span\u003e, \u003cspan citationid=\"CR46\" class=\"CitationRef\"\u003e46\u003c/span\u003e). When performing preventive infection interventions, operating room nurses were dependent on the nurse assistants' willingness to cooperate (\u003cspan citationid=\"CR45\" class=\"CitationRef\"\u003e45\u003c/span\u003e). Additionally, cooperative behaviour, where the surgeon was willing to assist with infection preventive interventions, was highly valued (\u003cspan citationid=\"CR52\" class=\"CitationRef\"\u003e52\u003c/span\u003e, \u003cspan citationid=\"CR53\" class=\"CitationRef\"\u003e53\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eOn the other hand, operating room nurses described conditions when cooperative behaviour was ineffective and unsafe. The necessary preoperative information from the operating surgeon was often lacking, and operating room nurses sometimes had to double-check information with the surgeon (\u003cspan citationid=\"CR44\" class=\"CitationRef\"\u003e44\u003c/span\u003e, \u003cspan citationid=\"CR46\" class=\"CitationRef\"\u003e46\u003c/span\u003e, \u003cspan citationid=\"CR47\" class=\"CitationRef\"\u003e47\u003c/span\u003e, \u003cspan citationid=\"CR52\" class=\"CitationRef\"\u003e52\u003c/span\u003e). Tensions in the team, unnecessary disturbances and poor communication skills were other conditions that negatively influenced infection prevention interventions (\u003cspan citationid=\"CR45\" class=\"CitationRef\"\u003e45\u003c/span\u003e, \u003cspan additionalcitationids=\"CR53\" citationid=\"CR52\" class=\"CitationRef\"\u003e52\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR54\" class=\"CitationRef\"\u003e54\u003c/span\u003e). A lack of trust, communication, or an understanding of each other's responsibilities could lead to risky events such as ineffective infection prevention interventions (\u003cspan citationid=\"CR48\" class=\"CitationRef\"\u003e48\u003c/span\u003e, \u003cspan additionalcitationids=\"CR53\" citationid=\"CR52\" class=\"CitationRef\"\u003e52\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR54\" class=\"CitationRef\"\u003e54\u003c/span\u003e). Bad tempered surgeons during the intraoperative phase could make them nervous and generate mistakes (\u003cspan citationid=\"CR48\" class=\"CitationRef\"\u003e48\u003c/span\u003e, \u003cspan additionalcitationids=\"CR53\" citationid=\"CR52\" class=\"CitationRef\"\u003e52\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR54\" class=\"CitationRef\"\u003e54\u003c/span\u003e). When assessing the reasons for tensions in the operating room, safety and sterility were not prominent concerns (\u003cspan citationid=\"CR42\" class=\"CitationRef\"\u003e42\u003c/span\u003e). For reasons of patient safety, they endeavoured to remain focused and not respond to any distractions or engage with any instances of bad behaviour (\u003cspan citationid=\"CR48\" class=\"CitationRef\"\u003e48\u003c/span\u003e). Fearful of conflicts, they sometimes avoided informing the surgeon of poor aseptic practices (\u003cspan citationid=\"CR42\" class=\"CitationRef\"\u003e42\u003c/span\u003e, \u003cspan citationid=\"CR49\" class=\"CitationRef\"\u003e49\u003c/span\u003e, \u003cspan citationid=\"CR51\" class=\"CitationRef\"\u003e51\u003c/span\u003e). In one study, the operating room nurses described needing to ensure that surgeon has a smooth experience during surgery (\u003cspan citationid=\"CR49\" class=\"CitationRef\"\u003e49\u003c/span\u003e).\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec15\" class=\"Section3\"\u003e \u003ch2\u003e3.2.2. Respect\u003c/h2\u003e \u003cp\u003eInterpersonal requirements included a desire for other team members to respect their area of ​​expertise. Operating room nurses want to be treated as equal team members with valuable duties that take time (\u003cspan citationid=\"CR41\" class=\"CitationRef\"\u003e41\u003c/span\u003e, \u003cspan citationid=\"CR43\" class=\"CitationRef\"\u003e43\u003c/span\u003e, \u003cspan citationid=\"CR45\" class=\"CitationRef\"\u003e45\u003c/span\u003e, \u003cspan citationid=\"CR46\" class=\"CitationRef\"\u003e46\u003c/span\u003e, \u003cspan citationid=\"CR53\" class=\"CitationRef\"\u003e53\u003c/span\u003e, \u003cspan citationid=\"CR55\" class=\"CitationRef\"\u003e55\u003c/span\u003e). They perceived that infection preventive interventions were considered less valuable by other team members, who did not prioritize dedicating time to these interventions over other surgical tasks (\u003cspan citationid=\"CR41\" class=\"CitationRef\"\u003e41\u003c/span\u003e, \u003cspan citationid=\"CR46\" class=\"CitationRef\"\u003e46\u003c/span\u003e, \u003cspan additionalcitationids=\"CR54\" citationid=\"CR53\" class=\"CitationRef\"\u003e53\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR55\" class=\"CitationRef\"\u003e55\u003c/span\u003e). Team members found it bothersome when operating room nurses alerted them to inadequate aseptic behaviour or initiated aseptic measures (\u003cspan citationid=\"CR44\" class=\"CitationRef\"\u003e44\u003c/span\u003e).\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv id=\"Sec16\" class=\"Section2\"\u003e \u003ch2\u003e3.3. Evidence Based Practice\u003c/h2\u003e \u003cp\u003eThe Evidence-Based Practice category contains prerequisites to integrate current evidence with clinical expertise in operating room nurses\u0026rsquo; work on infection prevention during the intraoperative phase. This category includes conflicting findings. In several studies operating room nurses were of the opinion that most infection prevention interventions recommended in guidelines were implemented and followed during the daily work (\u003cspan citationid=\"CR39\" class=\"CitationRef\"\u003e39\u003c/span\u003e, \u003cspan citationid=\"CR44\" class=\"CitationRef\"\u003e44\u003c/span\u003e, \u003cspan citationid=\"CR55\" class=\"CitationRef\"\u003e55\u003c/span\u003e). On the other hand, there were several examples where guidelines were not followed by other team members or by the operating room nurses themselves (\u003cspan citationid=\"CR42\" class=\"CitationRef\"\u003e42\u003c/span\u003e, \u003cspan citationid=\"CR44\" class=\"CitationRef\"\u003e44\u003c/span\u003e, \u003cspan additionalcitationids=\"CR49 CR50\" citationid=\"CR48\" class=\"CitationRef\"\u003e48\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR51\" class=\"CitationRef\"\u003e51\u003c/span\u003e, \u003cspan citationid=\"CR54\" class=\"CitationRef\"\u003e54\u003c/span\u003e). Adherence to guidelines varied between professionals in the team and between different operating room nurses (\u003cspan citationid=\"CR44\" class=\"CitationRef\"\u003e44\u003c/span\u003e, \u003cspan citationid=\"CR50\" class=\"CitationRef\"\u003e50\u003c/span\u003e). Not all infection preventive interventions had scientific evidence backing them up, and interventions with limited scientific evidence were, practised in various ways to a greater extent (\u003cspan citationid=\"CR39\" class=\"CitationRef\"\u003e39\u003c/span\u003e). A study reported that interventions were performed based on the operating room nurse's experience, routines, or emanated from the medical court (\u003cspan citationid=\"CR45\" class=\"CitationRef\"\u003e45\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eIn one study, most operating room nurses followed the recommended time for skin disinfection and wore double sterile gloves (\u003cspan citationid=\"CR39\" class=\"CitationRef\"\u003e39\u003c/span\u003e). Although there is evidence supporting recommended practices for skin disinfection, studies found that some not adhere to them (\u003cspan citationid=\"CR39\" class=\"CitationRef\"\u003e39\u003c/span\u003e, \u003cspan citationid=\"CR50\" class=\"CitationRef\"\u003e50\u003c/span\u003e). Most of them acquired the skill of performing skin disinfection by learning from colleagues during their clinical education (\u003cspan citationid=\"CR39\" class=\"CitationRef\"\u003e39\u003c/span\u003e).\u003c/p\u003e \u003cp\u003e The use of evidence-based interventions and the adherence to guidelines was impacted by the surgeon. Surgeons had final decision-making power and could decide on infection prevention interventions (\u003cspan citationid=\"CR48\" class=\"CitationRef\"\u003e48\u003c/span\u003e, \u003cspan citationid=\"CR49\" class=\"CitationRef\"\u003e49\u003c/span\u003e, \u003cspan citationid=\"CR54\" class=\"CitationRef\"\u003e54\u003c/span\u003e). Operating room nurses accommodate surgeons' specific requests, including deviations from guidelines and manufacturer recommendations (\u003cspan citationid=\"CR48\" class=\"CitationRef\"\u003e48\u003c/span\u003e, \u003cspan citationid=\"CR49\" class=\"CitationRef\"\u003e49\u003c/span\u003e).\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec17\" class=\"Section2\"\u003e \u003ch2\u003e3.4. Conditions\u003c/h2\u003e \u003cp\u003eSeveral studies reported prerequisites from outside the operating room nurses and the team. This category included prerequisites from the physical context in which operating room nurses practise infection prevention interventions. The category was based on the two subcategories: management and communication systems.\u003c/p\u003e \u003cdiv id=\"Sec18\" class=\"Section3\"\u003e \u003ch2\u003e3.4.1. Management\u003c/h2\u003e \u003cp\u003eThe environment provided prerequisites for infection prevention interventions. Operating room nurses required the environment to be calm during both the preparation and surgical procedure (\u003cspan citationid=\"CR40\" class=\"CitationRef\"\u003e40\u003c/span\u003e). Most often, they felt that there were good prerequisites for an aseptic environment (\u003cspan citationid=\"CR44\" class=\"CitationRef\"\u003e44\u003c/span\u003e, \u003cspan citationid=\"CR55\" class=\"CitationRef\"\u003e55\u003c/span\u003e). They stressed the need for all members of the team to have access to appropriate personal equipment such as surgical suits, gloves, helmets, and masks (\u003cspan citationid=\"CR40\" class=\"CitationRef\"\u003e40\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eChanges to timetables and team composition posed challenges in preparing for surgeries (\u003cspan citationid=\"CR46\" class=\"CitationRef\"\u003e46\u003c/span\u003e, \u003cspan citationid=\"CR47\" class=\"CitationRef\"\u003e47\u003c/span\u003e). Time constraints schedules did not include time to access patients\u0026rsquo; medical records and the available preoperative information was overly brief (\u003cspan citationid=\"CR44\" class=\"CitationRef\"\u003e44\u003c/span\u003e). Operating room nurses believed that management should allocate sufficient time for preparation and infection prevention interventions (\u003cspan citationid=\"CR40\" class=\"CitationRef\"\u003e40\u003c/span\u003e, \u003cspan citationid=\"CR43\" class=\"CitationRef\"\u003e43\u003c/span\u003e, \u003cspan citationid=\"CR44\" class=\"CitationRef\"\u003e44\u003c/span\u003e, \u003cspan citationid=\"CR47\" class=\"CitationRef\"\u003e47\u003c/span\u003e). Management needs to have insight into the situations faced by operating room nurses and communicate their resource needs to the organisation (\u003cspan citationid=\"CR47\" class=\"CitationRef\"\u003e47\u003c/span\u003e, \u003cspan citationid=\"CR53\" class=\"CitationRef\"\u003e53\u003c/span\u003e). They recognise good management as a crucial support for infection prevention interventions (\u003cspan citationid=\"CR52\" class=\"CitationRef\"\u003e52\u003c/span\u003e, \u003cspan citationid=\"CR54\" class=\"CitationRef\"\u003e54\u003c/span\u003e), whereas poor management can lead to unstable routines and serve as a barrier to effective infection prevention (\u003cspan citationid=\"CR46\" class=\"CitationRef\"\u003e46\u003c/span\u003e, \u003cspan citationid=\"CR52\" class=\"CitationRef\"\u003e52\u003c/span\u003e).\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec19\" class=\"Section3\"\u003e \u003ch2\u003e3.4.2. Communication systems\u003c/h2\u003e \u003cp\u003eWell-functioning communication systems were a necessary prerequisite concerning infection prevention interventions (\u003cspan citationid=\"CR40\" class=\"CitationRef\"\u003e40\u003c/span\u003e, \u003cspan citationid=\"CR44\" class=\"CitationRef\"\u003e44\u003c/span\u003e, \u003cspan citationid=\"CR47\" class=\"CitationRef\"\u003e47\u003c/span\u003e, \u003cspan citationid=\"CR54\" class=\"CitationRef\"\u003e54\u003c/span\u003e). Of the included studies, three described operating room nurses\u0026rsquo; access to insufficient and too-brief information from the anaesthesia assessment or from the operating room planning system (\u003cspan citationid=\"CR44\" class=\"CitationRef\"\u003e44\u003c/span\u003e, \u003cspan citationid=\"CR46\" class=\"CitationRef\"\u003e46\u003c/span\u003e, \u003cspan citationid=\"CR47\" class=\"CitationRef\"\u003e47\u003c/span\u003e). Feedback systems on surgical site infection rates or complications were requested to assess the effectiveness of infection prevention interventions and to gain insights to the efficiency of routines (\u003cspan citationid=\"CR40\" class=\"CitationRef\"\u003e40\u003c/span\u003e, \u003cspan citationid=\"CR44\" class=\"CitationRef\"\u003e44\u003c/span\u003e). The lack of feedback systems for surgical site infections was highlighted as barrier in two studies, as was not knowing the impact of performed interventions (\u003cspan citationid=\"CR44\" class=\"CitationRef\"\u003e44\u003c/span\u003e, \u003cspan citationid=\"CR54\" class=\"CitationRef\"\u003e54\u003c/span\u003e). Also, information about new practices and complications did not reach the right personnel (\u003cspan citationid=\"CR44\" class=\"CitationRef\"\u003e44\u003c/span\u003e).\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e"},{"header":"4. Discussion","content":"\u003cp\u003eTo ensure the safety of vulnerable surgical patients, optimal prerequisites for the performance of infection prevention interventions must be present. This integrative review identified several key factors that affect operating room nurses' ability to perform safe infection prevention interventions. These factors included intrapersonal prerequisites within individual operating room nurses, interpersonal prerequisites within the team, external conditions, and both facilitating prerequisites and barriers to implementing evidence-based practice.\u003c/p\u003e \u003cp\u003eIncluded studies show prevention was a high priority, and operating room nurses guarded the environment to protect the patient. This control is comparable to the attributes of patient advocacy, where healthcare professionals make sure that patients receive the best possible care and that their rights and interests are respected and protected (\u003cspan citationid=\"CR59\" class=\"CitationRef\"\u003e59\u003c/span\u003e). The operating room nurse plays an essential role in advocating for the patient's safety during surgical procedures. This striving for control is also similar to the concept of nursing vigilance; where nurses are meant to be scientifically, intellectually, and experientially aware of the situation, to assess the risks, and be prepared to minimise and respond to risks (\u003cspan citationid=\"CR60\" class=\"CitationRef\"\u003e60\u003c/span\u003e). As identified in this review, competence is crucial, not only for practising nursing vigilance but also for successfully implementing infection prevention interventions. Operating room nurses emphasised their distinctive role and extensive knowledge regarding aseptic and infection prevention interventions within the team. This unique theoretical and clinical competence has been described as essential to ensuring patient safety during surgery (\u003cspan citationid=\"CR61\" class=\"CitationRef\"\u003e61\u003c/span\u003e). Given this unique competence, operating room nurses are ideally positioned to lead infection prevention efforts within the team for patient safety and, therefore, must be given the necessary respect, time, and resources for this duty. As previously studied, operating room nurses have linked competence to knowledge, good communication skills, and teamwork (\u003cspan citationid=\"CR62\" class=\"CitationRef\"\u003e62\u003c/span\u003e). This review emphasises the importance of teamwork as a prerequisite for infection prevention, which is consistent with previous research on infection prevention in general (\u003cspan citationid=\"CR28\" class=\"CitationRef\"\u003e28\u003c/span\u003e, \u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e). It is crucial for all team members to follow infection prevention guidelines and take appropriate actions. A synergistic effect can be achieved in the ideal team, where each individual contributes specific knowledge and competence to enhancing overall performance. Trust in the skills of other team members and good communication were prerequisites for infection prevention interventions. Previous studies have shown that inadequate information sharing during the intraoperative phase increases the risk of complications or patient mortality (\u003cspan citationid=\"CR63\" class=\"CitationRef\"\u003e63\u003c/span\u003e). It has been suggested that operating room teams with consistent members improve quality of care, reduce conflicts, and contribute to a flatter team hierarchy (\u003cspan citationid=\"CR64\" class=\"CitationRef\"\u003e64\u003c/span\u003e, \u003cspan citationid=\"CR65\" class=\"CitationRef\"\u003e65\u003c/span\u003e). The extensive utilisation of temporary staff across several European nations raises concerns regarding patient safety, as it may have implications for effective communication, coordination, and adherence to hygiene rules and routines (\u003cspan citationid=\"CR66\" class=\"CitationRef\"\u003e66\u003c/span\u003e). Thus, from the perspective of patient safety, it is desirable to have more permanent teams.\u003c/p\u003e \u003cp\u003eThis review revealed that operating room nurses perceived a lack of respect for their area of responsibility, including team members who did not follow hygiene rules, and negative attitudes from surgeons with bad tempers. Disruptive behaviour in the operating room has been reported in previous studies (\u003cspan citationid=\"CR67\" class=\"CitationRef\"\u003e67\u003c/span\u003e, \u003cspan citationid=\"CR68\" class=\"CitationRef\"\u003e68\u003c/span\u003e). A study revealed that at least once per month, over 20% of operating room nurses reported experiencing recurring incidents of verbal abuse from physicians (\u003cspan citationid=\"CR69\" class=\"CitationRef\"\u003e69\u003c/span\u003e). To manage this, they have developed coping mechanisms, such as remaining silent after experiencing verbal abuse, to maintain a working relationship with specific surgeons (\u003cspan citationid=\"CR70\" class=\"CitationRef\"\u003e70\u003c/span\u003e, \u003cspan citationid=\"CR71\" class=\"CitationRef\"\u003e71\u003c/span\u003e). Surgeons' disruptive behaviour has been shown to have a negative impact on patient safety by causing a loss of focus, increasing the risk of errors, reducing productivity, and potentially leading to staff turnover (\u003cspan citationid=\"CR72\" class=\"CitationRef\"\u003e72\u003c/span\u003e, \u003cspan citationid=\"CR73\" class=\"CitationRef\"\u003e73\u003c/span\u003e). These findings should serve as a wake-up call for managers. Operating room nurses should feel empowered to report such behaviour and be confident that action will be taken to address it.\u003c/p\u003e \u003cp\u003eFurthermore, our findings addressed a hierarchical issue where the surgeon has ultimate decision-making power over the responsibilities of operating room nurses. Similar dilemmas were described for midwives, who lacked authority to make crucial decisions relating to births and faced ethical dilemmas because of hierarchical pressure from physicians and management (\u003cspan citationid=\"CR73\" class=\"CitationRef\"\u003e73\u003c/span\u003e). Even if surgeons have the formal responsibility of the surgery, they must follow established regulations and guidelines to ensure the safety and effectiveness of the procedure. For reasons of patient safety, operating room nurses must stop playing the role of \u0026lsquo;hostess\u0026rsquo;, as was described in this review, and not act solely as a surgeon's assistant (\u003cspan citationid=\"CR74\" class=\"CitationRef\"\u003e74\u003c/span\u003e). They must stop fulfilling requests from surgeons that do not comply with evidence and guidelines. Another skill required might be the ability to challenge authorities. Indeed, for patient safety, operating room nurses must meet the expectations within their area of responsibility and thoroughly follow established evidence-based practices. Operating room nurses claimed weak scientific evidence caused variation in routines. In fact, tradition-based infection preventive interventions are practised (\u003cspan citationid=\"CR33\" class=\"CitationRef\"\u003e33\u003c/span\u003e, \u003cspan citationid=\"CR75\" class=\"CitationRef\"\u003e75\u003c/span\u003e). Developing more evidence on infection prevention interventions can support them in their role as leaders of infection prevention interventions and contribute to patient safety.\u003c/p\u003e \u003cp\u003eThis review highlights the need for supportive conditions to ensure safe infection prevention interventions. Time constraints and lacking information and feedback from management were reported as negative prerequisites. An earlier study examined the reasons why operating room nurses decided to remain in their workplace. It identified positive prerequisites, such as supportive leadership, personal stability, and opportunities for personal and organizational growth, which are consistent with the findings of this review (\u003cspan citationid=\"CR76\" class=\"CitationRef\"\u003e76\u003c/span\u003e). Operating room nurses were often experienced stress and productivity demands. The concept of nurse resilience has gained increasing attention as a potential solution for enhance nurses well-being. Nurse resilience involves the ability of nurses to positively adapt to stress and adversity, incorporating both external resources and personal characteristics, which can vary with context and life circumstances (\u003cspan citationid=\"CR77\" class=\"CitationRef\"\u003e77\u003c/span\u003e). The essential attributes that contribute to nursing resilience include social support from colleagues, managers, friends, and families, as well as self-belief, work-life balance, self-care, humour, optimism, realistic assessment of challenges, and the establishment of attainable goal (\u003cspan citationid=\"CR77\" class=\"CitationRef\"\u003e77\u003c/span\u003e). This review revealed that novice operating room nurses encountered higher levels of stress and uncertainty when carrying out infection prevention interventions. With the right support, younger and less experienced can also experience resilience and growth in their profession, as one study highlighted that factors such as age, experience, and education have limited impact on the resilience of operating room nurses (\u003cspan citationid=\"CR78\" class=\"CitationRef\"\u003e78\u003c/span\u003e). In order to maintain their resilience, operating room nurses need to be able to identify and utilise their personal resources, receive support from management, and be provided with working conditions that promote resilience. If management is not attentive to these needs, it may lead to a shortage of nurses and reduced patient safety.\u003c/p\u003e \u003cp\u003eThis study emphasises the importance of ongoing research on infection prevention interventions to enhance patient safety and reduce practice variability. Improving the prerequisites for infection prevention interventions in clinical care decreases the risk of surgical site infections, improves patient safety, and increases resilience.\u003c/p\u003e \u003cdiv id=\"Sec21\" class=\"Section2\"\u003e \u003ch2\u003e4.1. Strengths and limitations\u003c/h2\u003e \u003cp\u003eThis integrative review follows the methodological recommendations of Whittemore \u0026amp; Knalf (\u003cspan citationid=\"CR34\" class=\"CitationRef\"\u003e34\u003c/span\u003e), and the preferred reporting items for systematic reviews (\u003cspan citationid=\"CR36\" class=\"CitationRef\"\u003e36\u003c/span\u003e). Studies were reviewed and assessed using critical appraisal tools. To ensure the credibility of the results, this review follows the stages of the constant comparative method. Additionally, all five authors of this review analysed and discussed the results together in order to prevent the authors from making any subjective interpretations (\u003cspan citationid=\"CR79\" class=\"CitationRef\"\u003e79\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eSeveral methodological limitations are worth considering in this integrative review. This integrative review includes studies from countries in Europe, as well as Canada and Iran, and the responsibilities of operating room nurses may differ between these. Thus, all the included studies provided insights into the operating room nurses\u0026rsquo; aseptic responsibility and infection prevention interventions. Only 9 of the 17 included studies (53%) came from the initial database searches. This is a known problem due to indexing issues and inconsistent search terminology, especially in qualitative studies, which often require screening large numbers of studies and the use of multiple search strategies (\u003cspan citationid=\"CR34\" class=\"CitationRef\"\u003e34\u003c/span\u003e, \u003cspan citationid=\"CR80\" class=\"CitationRef\"\u003e80\u003c/span\u003e). A comprehensive literature search should include at least two or three search strategies (\u003cspan citationid=\"CR81\" class=\"CitationRef\"\u003e81\u003c/span\u003e). This review included five search strategies. Risk of publication bias was present, as only studies published in English were selected, and included the risk of missing out of important results. Initially, narrower search approaches were attempted, but these did not yield studies that aligned with the objectives of the study. In discussions with librarians, the broader data search strategy was chosen. However, it is important for the accuracy of the results of the integrative review that the literature research process is clearly and transparently documented and comprehensible (\u003cspan citationid=\"CR34\" class=\"CitationRef\"\u003e34\u003c/span\u003e).\u003c/p\u003e \u003c/div\u003e"},{"header":"5. Conclusions","content":"\u003cp\u003eIn conclusion, the study highlights the need to improve the prerequisites to effectively execute safe preventive infection interventions. The lack of commitment by the team to preventing surgical site infections is a cause for concern, as it left operating room nurses feeling disrespected and raised concerns for patient safety. Operating room nurses must be willing to shoulder the responsibility of leading and must be supported by management as leaders of infection preventive interventions, as well as provided with necessary prerequisites such as readily accessible information, further education, and sufficient time for preparation and implementation. Regular feedback on surgical site infection rates or complications is essential. This study emphasises the importance of well-staffed and familiar teams and underscores the need for zero tolerance for abusive behaviour, which has been overlooked for far too long. Finally, resilience is essential to maintain operating room nurses own well-being and provide the best possible safe care to patients. These recommendations, if implemented, will help improve the prevention of surgical site infections and promote patient safety in the operating room.\u003c/p\u003e"},{"header":"Declarations","content":"\u003cp\u003e6.1. Ethics approval and consent to participate\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eNot applicable\u003c/p\u003e\n\u003cp\u003e6.2. Consent for publication\u003c/p\u003e\n\u003cp\u003e\u0026nbsp;Not applicable.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e6.3. Availability of data and materials\u003c/p\u003e\n\u003cp\u003eData is available upon reasonable request. All requests relating to data should be addressed to [email protected]\u003c/p\u003e\n\u003cp\u003e6.4. Competing interests\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eThe authors declare that they have no competing interest.\u003c/p\u003e\n\u003cp\u003e6.5. Funding\u003c/p\u003e\n\u003cp\u003eThis study was funded by the County Council of Region \u0026Ouml;sterg\u0026ouml;tland, Sweden.\u003c/p\u003e\n\u003cp\u003e6.6. Authors\u0026rsquo; contributions\u003c/p\u003e\n\u003cp\u003eThe authorship of this study was a collaborative effort involving IM, KB, GHF, MBL, and KFB. All authors actively contributed to the planning, goal setting, study design, and completion of this integrative review. Following the initial planning phase, the screening of studies after data searches was conducted through collaborative discussions by all authors. GHF, MBL, and IM carried out the initial analysis, while subsequent discussions involving KB and KFB were held. IM assumed the lead role in writing the manuscript and throughout the writing process, with each author providing feedback and making valuable contributions to the manuscript. The final version of the manuscript has been thoroughly reviewed and approved by all authors.\u003c/p\u003e\n\u003cp\u003e6.7. Acknowledgements\u003c/p\u003e\n\u003cp\u003eWe would like to thank the librarians Joakim Westerlund and Magdalena \u0026Ouml;str\u0026ouml;m at the Medical library, Link\u0026ouml;ping University, Sweden, for their support with the literature search.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\n\u003cli\u003eHoran TC, Gaynes RP, Martone WJ, Jarvis WR, Emori TG. CDC definitions of nosocomial surgical site infections, 1992: a modification of CDC definitions of surgical wound infections. Infection Control \u0026amp; Hospital Epidemiology. 1992;13(10):606-8; doi: 10.1016/s0196-6553(05)80201-9.\u003c/li\u003e\n\u003cli\u003eNational Healthcare Safety Network Center for Disease Control and Prevention. Surgical site infection (SSI) event. https://www.cdc.gov/nhsn/pdfs/pscmanual/9pscssicurrent.pdf2023 Accessed 30 may 2023.\u003c/li\u003e\n\u003cli\u003eBadia J, Casey A, Petrosillo N, Hudson P, Mitchell S, Crosby C. 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BMC Medical Research Methodology. 2004;4(1); doi: 10.1186/1471-2288-4-5.\u003c/li\u003e\n\u003cli\u003eConn VS, Isaramalai S-A, Rath S, Jantarakupt P, Wadhawan R, Dash Y. Beyond MEDLINE for Literature Searches. Journal of Nursing Scholarship. 2003;35(2):177-82.\u003c/li\u003e\n\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":true,"highlight":"","institution":"","isAcceptedByJournal":false,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true},"keywords":"antisepsis, infection control, review, nurse, operating room, patient safety, perioperative, postoperative complications, prevention, surgical site infections","lastPublishedDoi":"10.21203/rs.3.rs-3082832/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-3082832/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003ch2\u003eBackground\u003c/h2\u003e \u003cp\u003eSurgical site infections pose a significant threat to patient safety, causing morbidity and mortality. Preventing surgical site infections through infection prevention interventions during surgery is crucial in limiting the risk of contamination from environmental microorganisms or skin flora. In many countries, operating room nurses are responsible for the aseptic environment and the performing of preventive interventions during the intraoperative phase. For patient safety, optimal prerequisites should be present for the operating room nurses\u0026rsquo; performance of infection prevention interventions. This integrative review was conducted to explore the prerequisites for operating room nurses to effectively carry out infection prevention interventions during the intraoperative phase.\u003c/p\u003e\u003ch2\u003eMethod\u003c/h2\u003e \u003cp\u003eWhittemore and Knafl\u0026acute;s review method guided this integrative review. The search strategy includes multiple academic databases, backward and forward chaining, and targeted internet searches. The constant comparative method was used to analyse and synthesise data from 17 studies.\u003c/p\u003e\u003ch2\u003eResults\u003c/h2\u003e \u003cp\u003eThis review identified several key factors that affect operating room nurses' ability to perform safe infection prevention interventions. These factors included intrapersonal prerequisites of the operating room nurses, interpersonal prerequisites within the operating room team, external conditions, and both facilitating prerequisites and barriers to implementing evidence-based practice. The intrapersonal category emerges from the subcategories: have control, planning ahead, competency, and occupational stress. The interpersonal category originates from the subcategories: cooperative behaviour and respect. The conditions category emerges from the subcategories: management and communication systems. The evidence-based practice category includes prerequisites for the use of scientific evidence.\u003c/p\u003e\u003ch2\u003eConclusions\u003c/h2\u003e \u003cp\u003eThis study highlights the need to improve the prerequisites to effectively execute safe preventive infection interventions. The team's lack of commitment to preventing surgical site infections raises concerns for patient safety and leaves operating room nurses feeling disrespected. Operating room nurses should assume leadership responsibilities and be supported by management, with access to necessary prerequisites such as information, education, and sufficient time for preparation and implementation. Regular feedback on infection rates and complications is crucial. The study highlights the significance of well-staffed and familiar teams and the urgency of zero tolerance for abusive behaviour. Resilience is essential for operating room nurses' well-being and optimal patient care.\u003c/p\u003e","manuscriptTitle":"Prerequisites for infection prevention interventions during the intraoperative phase from the perspective of operating room nurses, An integrative review","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2023-07-03 14:16:05","doi":"10.21203/rs.3.rs-3082832/v1","editorialEvents":[{"type":"communityComments","content":0}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"e8a2ace5-024c-48d5-851e-60da46fe82ad","owner":[],"postedDate":"July 3rd, 2023","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"posted","subjectAreas":[],"tags":[],"updatedAt":"2024-04-22T08:56:35+00:00","versionOfRecord":[],"versionCreatedAt":"2023-07-03 14:16:05","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-3082832","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-3082832","identity":"rs-3082832","version":["v1"]},"buildId":"_2-kVJe1T_tPrBINL-cwx","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}