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Our nationwide study has shown a number of factors related to missed nursing care in the operating room, with one key reason being poor communication within teams.
Missed nursing care refers to situations where essential nursing interventions, tasks or activities are omitted, not performed as required, or delayed, potentially compromising patient wellbeing and safety (here).
Commonly missed activities across acute care settings include timely administration of medications, proper monitoring of vital signs, patient education, provision of comfort measures, and effective communication with patients and other health care team members (here).
Therefore, missed care encompasses all aspects of patient care, including communication tasks and activities.
Missed nursing care has been well studied across various clinical environments, including acute medical-surgical, intensive care, midwifery and paediatrics. However, only a few studies of missed nursing care have focused on the operating room, none of which were Australian.
To address this gap, we undertook a national survey to understand the prevalence, patterns and predictors of missed nursing care across Australian operating room contexts (here).
As operating room nurses, we are passionate about preventing missed care because we have a deep commitment to prioritising the safety and wellbeing of the surgical patients in our care. Patients are at their most vulnerable in surgery and rely on us to advocate for them, especially while they are under anaesthesia.
The nationwide survey
From March to August 2022, we conducted a national online survey of operating room nurses who were members of the Australian College of Perioperative Nurses (ACORN). A census sample of perioperative nurses who practised in circulating, instrument, anaesthetic and recovery room, and education and management roles across public and private sectors were invited to complete the anonymous survey.
After receiving ACORN’s endorsement to distribute the survey, we obtained approval from the human ethics committee at Griffith University to circulate the survey.
Data collection
The online 111-question survey had three components:
- Operating room nurses’ demographic information (eg, age, sex, qualifications, primary role, years of operating room experience, state/territory), hospital characteristics (public/private, number of operating rooms), staffing levels, overtime worked in the past three months, intention to leave, and job satisfaction.
- We made minor modifications to a survey tool developed in the United States called the MISSCARE Survey-Operating Room version. This survey was based on Kalisch and colleagues’ original and widely used version. The operating room version has been previously validated and covers the pre- and intra-operative periods. Part A includes components of missed nursing care, and part B includes the reasons for missed nursing care across both the pre-and intra-operative periods. Response options for the pre-operative and intra-operative care items include “never”, “rarely missed”, “occasionally missed”, “always” and “not applicable”. Response options for reasons for missed nursing care include “significant”, “moderate”, “minor”, and “not a reason for missed nursing care”.
- The Perceived Perioperative Competence Scale-SF uses a five-point Likert scale and includes 18 items covering six dimensions of peri-operative competence: foundational knowledge, proficiency, professional development, leadership, collaboration and empathy.
Results
Nurse demographic characteristics:
- Of the 5500 nurses invited, 853 (15.5%) responded but only 602 (70.6%) of those provided data to be analysed.
- Most respondents were female (82.6%), and the average age of respondents in the sample was 46 years (standard deviation, 11.4 years).
- 64.1% of respondents reported that they had ten or more years of operating room experience.
- The respondents’ primary peri-operative role was circulating/instrument nurse (50.5%).
You can read more in our study (here and here).
Prevalence and patterns of missed nursing care
The most frequently missed tasks across both the pre- and intra-operative periods included time-intensive tasks (eg, implementing isolation precautions) and communications with other members of the team.
The most frequently reported reasons for missed nursing care were staff-related, including staffing numbers, skill mix, and fatigue, all of which affected teamwork.
There were no statistical differences between the reported frequency of missed care for the pre-operative or intra-operative periods based on nursing role.
The reasons for missed care differed according to operating room role. Operating room nurses in management roles reported fewer reasons for missed nursing care when compared with recovery room nurses.
Predictors of missed nursing care
Importantly for health service managers, there are some predictors of missed nursing care, which may be helpful.
Here are our results:
Participant age was linked to the frequency of missed nursing care, with younger peri-operative nurses reporting higher frequency of missed nursing care and lower satisfaction levels.
Lower role satisfaction was associated with a higher frequency of missed nursing care.
Perceived peri-operative competence is important; those with higher perceived competence reported less frequent missed nursing care instances.
Missed nursing care reasons such as inadequate staffing, fatigue, and equipment and supplies being unavailable emerged as the strongest predictor of the frequency of missed nursing care, followed by satisfaction and perceived peri-operative competence.
Surprisingly, factors such as intention to leave and years of operating room experience did not directly predict the frequency of missed nursing care, although age and satisfaction indirectly influenced it.
Years of experience indirectly influenced the frequency of missed nursing care, mediated by perceived peri-operative competence.
What can be done?
Our results suggest that missed nursing care in operating room environments is complex and can be attributed to several factors. Yet, it is concerning that one of the most missed tasks across both the pre- and intra-operative periods was team communication.
There are several strategies that can be used to enhance team communication and mitigate instances of missed care in the operating room.
For example, introducing pre-operative briefings and team huddles to review the surgical plan, discuss patient-specific needs, and identify potential risks or concerns related to missed care. This provides an opportunity for team members to communicate effectively and address any gaps in care before the procedure begins.
Using closed loop communication, where information is conveyed, acknowledged and confirmed by the recipient will promote mutual understanding. And, encouraging team members to speak up if they identify occasions of missed care will help reduce its prevalence.
Undertaking team training and simulation sessions to practise communication skills, teamwork and crisis management allows team members to build confidence and competence in effective communication strategies.
Clear and open communication among surgical team members enables the timely exchange of critical information, such as patient status, procedural steps and equipment needs, thereby reducing the risk of errors and complications during surgery.
The operating room is a “high stakes” environment. As medical and nursing professionals, none of us want a situation where care is missed or overlooked, and we hope our study can go someway in helping reduce these occurrences.
Brigid M Gillespie is a Professor at the National Health and Medical Research Council (NHMRC) Centre of Research Excellence in Wiser Wound Care at the School of Nursing and Midwifery at Griffith University; and is conjoint Professor of Patient Safety at Gold Coast Hospital and Health Services.
Emma Harbeck is a Research Fellow at the NHMRC Centre of Research Excellence in Wiser Wound Care at the School of Nursing and Midwifery at Griffith University.
Wendy Chaboyer is a Professor and Director at the NHMRC Centre of Research Excellence in Wiser Wound Care at the School of Nursing and Midwifery at Griffith University.
The statements or opinions expressed in this article reflect the views of the authors and do not necessarily represent the official policy of the AMA, the MJA or InSight+ unless so stated.
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