Create an analysis of the factors that contribute to the non-adherence of the perioperative surgical team discussed in this article.
Please read the following article:
Manamela, L. M., Rasweswe, M. M., & Mooa, R. S. (2022). Factors contributing to non-adherence of the peri-operative surgical team to WHO surgical safety checklist in the Kingdom of Saudi Arabia. Perioperative Care and Operating Room Management, 29. https://doi.org/10.1016/j.pcorm.2022.100292
Create an analysis of the factors that contribute to the non-adherence of the perioperative surgical team discussed in this article. Present a plan to overcome these barriers so that the surgical risks are reduced and quality and patient safety are improved.
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Factors contributing to non-adherence of the peri-operative surgical team to WHO surgical safety checklist in the Kingdom of Saudi Arabia Lorraine Motlalepula Manamelaa,*, Melitah Molatelo Raswesweb, Ramadimetja Shirley Mooaa aDepartment of Nursing Sciences, Faculty of Health Sciences, University of Pretoria, Gauteng Province, South Africa bDepartment of Nursing Science, Faculty of Health Sciences, University of Limpopo, Limpopo Province, South Africa ARTICLE INFO Keywords: Adherence Factors Kingdom of Saudi Arabia Non-adherence Peri-operative surgical team Surgical Safety Checklist Who Health Organization ABSTRACT Introduction: The World Health Organization Surgical Safety Checklist addresses acceptable practices for patient safety. This paper aimed to explore and describe the factors that contribute to non-adherence of peri‑operative surgical team to WHO surgical safety checklist at the selected hospital in the Kingdom of Saudi Arabia. Methods: The study adopted a qualitative design. The population consisted of a 12 peri‑operative surgical team with an average of 12 years’ experience in their respective medical fields. This population was purposely selected from a selected hospital operating theatres in Saudi Arabia. Non-probability purposive sampling was used to select the participants. Data was collected by means of semi-structured individual interviews. Content analysis was used to analyze data. Results: The findings revealed that peri‑operative surgical team experience challenges when implementing WHO SSC (2008). The challenges affect their adherence, which depends on a convergence of intertwined factors, such as the use of WHO SSC related to issues in the checklist steps and uncertainties regarding the safe use of WHO SSC, team factors, checklist items factors and procedural factors. Conclusion: The study clearly identified factors that contributed to suboptimal WHO SSC execution by peri‑op-erative surgical team in the Kingdom of Saudi Arabia, addressed at the institutional level. It is therefore important for the managerial teams to be supportive to the surgical perioperative team to improve adherence to WHO SSC. Support can be provided through continuous supervision, in-service training, mentoring, evaluation and awarding merits for the good adherence to patient safety. Furthermore, these findings can be used to develop strategies to promote perioperative surgical team adherence to WHO SSC and can be used for further research. 1.Introduction and background The Surgical Safety Checklist (SSC) is the guide that was developed in 2008 after World Alliance for Patient Safety launched the Safe Sur-gery Saves Lives campaign through World Health Organization (WHO). The main aim was to standardize peri-operative care and reduce the number of surgical mishaps across the world by either preventing an error from occurring or from causing any harm to the patient 1. The guide also focuses on improving the communication and safety attitudes among operating theater staff [ibid]. The WHO SSC consists of many items or elements and processes to be followed by the peri‑operative surgical team prior, during and after the surgical procedure and it is divided into three phases: sign in before induction of anesthesia, time out/surgical pause before skin incision, and sign out before patient leaves operating room 1. The items included in three phases assist in ensuring that peri‑operative surgical team consistently follow critical safety steps, thus minimizing avoidable risks of endangering the lives of patients who undergo surgery 2. The implementation of this checklist in operating rooms in a range of settings showed marked reduction in surgical mishaps and improvement in communication among the team members. For example, a relative reduction of the postoperative complication of 36% was observed in one study 1. In Scotland, a reduction of 36⋅6 (95 percent c.i. –55⋅2 to –17⋅9) percent in mortality (P <0⋅001) was reported 3. While, in a cohort study crude mortality decreased from 3.13% – 2.85% (P =0.19) 4. A lowered mortality rate (odds ratio, 0.49; 95% CI, 0.32 to 0.77) was also reported after the use of WHO SSC 5. Improved surgery outcomes were also observed in high-risk pediatric surgery in developing countries 6. The recent study conducted in China revealed that to date the WHO SSC is still an effective instru-ment capable to improve surgical patient safety 7. Moreover, WHO *Corresponding author at: Institution: University of Pretoria, LinkedIn- Lorraine Motlalepula Manamela, Postal address: University of Pretoria. E-mail address: [email protected] (L.M. Manamela). Contents lists available at ScienceDirect Perioperative Care and Operating Room Management journal homepage: www.elsevier.com/locate/pcorm https://doi.org/10.1016/j.pcorm.2022.100292 Received 17 January 2022; Received in revised form 12 August 2022; Accepted 12 October 2022
recommends that all the operating room facilities should follow the SSC guide globally. However, despite the suggested effectiveness of safety check lists, the practices in different settings are debatable due to the reported non-adherence rate 8. The selected hospital adopted and implemented the WHO SSC before the year 2015 using a manual recording. In the year 2017 the hospital upgraded to the electronic format. Despite a successful implementation of the electronic format, which produced high documented adherence rate, on the actual observation and during the audit, the adherence was low(below 100% which is the set target). When the first author audited 16 files in November 2017 on the electronic system, all items were ticked off yet on observation some items were not called out. Therefore, recorded adherence was found unreliable and significantly higher than observed adherence. All of this indicated that there were certain process defects that needed to be identified and improved. A systematic review and meta-analysis of the effect of the World Health Organization sur-gical safety checklist on postoperative complications revealed the same 9. The study conducted in Queensland university hospital, Australia also reported both high and low adherence 10. Abbott et al. 5 revealed that in many countries, the adherence rate of surgical safety checklist has badly decreased due to the multiple factors that hindered its implementation. In the operating theatres of United States of America non-adherence caused 40% of adverse errors that would have been prevented if WHO SSC steps were followed 11. In the Kingdom of Saudi Arabia, there are few research studies that have been done to investigate factors that contribute to non-adherence of the peri‑operative surgical team to WHO surgical safety checklist. Adherence to WHO SSC should be considered critical to patient safety and may not be achieved if factors contributing to non-adherence are not investigated among a peri‑operative surgical team. Non-adherence to the WHO SSC might place patients at risk of “never events” like retained foreign objects, for example: sponges and instruments; wrong patient surgery, wrong site surgery, wrong procedure, and more [11,12]. Un-derstanding these factors may be necessary to identify and address adherence issues and ensure that WHO SSC use is sustained. Hence this study was conducted to fill the identified gaps. The focus was on the factors that contribute to non-adherence of peri‑operative surgical team to WHO surgical safety checklist at the selected hospital in the Kingdom of Saudi Arabia. 2.Method 2.1.Design A qualitative design was employed to answer the research question, which was what are the factors that contribute to non-adherence of peri‑operative surgical team to WHO SSC at the selected hospital in the Kingdom of Saudi Arabia. Probing questions followed based on the answer provided by each participant. A purposive qualitative approach was employed to select the participants. 2.2.Setting and participants The study was conducted in a private secondary hospital with nine (9) operating theatres in Kingdom of Saudi Arabia. The hospital is accredited by the Joint Commission International (JCI) and by the Saudi Central Board for Accreditation of Healthcare Institutions (CBAHI). The participants of this study were a multicultural, multinational peri‑op-erative surgical team coming from different countries but working in the selected operating theater during data collection. The sample was cho-sen purposively as it consisted of a perioperative surgical team that were in contact with patients who undergo surgery daily and knowledgeable about WHO SSC because they utilize it regularly. The study included registered peri‑operative nurses, qualified surgeons and anesthesiolo-gists. Post-anesthesia care registered nurses, operating theater technol-ogists and assistant surgeons were excluded. 2.3.Data collection Data were collected between October 2020 and March 2021 using face-to-face semi-structured interviews. Face to face interviews allowed an opportunity to flexibly observe and explore nonverbal expressions such as body movements displayed by the participants when responding to questions. This assisted the researchers to be aware of any distortions or inaccuracies in the information provided by the participants. Meeting participants in person did not overstep the Covid-19 restrictions because at the time of data collection, the Kingdom of Saudi Arabia had less reported Covid-19 cases and safety precautions were followed as advised by infection control protocol. The conference room of the operating theater which accommodate 12 people was utilized as the venue for interviews for registered nurses and anesthetists, whereas surgeons’ interviews were conducted in their consultation rooms outside the operating theater complex. Permission to collect data and cooperation from the operating the-ater manager had been ensured in advance. The English language was used during interviews because the participants were multiracial and able to understand and speak in English as a medium of the instruction in the selected hospital. Each interview was limited between 45 and 60 min for the researcher to gather sufficient information while avoiding participant exhaustion. All the interviews were audio recorded as per participant verbal consent. Data collection continued until reaching a criterion for discontinuing data collection (data saturation), which took place when the participants provided no new information to the ques-tions asked. The data saturation was reached with participant number 10. However, 2 more participants were interviewed to ensure that the study does not omit any other different information that may emerge after concluding that saturation is reached. 2.4.Data analysis In this study, data analysis was performed concurrently with data collection using content data analysis with an inductive approach. Participants’ narratives formed the units of analysis and meaning units, in which words or whole phrases were identified and consolidated into themes or categories. The process included coding, categorizing, and classifying the emerging meaning units into similar sub-categories. These sub-categories were then interpreted according to their content and meaning, before been grouped into broader themes. The Atlas.ti, qualitative data analysis software, its headquarters based in Berlin, Germany, was used to confirm the emerged categories and codes, and unique codes were assigned to the dialog concepts. Similar topics were clustered together and formed into drawn columns. Then similar topics were arranged into major topics, unique topics, and irrelevant issues. Manually the researchers reduced the total list of categories by grouping the topics related to each other. Lines were drawn between the cate-gories, separating them according to their relationship and continually comparing manual analysis with the results generated by Atlas.ti soft-ware. The codes were then combined into super codes, which were then compared with the manually coded data and used to formulate relevant themes. The emerging themes were then integrated with the initial meanings of the units and formed the basis for the presentation of the findings, including a selection of illustrative quotations. 2.5.Trustworthiness The following measures of trustworthiness were applied: credibility, dependability, confirmability, and transferability. Credibility was ensured by means of prolonged engagement with the participants and clarifying some issues with the participants through probing. Depend-ability was attained by describing the study process and methods used in data collection. The independent co-coder, who was familiar and experienced with the process of qualitative data analyses was used, to verify emerged themes. To achieve confirmability audio recording were L.M. Manamela et al.
used and listened several times during data analysis. The raw data (recorded interviews and transcripts) are kept for safe and will be dis-carded after five years as advised by the University standards. The in-dependent coder was also consulted to confirm the transcripts and analyzed data. To achieve transferability, the researcher ensured that a comprehensive description of the research process and data analysis are provided in detail for other researchers to apply or use in similar set-tings. The researchers also ensured realization of the sample by purpo-sively selecting peri‑operative team members who are familiar with WHO SSC. 2.6.Ethical considerations Ethics approval was obtained from the University (Ref No. 530/ 2020) and permission to conduct the study was sought from the program Director Office/CEO in a selected hospital and the Director of Nursing. In addition, prior to the interviews, all participants signed an informed written consent document and were given an information sheet that explained the research’s goals. Furthermore, participants were informed that they were under no obligation to participate, and that their privacy would be protected as their names won’t be mentioned anywhere in the study. We also advised participants of their rights to discontinue participation anytime during the data collection period. 3.Findings and discussions 3.1.Participants demographic profile The demographic profile comprised twelve (12) participants, in which two (2) were male anesthesiologists, eight (8) registered nurses were females, and two (2) were male surgical specialists. Their ages varied from thirty (30) to fifty (50) years old. Their years’ experience in the health care area varied from ten (10) to nineteen (19) years. During data collection, all the participants were working at the selected hos-pital. Their ethnic group comprised four (4) Saudis, one (1) Pakistani, two (2) Asian/Filipino, and five (5) Asian/Indians among the participants. 3.2.Factors contributing to non-adherence of the peri‑operative surgical team to WHO SSC Four themes emerged describing factors contributing to non- adherence of the peri‑operative surgical team to WHO SSC: the use of WHO SSC factors, team factors, checklist factors and procedural factors. The themes, categories and subcategories that emerged from the data analysis are summarized in Table 1. 3.2.1.Theme 1: Use of WHO SSC factors The routine use of WHO SSC is recommended to reduce perioperative errors and its complications. The WHO SSC has numerous steps in a form of a checklist to be completed by surgical team collectively. It is there-fore, important to educate the surgical team on why the use of WHO SSC is important during implementation and through in-service sessions. The participants in our study considered the use of WHO SSC as a factor that contributes to the non-adherence by the peri‑operative surgical team. This was related to issues in the checklist steps and uncertainties regarding the safe use of WHO SSC. 3.2.1.1.Checklist steps and uncertainty regarding the safe use of WHO SSC.Difficulties in following the steps on the checklist and uncertainty regarding the safe use of WHO SSC were verbalized and often related to lack of knowledge regarding the importance of following WHO SSC, lack of awareness of checklist elements/ vital checklist items omitted and using the surgical safety checklist as a ‘tick-n-flick’ practice, which refers to writing or completing WHO SSC without performing safety assess-ment or check. The participants further indicated that there is non- adherence to WHO SSC because they do not know the importance of completing the checklist. This was evident in the direct comments from participants: “I believe that all members of the perioperative surgical team should attend an education program or awareness campaign about the signifi-cance of the WHO SSC, which includes a step-by-step implementation approach and clear roles and responsibilities” (Participant 5) This finding shows that the surgical team usually do not check all the items on the checklist but falsely complete the remaining items. The participants stated that not knowing the importance of applying WHO SSC by other team members hinder the adherence as some of the items are omitted as quoted below: “Surgeons confirm patients in the holding or reception area, but sign- in items are not confirmed during that same time”. “I do not think anesthetists are aware of the items that are specific to them, for sign out items, blood loss and specimen are the once we ask surgeons” (Partici-pant 5) “Most of anesthesiologists and surgeons consider WHO SSC to be a nursing practice. They don’t realize that it applies to all members of the peri‑operative surgical team. Some registered nurses are just doc-umenting this WHO SSC in the system, they are unaware of its signifi-cance” (Participant 12). This subtheme further revealed that pressure of documentation compliance instead of actual compliance has led to registered nurses who run the process of WHO SSC completion into performing tick and flick practice, the major issue was that if a system item was left blank, the system would not allow an incomplete checklist to be saved. The registered nurses reported that they complete items on the system, even if they were not called, because the system will fail and not save the entire items. One participant stated that: “This is a question they don’t want to hear. When we call out com-ponents of the checklist, we will ask certain questions while skipping others, however, in the system, we are obviously going to tick and save on all elements of WHO SSC in all stages”. “We do omit calling the items, but documentation will be complete in the system. We don’t ask about things like surgery duration and unanticipated blood loss in simple pe-diatric procedures during time out. We tick and save the items that we didn’t even call” (Participant 5). This finding shows that the surgical team usually do not check all the items on the checklist but falsely complete the remaining items. 3.2.2.Theme 2: Team factors The peri‑operative surgical team indicated that the attitudes of the team members contribute to not adhering to SSC. These were grouped into personal attitudes and uncertainty regarding who is responsible for leading the process. 3.2.2.2.Personal attitudes.The personal attitudes were expressed in terms of “surgical team absent at key times of WHO SSC completion”, “lack of commitment or interest in involved tasks from the surgical team members”, “poor or inadequate communication among the surgical team members” and “insecurity and resistance from other surgical team Table 1 Themes and subthemes. Themes Subthemes 1. Use of WHO SSC factors Checklist steps and uncertainty regarding the safe use of WHO SSC 2. Team factors Personal attitudes Uncertainty regarding who is responsible for leading the process. 3. Checklist items factors Most of the items are duplication of the existing checks. Completion of checklist items are repeating during periods of high workload. 4. Procedural factors Time constraints L.M. Manamela et al.
members”. Regarding surgical team absent at key times of WHO SSC completion, some of the peri‑operative surgical team members raised the concern of incomplete team during sign in and sign out phases, specifically consultant surgeons who they mentioned as the most responsible sur-gical team member. Others indicated that mostly during sign in and sign out phase the peri‑operative surgical team is incomplete thus leading to non-adherence. Participants stated: “During sign-in, only the anesthesiologist is present. The most responsible physician, the consultant surgeon, is usually unavailable during sign-in” (Participant 5). “One of the observations I’ve encountered throughout these phases of the surgical safety checklist is that not all members of the peri‑op-erative surgical team are present in the operating theatres. Surgeons are not there during sign in” (Participant 8). In our study, the peri‑operative surgical team felt that during WHO SSC implementation, some members continued with other tasks, continued with conversations not related to the current checklist pro-cess, which indicated lack of interest as commented:” When we are conducting time out especially, the surgeons will begin talking and will not listen; even the anesthesia team will not listen at times” (Participant 6) The current study participants also find it very challenging when calling out and completing SSC because of poor communication among the team members. The participants highlighted that usually there is no response from a responsible person and the one doing call out feels like talking alone and stop calling out and just complete the checklist in silence. This was found to hinder adherence, because the completion process requires a team effort. One participant stated that: “Inside the operating theatres, peri‑operative surgical team does not engage verbally with the surgeon, anesthesiologist, nurses, or technol-ogist; they need to communicate to each other, creating a closed loop communication system. It seems registered nurses prefer writing to verbalizing; they prefer to document elements of WHO SSC checklist on the system. Communication is also influenced by language barrier” (Participant 12). Some of our study participants reported that some surgical team members show signs of insecurities and resistance when it comes to the completion of SSC as stated below: “Some peri‑operative surgical team members are ignorant and refuse to follow the process of SSC, I think they are resisting because of insecurities” (Participant 9). Resistance limits the success to adhere or full completion of the checklist. 3.2.2.3.Uncertainty regarding who is responsible for leading the process. When it comes to uncertainty regarding who is responsible for leading the process, the findings revealed that non-adherence in executing the WHO SSC was related to not knowing the roles and responsibilities of each surgical team member during the implementation. It was clear from the surgical team members that there are some doubts as to who was supposed to be involved in some elements of the surgical safety checklist such as verification of patient’s identification, others indicated lack of uniformity which causes uncertainty during the surgery checklist call out as quoted below: “Now, let’s look at the sign in part. So, who does the patient iden-tification confirmation procedure, the anesthesiologist, the surgeon, or the scrub nurse”? (Participant 4) “Registered nurses always take over if there is no one taking his or her responsibility in the reading and application of WHO SSC” (Partic-ipant 5). “Registered nurses are always taking a lead in the whole process, I think it is their responsibility, but some will refuse to lead but still ask you to do it, I’m confused” (Participant 3). Being uncertainty on when to perform or/and by who will lead to non-adherence. 3.2.3.Theme 3 Checklist items factors The participants indicated that the checklist items have some con-straints that affect the surgical team members from adhering to the process. They verbalized that most of the items are duplication of the existing checks and completion is during periods of high workload. 3.2.3.4.Most of the items are duplication of the existing checks.The peri‑operative surgical team complained that the items in the checklist are duplicate of other activities that are conducted whenever the patient is coming for a surgical procedure. For example, checking patient identity, sterility indicator checks, surgical counts or confirming avail-ability of implants are carried out before the use of the checklist, as a standard operating procedure in the operating theatres. In their facility, an electronic system is used and easily shows when there is duplication. Therefore, they get bored and more often ignore those items during checklist call out. The quotations below support this finding: “Items that are repeated we omit, we don’t ask about blood loss at sign-in because this is something, we usually ask about during time out” (Participant 10). “Time out elements are repeated and have previously been called out at sign in. Due to repetition, we already know responses to some of the questions. The number of time-out items should be decreased due to repetition” (Participant 12). Drawing from the data it was obvious that the use of the WHO SSC as a “check box” exercise appears to be facilitated by electronic recording in the current setting. 3.2.3.5.Completion of checklist items are repeating during periods of high workload.Participants also noted that beside repetition of some items, the completion of SSC is carried out during periods of high workload which makes it difficult for them to adhere to call out items that are a repetition. They indicated that routine tangible tasks repeat during sign in period, when the anesthetist team is busy attaching monitors, inserting intravenous cannulas for fluid and anesthetic agents, preparing the correct size endotracheal tubes, gas induction on restless and anxious pediatric patients without an intravenous line. These make it difficult for them to verify the patient’s identity again, because the anesthetic team identify them whilst in the ward and reception. The following quotations provide evidence that support the high workload clashing with the sign in phase: “During sign in, the anesthetist is busy preparing endotracheal tubes, inspecting the machine to optimize the patient before the surgery be-gins, alright. I’ve also seen that during this final time out, the surgeon and circulating nurse are still preoccupied with settling the drapes and other such tasks; this should not be the case” (Participant 2). “Signing in is difficult, circulating nurses are the ones who are really confirming patient identity, other members of the perioperative team are absent, and the anesthetists are busy preparing endotracheal tubes and medications for the patient. No one else participates” (Participant 9). The participants further, shared their frustrations with time out phase, which clashes with routine activities such as connecting surgical equipment and causing the surgical team not pay attention and engage during the surgical pause phase. The following quotations provide evi-dence that support the high workload clashing with time out phase: “Due to activities that conflict with calling time out, such as con-necting machine cables and tying assistant surgeons’ gowns, adherence is difficult with only two registered nurses in an operating theater” (Participant 11). “Everyone is busy during surgery checklist times; therefore, they don’t respond to issues that demand their response” (Participant 12). 3.2.4.Theme 4 procedural factors Procedures involved during the completion of SSC was revealed as one of the factors contributing to non-adherence. In our study, L.M. Manamela et al.
difficulties in completing SSC were verbalized and often indicated to be related to time constraints. Many participants highlighted that there is a lot of pressure on the team to complete the SSC given the activities and time needed to carry a surgical procedure. They also mentioned that the process delays a list of booked patients that awaits to be operated within the prescribed waiting time. 3.2.4.6.Time constraints.Time constraints was often indicated to be related to “length of the WHO SSC completion being too long due to time taken to review the SSC”, “delayed confirmation of booked surgeries on the system due to time taken to review the WHO SSC”, “difficulties of completing the WHO SSC during life threatening emergency proced-ures”, and “difficulties of completing WHO SSC during short and local surgery procedures” The participants verbalized that some peri‑operative surgical team members, surgeons to be specific, are impatient when it comes to duration
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