Research in peri-operative nursing care

Affiliation.

  • 1 Department of Surgery, Turku University Hospital, Finland.
  • PMID: 10401345
  • DOI: 10.1046/j.1365-2702.1999.00239.x

This review analyses 97 research reports dealing with peri-operative care which included patients. The literature review was done as the basis of a development project to measure the quality of intra-operative nursing care from the patient's perspective. The pre-operative phase provides information about the teaching, anxiety and stress of patients. Few sources dealt with the intra-operative phase; there were a small amount of reports concerning concrete nursing activities (e.g. surgical position and warming the patient). The most information was available on the post-operative phase, such as recovery, adaptation and the treatment of pain. Peri-operative research is mainly concerned with the quality of nursing care, control of life and ambulatory surgery. The main defects of analysed studies can be characterized as follows: small samples and a single hospital, lack of definition of terms, theoretical ambiguity, short follow-up times, anaesthetic or other drugs used during the care not mentioned in the report (especially in studies on pain and quality). Previously developed research tools had usually been well tested, but there was great variety in the testing of investigator-constructed tools. There were also discrepancies in the evaluation of validity and reliability. Future research should especially deal with treatment of pain and anxiety, information and guidance given to patients, and the costs of surgical care; there is also a need for studies dealing with intra-operative care from the patient's perspective. Although information is already available on the above mentioned topics, more detailed and comprehensive facts are still needed.

Publication types

  • Clinical Nursing Research / methods*
  • Clinical Nursing Research / standards
  • Perioperative Care* / methods
  • Perioperative Care* / standards
  • Perioperative Nursing* / methods
  • Perioperative Nursing* / standards
  • Research Design / standards
  • Research article
  • Open access
  • Published: 09 December 2014

Perioperative nursing in public university hospitals: an ethnography

  • Erik Elgaard Sørensen 1 , 2 ,
  • Ida Østrup Olsen 3 ,
  • Marianne Tewes 4 &
  • Lisbeth Uhrenfeldt 5  

BMC Nursing volume  13 , Article number:  45 ( 2014 ) Cite this article

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In recent years, perioperative nursing has received ongoing attention as part of an interprofessional collaboration. Perioperative nursing is constantly faced with new challenges and opportunities that necessitate continual updates of nursing knowledge and technical skills. In light of the longstanding relationship between nursing and technology, it is interesting that few studies with this focus have been performed. Therefore, our research question was: What is the content of perioperative nursing and how do nurses facilitate the interaction between nursing care and technology in highly specialized operating rooms in public university hospitals?

An ethnography involving participant observations and interviews was conducted during a 9-month study period. The participants comprised 24 nurses from 9 different operating wards at 2 university hospitals in different regions of Denmark.

Patients were addressed as either human beings or objects. Likewise, the participants’ technical skills were observed and described as either technical flair or a lack of technical skills/technophobia. The different ways in which the technical skills were handled and the different ways in which the patients were viewed contributed to the development of three levels of interaction between technology and nursing care: the interaction, declining interaction, and failing interaction levels.

Nursing practice at the interaction level is characterized by flexibility and excellence, while practice at the declining interaction level is characterized by inflexibility and rigidity. Nursing practice at the failing interaction level is characterized by staff members working in isolation with limited collaboration with other staff members in operating rooms. Considering that the declining and failing interaction levels are characterized by inflexibility, rigidity, and isolation in nursing practice, nurses at these two levels must develop and improve their qualifications to reach a level of flexible, excellent interaction. Nurse leaders must therefore refocus their skills on proficiency in perioperative nursing.

Peer Review reports

Perioperative nursing has been explored from different angles for more than a decade [ 1 ]-[ 3 ]. The interaction between nursing care and technology has been discussed in particular detail [ 2 ],[ 4 ]. This discussion has raised a number of questions about the tendency to view nursing in operating rooms (ORs) as invisible to the patient and as surgical interventions without nursing activities [ 5 ],[ 6 ].

Perioperative nursing as an act of technology includes the knowledge and skills to work proficiently with instruments, equipment, and machinery [ 7 ]-[ 9 ]. Numerous advances in technology such as robots, digital displays, artificial organs, magnetic sensors, and communications technology [ 7 ],[ 10 ] require that nurses also become educated in information technology (IT) [ 8 ]. In ORs, the team members work and activities are structured around the management of the “operating list” [ 11 ].

The surgical event is viewed as a social and technical process [ 12 ] that involves the entire team, including the surgical nurse, circulating nurse, anesthesia provider, surgical technician, and surgeon. Furthermore, the content of perioperative nursing is viewed as a number of activities that often occur simultaneously. The use of specific instrumentation and procedures illustrates the central nature of the actions in ORs, where the dominant goal is to conduct a successful operation for the treatment of a specific disease or injury [ 6 ] with a focus on patient safety and prevention of surgical infection [ 13 ],[ 14 ].

From a patient perspective, technology can be quite frightening, despite the fact that nurses find all aspects of perioperative nursing and the large display of technology familiar [ 15 ]. According to Sweeny [ 8 ], the use of technology and related transitions can reduce human contact. A recent review highlighted the transitions that increased patients’ anxiety [ 16 ], adding importance to the implementation of individualized nursing care in the perioperative setting.

However, the involvement of such care (e.g., when using the term “advocacy”) in perioperative nursing in the OR is unclear. A descriptive study of OR nurses’ perceptions of the implications the concept “advocacy” included interrelated and overlapping themes such as protection, communication/vocalizing, doing, comfort, and caring [ 17 ]. When Westerling and Bergbom [ 18 ] evaluated effective perioperative nursing care from the patient’s perspective, they found that the value of being acknowledged as an individual carried particular importance to the patients, and that the ability of patients to share their perioperative experience with familiar nurses made the patients feel calm, safe, and secure. This perspective was first identified by Rudolfsson et al . [ 19 ] and later actualized by Rudolfsson [ 4 ] in their elaboration of a model illustrating the perioperative dialogue/ethos, showing that the patients felt that it was safe to hand over the responsibility to the nurse when they felt acknowledged, listened to, and met with empathy. Likewise, another study demonstrated the creation of continuity through preoperative dialogue, its manifestation in intraoperative dialogue, and its closure in postoperative dialogue [ 20 ]. Although the interaction between nursing care and technology has been taken for granted by many OR nurses [ 6 ], the interaction has also been viewed as a challenge [ 21 ]-[ 24 ] because perioperative nursing has been, and remains, inextricably linked to the development of technology with the risk of eroding the quality of care [ 6 ]. Therefore, perioperative nursing is constantly faced with new challenges and opportunities that necessitate continual updates of nursing knowledge and technical skills [ 3 ],[ 25 ]. In light of the longstanding relationship between nursing and technology, it is interesting that only few studies with this focus have been performed [ 21 ]-[ 24 ]. Furthermore, these studies are >10 years old.

With this background, the purpose of the present study was to investigate the actual content of perioperative nursing in highly specialized ORs in public university hospitals. The research question was: What is the content of perioperative nursing and how do nurses facilitate interactions between nursing care and technology in highly specialized ORs in public university hospitals?

This ethnography was based on participant observations and interviews inspired by practical ethnographic principles [ 26 ]-[ 28 ]. We directly observed OR nurses in the field and interviewed them about their experience to capture the concrete, everyday practice in ORs and understand the content of perioperative nursing. The participants comprised 24 registered female nurses selected from 8 surgical specialties at 3 urban geographical locations in 2 public university hospitals to ensure diverse and nuanced data. The surgical specialties included orthopedic, thoracic, gastrointestinal, breast, ear-nose-throat, neurosurgical, urological, and gynecological surgery. The participants’ ages ranged from 31 to 63 years. They had from 3 to 24 years of nursing experience in ORs. A minimum of 3 years of clinical nursing experience was required for enrollment in this study to ensure a strong nursing identity and clinical knowledge [ 29 ],[ 30 ].

Data were collected through field observations of each participant for a period of 3 to 5 days for 5 to 8 hours per day depending on the participant’s daily work in the OR. This time period was based on both experience from another field study and the aim of achieving empirical saturation [ 31 ]. This saturation was achieved when the nuances in the nurses’ experiences decreased though changes in settings and geography.

During the field observations, the authors (E.E.S. and I.Ø.O.) produced handwritten field notes [ 27 ]. Each participant observation was followed by an ethnographically inspired interview [ 26 ]. The interviews were based on semistructured interview guides individually created based on the previous field observations. One interview question was: “You told me you had technical flair. Could you please tell me more about this flair?” The interviews were intended to contribute to a deeper understanding of the context-bound events from the participant observations [ 28 ]. The overall study period included 122 operations performed during 9 months, amounting to 273 hours in 44 days and 6 nights. This strategy allowed for repetitions over time and set aside the “tip-of-the-iceberg” assumption [ 27 ].

Data analysis and preunderstanding

The authors (E.E.S. and I.Ø.O.) transcribed all field observations, notes, and interviews into verbatim text. This text was later subjected to a hermeneutic back-and-forth process [ 32 ] in a stabilization analysis phase and an adaptation analysis phase (E.E.S., I.Ø.O., and L.U.) according to Hammersley and Atkinson’s guidelines [28:333–367].

The stabilization phase involved preparation of data for analysis, systematization, and pattern identification using the qualitative analysis program NVivo9 [ 33 ] to develop the content of perioperative nursing (first part of the research question). This led to the formation of two themes: “Technical skills” and “Understanding of the individual patient.” These themes were developed into subthemes (Table  1 ), and the themes and their subthemes were grouped within the first main finding: OR nurses ’ interaction between skills and understanding .

In the adaptation phase, the analysis focused on gaining an understanding of the interaction between nursing care and technology in perioperative nursing (second part of the research question). Themes and subthemes of nursing care and technology were coded and collected based on mutual links and internal relationships and structures [28:241]. The coherence between the themes and subthemes contributed to the development of three levels of interaction: the “interaction level,” “declining interaction level,” and “failing interaction level” (Table  2 ). These three levels were grouped in the second main finding: OR nurses ’ interaction between nursing care and technology .

Recent theory-, experience-, and research-based work [ 31 ],[ 34 ],[ 35 ] from public urban university hospitals with a practice-theory termed “interactional nursing practice” [ 36 ],[ 37 ] has inspired our data analysis with a theoretical preunderstanding during all steps in the data analysis. The theoretical and practice perspectives of this practice theory are closely interwoven. This preunderstanding challenged and problematized the normative nature of perioperative nursing during the field observations and interviews [ 37 ]. Therefore, the observations and interviews allowed for investigation of three possible modes of action. The first is the cognitive - instrumental mode of action , which contributes to problem-solving and result-oriented activity representing technical activities. The aesthetic - expressive mode of action concerned nurses’ self-knowledge and understanding of the individual patient’s situation based on dialogue and communication. The third mode of action, the moral - practical mode of action , handles discussions and actions in relation to the patient’s overall situation. These three different modes of action were only separated for theoretical reasons in the present study; in nursing care, they are part of a whole. Their separation in nursing practice may result in narrow-minded moralism and dogmatism [ 36 ],[ 37 ].

Ethical considerations

The North Denmark Regional Research council approved the study protocol before study start (Data Protection Agency, journal no. 2008-58-0028). The study adhered to the ethical guidelines for nursing research in the Nordic countries with regard to participant information, including declarations of consent and anonymity [ 38 ]. The nursing directors at the two university hospitals were gatekeepers [28: 49]. The leaders, OR nurses, anesthesia providers, and surgeons met the researchers (E.E.S. and I.Ø.O.) during the information sessions and were informed about the investigation. Knowledge transfer was secured by a Danish publication [ 35 ]. All 24 participants provided written informed consent, and none withdrew during the study. Direct encounters between the researchers and awake patients were avoided by standing behind apparatuses or screens. When this was impossible, the researchers introduced themselves to the patients.

The results of the analysis led to two main findings. The first main finding concerned OR nurses ’ interaction between skills and understanding , and the second concerned OR nurses ’ interaction between nursing care and technology . In the Results section, each citation of an observation or interview statement has been assigned a reference number for one of the 24 participants, who practiced as either the circulating nurse (CN) or surgical nurse (SN).

OR nurses’ interaction between skills and understanding

The first theme is entitled “technical skills” and concerns the different ways in which the technical assignments and developments were handled. The second theme is entitled “understanding of the individual patient” and concerns the different ways in which the patients were viewed. Table  1 shows how the relationships between the main finding (interaction between skills and understanding) and the subthemes were developed.

Technical skills

Technical skills were expressed in two ways: technical flair and a lack of technical skills.

Technical flair was considered to be present when nurses demonstrated skill in carrying out procedures and operating instruments regardless of the amount, size, construction, or variety of different types of machinery and equipment. Technical flair also involved the ability to easily acquire new knowledge and skills in using instruments and machinery, including the consequences of their use in a specific patient situation. Technical skills were reflected in the following observation: The SN [ participant ] unpacks and prepares for the operation and says to the CN , “ Look at the scope — it has been assembled before autoclaving. It is not supposed to be assembled. It has to be separated in its many parts , springs , and screws before being autoclaved , and then the parts have to be assembled during preparation for the operation .” The SN acquires a new scope , easily assembles it , and says , “ I think I am what you would call practical. I have a flair for technical things and electronics. It is easy for me and it interests me a lot ” (21).

A lack of technical skill was characterized by the ability to assist in routine operations and apply already-known instruments, equipment, and machinery without problems. However, such nurses were unable to acquire knowledge and skills in using new instruments or establish routines involving complex technical procedures and computer-based equipment. This lack of skill had negative consequences as shown by the following interview response: “ I don ’ t have technical flair. It is not easy for me and it doesn ’ t interest me. I fall short as soon as I have to work with a computer. One day , I made a mistake when a patient was connected to the navigation system [ complex computer - based surgical equipment ]. I touched ‘ something ’ and the patient had to undergo the surgery without the advanced technique ” (1).

Technophobia was also viewed as a lack of technical skills. Technophobia was characterized by a lack of skills in certain procedures, potentially leaving the nurse feeling fearful and clumsy. This was expressed in the following statement during an operation: “ I don ’ t feel good about mixing the cement. I am afraid that I might screw things up. That [ the procedure ] takes up so much [ energy ]. It is annoying to think about during the whole operation. I feel like a clown ” (17).

Understanding of the individual patient

The nurses’ understanding of the individual patient was expressed in two different ways: the patient was viewed as either a human being or an object. Viewing the patient as a human being was shown by the way the nurses considered a patient’s situation during an operation: A 65 - year - old woman is lying on the operating table after an ostomy operation. The surgeon has left the operating room. When removing the sterile cover , the CN [ participant ] notices that the ostomy is “ uneven .” She encourages the SN to contact the surgeon. The surgeon agrees that the ostomy does not have the desired shape. He cuts the lowest suture , pulls the bowel further up , and places a new suture. Everyone is satisfied with the shape of the ostomy (23).

This participant was asked to elaborate on the above-described episode and said, “ It is a trauma in itself to have a life - threatening disease and an ostomy. If the patient , on top of this , will have problems adhering the plate and the ostomy bag because we haven ’ t done our job properly … well , that just aggravates the situation. I have worked with ostomy patients and I could see that the ostomy was not okay ” (23). In this episode, the CN applied her experience-based knowledge for the benefit of the patient. She expressed her understanding of the patient as an ill and vulnerable human being.

There were also nurses who viewed patients as objects. This was observed in a situation in which the SN did not allow the CN to speak up for a patient: A 45 - year - old woman with cancer is undergoing surgery for a pathological fracture. The CN notices that the surgeon is uncertain about the instrumentation used to measure the size of the prosthesis. The surgeon asks the SN for a prosthesis of a certain size. The CN reacts by saying , “ But your measurement was larger than this ” [ implying that the surgeon asked for the incorrect prosthesis ]. The SN reacts by saying to the CN , “ Hey !” [ implying that she was interfering with something with which she was not supposed to interfere ] (17). The prosthesis was subsequently discovered to be too large, and the patient required further surgery. According to the field notes, the SN was struck by passivity. Moreover, she prevented the CN from getting involved in the situation. In this example, the approach was characterized by a lack of interest in the patient as a human being; the patient was instead seen as an object.

OR nurses’ interaction between nursing care and technology

In the second main finding, OR nurses ’ interaction between nursing care and technology , the coherence between the themes and subthemes contributed to the development of three levels of interaction: the interaction, declining interaction, and failing interaction levels (Table  2 ). The different ways in which the technical assignments and developments were handled and the different ways in which the patients were viewed contributed to the development of all three levels of interaction.

Interaction level

The interaction level was characterized by the interaction between the presence of technical flair and viewing the patient as a human being. This was expressed in the following way: The SN [ participant ] is assisting during an operation of a 72 - year - old woman. The SN says , “ I haven ’ t done this [ specific operation ] for a long time .” The SN gets five large boxes and separates instruments from a depot , takes the instruments to the operating room , and unpacks and prepares the instruments for the operation. She now places her hand on the patient ’ s shoulder after the patient has been sedated and assists in connecting her to the respirator. Later during the operation , the SN says , “ She [ the patient ] is such a fine little lady .” With eyes on the surgical field and without speaking , the surgeon reaches a hand toward the SN , who passes a specific type of suture to the surgeon. The SN looks at the surgical field and says , “ Wait. Is that the right suture for that place ? If not , you ’ ll need a different one .” She then passes another type of suture to the surgeon (23).

In this episode, technical flair was evidenced by the SN’s confidence in using the equipment and proficient grasp of the situation despite the fact that it had been a while since she had assisted in this type of operation. The underlying understanding of the patient as a human being was expressed during the SN’s participation in the patient’s sedation, in which she placed her hand on the patient’s shoulder while assisting the anesthetic nurse. The SN referred to the patient in a respectful manner by using the expression “such a fine little lady,” and it is evident that she understands, sees, and meets the patient as a human being.

Declining interaction level

The declining interaction level was characterized in two ways: as an interaction between the presence of technical flair and viewing the patient as an object and as an interaction between a lack of technical skills and viewing the patient as a human being.

The interaction between the presence of technical flair and viewing the patient as an object was expressed when a participant spoke about a colleague: “ She [ a colleague ] is technically very skilled. She can manage everything when it comes to technology and IT systems. Therefore , she is our expert , but only when it comes to technique. She has no interest in the patients. She cannot talk to [ understand ] them [ the patients ]” (4).

The participant who spoke about the colleague was later asked to elaborate on this statement and answered, “ Yes , you have a point there ” (3). This colleague was perceived as a skilled technician with technical flair. Her lack of interest in vulnerable patients, however, is an example of viewing the patient as an object.

The interaction between a lack of technical skills and viewing the patient viewed as a human being is shown in the following scenario: The SN [ participant ] is about to assist in a very complicated operation. She says , “ I haven ’ t assisted in such an operation in 100 years .” The CN assists the SN with the preparation. After unpacking the equipment for the operation , the CN is about to leave the room. Very promptly , the SN says , “ No , you can ’ t go .” The SN was later asked to elaborate on this episode and stated , “ When I am insecure about the techniques , I get very affected by the way the surgeon enters the room and whether I can sense that he seems insecure. Today , when we were using new equipment , there had to be a technically minded colleague next to the surgeon to assist him. And while my colleague is technically minded , I am caring - minded. I am very considerate of the sedated and defenseless patient. I see him as a human being ” (4). In this example, the technically unskilled nurse was insecure and using new equipment. The nurse acknowledges that she was insecure and expressed the need to have a technically skilled nurse present in the OR. The expressions “ No , you can ’ t go ” and “ I get very affected ” reflect the presence of technophobia in this technically unskilled nurse. In this scenario, it seemed as though the lack of technical skills was legitimized by viewing the patient as a human being.

Failing interaction level

The failing interaction level was characterized by the interaction between a lack of technical skills and viewing the patient as an object. This was demonstrated in a scenario involving the above-described 45-year-old woman with cancer who underwent surgery for a pathological fracture (see earlier theme, “Understanding of the individual patient”). In contrast to the CN, the SN did not interfere with the surgeon and his novice use of the instrumentation while measuring the prosthesis size. Furthermore, the SN prevented her colleague from providing the novice surgeon with important knowledge by saying, “ Hey !” [ implying that she was not supposed to interfere ] (17). At the end of the operation, the surgeon said to the SN, “ I have not been satisfied with your assistance .” The SN replied, “ Well , it is not my fault that you chose a prosthesis that was too big. You are supposed to know how this should be done ” (17). Before the operation, this particular participant said, “ I don ’ t bother about the patient contact. I have often felt that I am unable to do anything for them [ patients ]” (17). According to the field notes, the SN exhibited passivity and was unable to share her (limited) technical, practical, and experience-based knowledge. Moreover, she prevented the CN from getting involved in the situation. In this example, the lack of technical skill was combined with a lack of interest in the patient as a human being; the patient was only an object.

The purpose of this descriptive study was to investigate the content of perioperative nursing in highly specialized ORs in public university hospitals and elucidate perioperative nurses’ interactions between nursing care and technology. The findings suggest three different levels in which perioperative nurses navigate between nursing care and technology. Thus, this study supports earlier research regarding nurses’ ability to combine technical and relational skills [ 6 ],[ 21 ]-[ 24 ]. Bull and FitzGerald [ 6 ] reported similar findings from an ethnographic study in Australia. They stated that the necessity of combining technological proficiency and caring in the OR was taken for granted by nurses. However, our study suggests that this is not always the case when the interaction between nursing care and technology is declining or failing.

Research-based knowledge is needed to inform leaders and nurses about the technological and nursing tasks involved in perioperative nursing [ 39 ],[ 40 ] and to apply this knowledge to patient safety [ 16 ]. According to Scheel [ 36 ], the cognitive-instrumental mode of action in this study is presented by the nurses’ different levels of technological skills, which range from technical flair to a lack of technical skills. The aesthetic-expressive mode of action is observed by the way Informant 23 referred to the patient in a respectful manner. The opposite occurred when Informant 17 stated that she did not care about patient contact. The third mode of action, the moral-practical mode, is represented by Informant 23, who applied her experiential knowledge about ostomy care. This was what the patient and the actual situation demanded from the nurse. The opposite occurred when Informant 17 prevented a colleague from speaking up for the benefit of the patient.

These three different modes of action require unification [ 36 ]. At the interaction level , the interactions among the three modes of action are always part of the current patient–nurse interaction. At the declining interaction level , the cognitive-instrumental or aesthetic-expressive mode of action is particularly prioritized depending on the individual nurse. Thus, the three modes of action do not always interact at this level. This leads to the risk of inadequate nursing care unless the OR is staffed with nurses with different skills who can ensure an interaction among the three modes of action. The failing interaction level was characterized by a lack of interaction among the three modes of action. According to Scheel’s [ 36 ] terminology, this is not nursing. This interpretation was confirmed by Bull and FitzGerald [ 6 ] who concluded that the combination of technological proficiency and patient-focused ethics of care defines whether nurses’ actions in the OR can be characterized as “nursing” ( interaction level ) rather than “technical” tasks ( failing interaction level ). In other words, there is a risk that technology undermines care. However, the present study also showed that nurses at the declining interaction level prioritize nursing care, perhaps because of their lack of technical flair. Interestingly, however, most studies on perioperative nursing have focused on nursing care in contrast to OR nurses’ technical skills [ 2 ],[ 4 ],[ 41 ],[ 42 ]. Barnard [ 21 ] and Sandelowski [ 23 ] are well known for their theoretical studies on nursing and technology. Similarly, Barnard and Gerber (1999) investigated nurses’ understanding of technology through interviews. Nevertheless, the study was based on ethnographic principles and thus revealed new dimensions in technical skills. Some nurses possessed technical flair, while others were technically unskilled. This raises new questions and concerns about nurses’ varying technical skills and may thus inspire further research and discussion.

In this study, nurses at the interaction level combined nursing care and technology with self-reflection and a great understanding of the interdisciplinary team. Nursing practice was characterized by flexibility and excellence because the same nurse interacted with all three modes of action [ 37 ] in that she managed all tasks in the OR. Nurses at the declining interaction level prioritized either the technical or the nursing care dimension, and self-reflection was directed toward elements of the tasks in the OR. A match between two different nurses in the OR is required to ensure interaction among all three modes of action. This limits the implementation of perioperative nursing because the nurses cannot perform all of the tasks in the OR. Nurses at the failing interaction level lacked self-reflection and showed no interest in the patient. New technological challenges were limited by the nurses’ lack of technical skills. Nursing practice was characterized by inflexibility and rigidity because the nurses worked in isolation with limited collaboration with the other staff members. This interpretation was confirmed by Coe and Gould [ 43 ] and Finn [ 44 ], who claimed that well-functioning interdisciplinary teamwork is described as excellent. Thus, the present study’s findings regarding flexible versus inflexible nursing practice add to the discussion on generalist versus specialist nurses [ 45 ], as well as to the discussion on seeing the big picture in nursing, which indicates a desire to provide good care to both patients and staff [ 46 ]. An individual who fails to see the big picture might act rigidly, rather than appropriately, resulting in blind action due to mechanical and automatic thinking.

The findings in this study suggest three different levels at which perioperative nursing care and technology interact in highly specialized ORs in public university hospitals. This categorization of perioperative nursing into levels is not new. In a quantitative, descriptive, correlational study of perioperative nurses’ ability to think critically, Fesler-Birch [ 3 ] calculated the average level of critical thinking to be 2.12 on a scale of 1 to 4, in which 1 indicates no critical thinking and 4 indicates complex critical thinking. Because critical thinking may be central to nurses’ ability to meet patients’ expectations regarding care and skill, this average level of 2.12 can be costly from a patient perspective, in that as intraoperative problems arise, quick clinical judgment decision making may weaken. Fesler-Birch’s study cannot be compared to the present study in that the two were based on different methodologies. However, a number of new questions are raised when comparing one study to the other. For example, could a correlation exist between perioperative nursing at the failing interaction level, which is characterized by nurses’ lack of self-reflection, and level 1 critical thinking, which is characterized by the absence of critical thinking? On the contrary, could a correlation exist between perioperative nursing at the interaction level, which is characterized by nurses’ self-reflection, and level 4 critical thinking, which is characterized as complex? If so, both the failing interaction level and level 1 critical thinking can be costly from a patient perspective. Although there is no solid basis for this conclusion, these questions may inspire further research and discussion.

Limitations of this study

In this study, the content of perioperative nursing was analyzed based on data from highly specialized ORs in two public university hospitals, and the results were interpreted as main findings, themes, and subthemes. Because of the particular sample and special health care context, the findings may be dismissed as unique with no scientific value. However, there are aspects of the universal within the unique [ 47 ],[ 48 ]. Accordingly, the main findings of this study might be applicable by perioperative nurses at other hospitals. A few limitations are noteworthy. For example, the fieldwork was performed in daytime and in the evening, and the night hours were limited. Therefore, the study did not address the content of perioperative nursing and what characterizes this practice in relation to emergency surgery in night hours The study context focused on perioperative nursing in highly specialized ORs in public university hospitals, which are characteristically populated by seriously ill and vulnerable patients undergoing complex surgical procedures. Because the study context did not focus on the research question as related to less severely ill patients and short-term surgical procedures, this should also be seen as a limitation.

Field relationships between informants and researchers are central to any ethnographic study [ 49 ]. A typical question raised is how to account for bias associated with the fact that the participants knew that they were being observed. According to Hammersley and Atkinson [ 28 ], the underlying belief is that human behavior cannot be studied in isolation or independently from the context in which it occurs. Contextualizing the data enables the researcher to place it within a broader perspective and capture a more holistic view. This involves extensive fieldwork in naturalistic settings for prolonged time periods in which the researcher has direct, personal, face-to-face contact with informants [ 49 ]. In the present study, we observed individual nurses for 3 to 5 days for 5 to 8 hours per day. Pretending to be a completely different person than who you are is impossible for such a long period of time [ 34 ]. Therefore, we were able to capture more than just a snapshot of the nurses’ activity and were able to observe routine, repeated, and patterned social practices and processes.

Conclusions

Perioperative nursing in highly specialized ORs in public university hospitals is performed at three different levels depending on the interaction between nursing care and technology. This leads to different characteristics of practice: Practice at the interaction level is characterized by flexibility and excellence because nurses exhibit interaction among (a) technological activities based on technical flair, (b) an understanding of the individual patient and self-reflection based on dialogue and communication, and (c) acting in relation to the patients’ overall situation. Nurses at the interaction level perform all tasks in the OR. Practice at the declining interaction level is characterized by less flexibility because nurses prioritize either (a) technological and instrumental activities based on technical flair or (b) nursing care based on an understanding of the individual patient. Nurses at the declining interaction level are unable to perform all tasks in the OR. Finally, practice at the failing interaction level is characterized by inflexibility and rigor because nurses’ self-reflection and interest in the patient are lacking. New technological challenges are limited by nurses’ lack of technical skills or technophobia. Nurses at the failing interaction level work in isolation with limited collaboration with other staff in the OR.

The findings of this study are useful in organizational, clinical, and educational settings in updating policies for perioperative nursing and enlarging perioperative nurses’ understanding of the relationship between nursing care and technology. Considering that practice at the declining interaction level and failing interaction level is characterized by inflexibility and isolation, nurses at these two levels must develop their competency to the flexible and excellent interaction level . An important task for nurse leaders with respect to recruiting and retention is to be aware of the need for proficiency in this field. The present findings also have some potential in relation to other areas where technology is increasing in the nursing field; e.g., the use of telehealth and technology to support older people in their homes as well as other highly technical areas such as high-dependency units and intensive (coronary) care.

Our discussion is an example of how to use nursing theory in research and expressions such as nursing care and technology, which might lead to constrained nursing practices if misunderstood. Further empirical studies are required to challenge our conclusion that nurses perform perioperative nursing in highly specialized operating departments at three different levels depending on the interaction between nursing care and technology.

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The authors thank Connie Skrubbeltrang for assisting with the literature search and Line Jensen for assisting with language revision.

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EES and MT developed the idea for the study. EES, IØO, and LU performed the data collection and analysis. EES and LU performed the literature review. EES and LU critically reviewed the Background, Methods, Results, and Discussion sections. EES drafted the manuscript. All authors have read and approved the final manuscript.

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Sørensen, E.E., Olsen, I.Ø., Tewes, M. et al. Perioperative nursing in public university hospitals: an ethnography. BMC Nurs 13 , 45 (2014). https://doi.org/10.1186/s12912-014-0045-7

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Nurses’ Priorities for Perioperative Research in Africa

Author’s individual contribution

Juan Scribante: this author helped with data acquisition.

Judita Bila; this author helped with data acquisition.

Caritas Chiura: this author helped with data acquisition.

Priscilla Chizombwe: this author helped with data acquisition.

Betsy Deen: this author helped with data acquisition.

Lucy Dodoli: this author helped with data acquisition.

Mahmound MA Elfiky: this author helped with data acquisition.

Ifeoluwapo Kolawole: this author helped with data acquisition.

Tina Makwaza: this author helped with data acquisition.

Seleman Badrlie M’Baluku: this author helped with data acquisition.

Gaone Mogapi: this author helped with data acquisition.

Christine Musee: this author helped with data acquisition.

Dominic Mutua: this author helped with data acquisition.

Worku Misganaw: this author helped with data acquisition.

Jessy Nyirenda: this author helped with data acquisition.

Lucia Ojewale: this author helped with data acquisition.

Uwayesu Roda: this author helped with data acquisition.

Bruce M Biccard: this author helped conceptualise and design the project, contributed to statistical analysis, and drafting of the manuscript.

Associated Data

Mortality rates among surgical patients in Africa are double that of surgical patients in high-income countries. Internationally there is a call to improve access to and safety of surgical and perioperative care. Perioperative research needs to be co-ordinated across Africa to positively impact perioperative mortality.

The aim of this study was to determine the top 10 perioperative research priorities for perioperative nurses in Africa, using a research priority-setting process. A Delphi technique with four rounds was used to establish consensus on the top 10 perioperative research priorities. In the first round, respondents submitted research priorities. Similar research priorities were amalgamated into single priorities where possible. In rounds two, respondents ranked the priorities using a scale from 1 – 10 (where 1 is the first/highest priority and 10 is the last/lowest priority). The top 20 (out of 31) were determined after round two. In round three, respondents ranked their top 10 priorities. The final round was an online discussion to reach consensus on the top 10 perioperative research priorities.

A total of 17 perioperative nurses representing 12 African Countries determined the top research priorities were: (1) Strategies to translate and implement perioperative research into clinical practice in Africa, (2) Creating a perioperative research culture and the tools, resources, and funding needed to conduct perioperative nursing research in Africa, (3) Optimising nurse-led postoperative pain management, (4) Survey of operating theatre and critical care resources, (5) Perception of, and adherence to sterile field and aseptic techniques among surgeons in Africa (6) Surgical staff burnout, (7) Broad principles of infection control in the surgical wards, (8) The role of interprofessional communication to promote clinical teamwork when caring for surgical patients, (9) effective implementation of the surgical safety checklist and measures of its impact, and (10) Constituents of quality nursing care.

Conclusions

These research priorities provide the structure for an intermediate-term research agenda for perioperative research in Africa.

Glossary of Terms

Introduction.

There is currently limited co-ordination of perioperative research in Africa. The South African Perioperative Research Group (SAPORG) previously used a Delphi technique (an anonymous consensus-building technique) 1 to determine the top ten national research priorities 2 for South Africa. This has been an unprecedented success which has addressed four of the 10 priorities 3 – 7 , and others are currently being studied. Given that the primary uses of the Delphi technique is to generate consensus 8 among experts and facilitate international collaboration, it is the ideal study design for determining African clinicians’ research priorities for perioperative research in Africa.

Internationally there is a call to improve access to and safety of surgical and perioperative care 1 , 9 . To do this in Africa, we need to understand what researchers and clinicians in Africa consider research priorities that need to be addressed to improve surgical outcomes. The African Perioperative Research Group (APORG) network 5 , which includes researchers from over 30 countries, provides a unique opportunity to determine research priorities for Africa. Defining the research priorities for the continent will help to co-ordinate researchers in Africa on the most important issues that need to be addressed in the resource-limited African environment. Previously, we determined the top 10 perioperative research priorities for doctors in Africa 10 . However, what may be considered priorities for doctors may differ from other healthcare providers. Differing priorities may hamper the delivery of these research projects. To provide a more holistic picture of the perioperative research priorities for Africa, it is also essential to understand the priorities of perioperative nurses. Therefore, the aim for this study was to determine the top 10 research priorities for perioperative nurses in Africa, using a research priority setting process using a Delphi process.

Ethical approval was obtained from the Human Research Ethics Committee of the University of Cape Town (HREC 501/2019). All respondents provided written consent prior to participation. A Delphi technique 11 was used for this research priority setting project, which was conducted as an e-survey over three rounds with a final round virtual meeting. The Delphi was conducted between October 2020 and March 2021. This approach to consensus development for priorities was modelled on the previous priority setting processes conducted in South Africa 2 , and Africa 10 .

We asked the national leaders of the African Surgical Outcomes Study (ASOS) 5 and the African Surgical OutcomeS Trial-2 (ASOS-2) trial 12 to nominate one or two perioperative nurses in their surgical units (purposive sampling) to participate in this Delphi study. An email invitation including the participant information sheet was sent to all identified nurses ( Appendix 1 ). This was a closed survey within this group and was not openly advertised. Participation was voluntary. There were no incentives for participation. The survey was piloted and checked by GJB on RedCap to ensure the scoring system was working accurately before each round. All survey data will be stored in a password protected Google Drive for 10 years after study completion.

In the first round, respondents were asked “what research questions do you think should be prioritised for perioperative research in Africa?”. They were requested to submit at least 6 potential priorities (i.e. research questions) via RedCap ( https://www.project-redcap.org/ ) for perioperative research in Africa. The responses were collated into common themes and where appropriate, similar research priorities were amalgamated into a single priority by GJB and BMB. Conflicts were discussed until consensus between GJB and BMB was reached. In the second round, these potential research priorities were circulated to all respondents. They were asked to rank each priority on a scale from 1 – 10 (where 1 is the first/highest priority and 10 is the last/lowest priority). In the third round, the top 20 research priorities from round two were presented in rank order and respondents were asked to consider re-ranking their previous submissions from round two based on the grouped ranking results. If the respondents preferred not to change their previous rankings, they were encouraged to provide justifications for their decision.

The fourth and final round was held via an online meeting. We planned to present the top 10 (of the top 20 from round three) and confirm consensus with respondents on the final top 10 priorities. However, the mean score for the 9 th , 10 th and 11 th priorities were the same. Therefore, we deviated from protocol and respondents were presented with the top 11 research priorities from the results of the third round. Respondents were encouraged to openly discuss and negotiate these bottom three priorities and come to a consensus on the top 10 priorities.

The first round of the survey was conducted in English and French, with all communications, responses and proposed priorities communicated in both languages. In the first round, none of the respondents responded in French. Therefore, the remaining rounds were conducted in English only. All priorities were visible on a single screen in the second and third rounds, and all responses were captured electronically. If a response were incomplete, or the respondent wanted to change the response, they could resubmit a response during that round of the Delphi. The most complete response from a respondent in a round was included in the ranking. All responses were identifiable to GJB, who collated the responses per round for analysis, to ensure that the e-survey was completed only by the invited nurses, and to prevent inclusion of multiple e-surveys per round by a single respondent. Following collation of these responses, the database was then de-identified.

This e-survey is presented according to the Checklist for Reporting Results of Internet E-Surveys (CHERRIES) guidelines ( Appendix 2 ) 13 .

Statistical analysis

The rank-order of the research priorities from the second and third rounds was calculated by using a reverse scoring system. A rank of one was assigned 10 points, with a descending point allocation down to a rank of 10, which was allocated one point. The scores of each respondent for each proposed priority were summed to present the research priority rank order. Incomplete responses (less than 10 priorities ranked) were included in the analysis, and no adjustments were made for incomplete responses.

Twenty nurses working in surgical units across 17 African countries (Botswana, Democratic Republic of Congo, Egypt, Ethiopia, Kenya, Madagascar, Malawi, Mali, Niger, Nigeria, Rwanda, Sierra Leone, South Africa, Tanzania, Uganda, Zambia and Zimbabwe) were invited to participate in this Delphi study. Of the 20 invited nurses, seventeen participated, representing 12 African countries: Botswana, Egypt, Ethiopia, Kenya, Malawi, Mozambique, Nigeria, Rwanda, Sierra Leone, South Africa, Zimbabwe, and Zambia. The clinical and research characteristics of these respondents are shown in Table 1 .

Figure 1 summarises the Delphi process. In the first round, all 17 respondents proposed a total of 79 research priorities. Where appropriate, similar priorities were combined and grouped within seven themes: education and training, equipment and systems, preoperative, intraoperative, postoperative, staff collaborations, and quality of care. Similar research priorities were amalgamated into a single priority by GJB and BMB. A summary of this grouping and amalgamating process can be seen in Appendix 3 . In the second round, 31 priorities were presented to all respondents. Eleven (of 17) provided a ranking (1 – 10, where 1 = first/highest priority and 10 = last/lowest priority) of all priorities. In the third round, the top 20 priorities ranked from round two were presented to all respondents. Thirteen (of 17) provided a ranking (1 – 10, where 1 = first/highest priority and 10 = last/lowest priority) for their top 10 priorities.

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After the third round, there was a tie in the ranking for priorities 9, 10 and 11. Therefore, the top 11 priorities were presented to all respondents in the fourth round. Respondents discussed and reached consensus on the final agreed top 10 priorities, within six themes: education and training, equipment and systems, intraoperative, postoperative, staff collaboration, and quality of care, for perioperative research in Africa. These are shown in Table 2 . None of the priorities within the ‘preoperative’ theme were ranked high enough to include in the final top 10 list.

Ten research priorities have been identified for perioperative research in Africa. These priorities, together with those identified from our previous research 2 , 10 provide the structure for an intermediate-term, African collaboration perioperative research programme. These priorities represent the consensus of perioperative nurses from 12 African countries, and they cover a broad range of topics which are context-sensitive to the challenges and needs of perioperative research in Africa 14 . Interestingly, our sample of nurses identified research priorities related to training and education, and quality of care. In contrast, doctors in our previous research 10 identified research priorities mostly related to patient outcomes. Both this current study and our previous research identified staff collaboration as a perioperative research priority. Despite there being some commonalities, the nurses identified unique perioperative research priorities, emphasising the need for interdisciplinary collaboration in perioperative research.

Priority number 1: Strategies to translate and implement perioperative research into clinical practice in Africa

Given that this was the highest priority, it is likely that nurses are aware of research that is not being implemented into clinical practice. We have previously identified that the common barriers for conducting and implementing perioperative research in Africa are limited human resources and structural barriers, such as access to reliable internet access 14 . Clearly translation of research into clinical care is a neglected aspect of research in low- and middle-income countries. We need to address these barriers in tandem to achieve this priority.

Priority number 2: Creating a perioperative research culture and the tools, resources, and funding needed to conduct perioperative nursing research in Africa

This priority is consistent with our previous work: clinician-researchers across Africa believe that research is an important component of clinical practice and are motivated to contribute to collaborative African research 14 . The basic barriers explained under priority 1 need to be addressed to allow for the development of a perioperative research culture and establishment of ongoing perioperative research by nurses in Africa. In a human resource-limited environment, it is important that there is a focus on funding to provide research capacity, as the dual provision of clinical service, and perioperative research is unlikely to deliver quality research in this environment.

Priority number 3: Optimising nurse led postoperative pain management

Postoperative pain is poorly managed globally, however, poor postoperative pain management is particularly high in low-and middle-income countries 15 , 16 . Poor postoperative pain management is associated with delayed mobilisation, compromised pulmonary function and chronic pain 17 . Nurses are ideal for leading postoperative pain management within the multidisciplinary team 18 . The implementation of nurse-led postoperative pain management has contributed to improved postoperative outcomes 19 – 21 and patient satisfaction with care 22 . However, inadequate training in pain assessment and management is a barrier to effective nurse-led postoperative pain management 23 . A Nigerian study reported that pain management needs to be included in the undergraduate nursing curriculum 21 . There is a need for improved pain education among all members of the multidisciplinary team to effectively optimise nurse-led postoperative pain management and improve patient postoperative outcomes.

Priority number 4: Survey of operating theatre and critical care resources

There are well-established international guidelines for perioperative resource requirements from high-income countries 24 . However, these guidelines are often inappropriate for the poorly resourced African settings due to the large disparities between the guideline, and the context on the ground. Our previous work 10 and this current study indicate that both physicians and nurses in Africa want to know (1) what resources are currently available, (2) what resources are critically needed and most importantly (3) what resources are realistically attainable in their perioperative care setting. Our impression is that the international resource recommendations are far removed from the reality of the resources that are available, hence there is a call by clinicians 10 and nurses to document this disparity, and develop a strategy to address this limitation.

Priority number 5: Perception of and adherence to sterile field and aseptic techniques among surgeons in Africa

Sepsis is a global health concern, contributing to postoperative morbidity and mortality. The incidence of sepsis is substantially greater in low- and middle-income countries than in high-income countries; additionally African countries may carry a higher rate of antibiotic resistance 24 . Surgical site sepsis has been reported as the most common postoperative complication in Africa 5 , 25 . To decrease the incidence of surgical site sepsis, it is vital for researchers to examine the perception of and adherence to sterile field and aseptic techniques intraoperatively among surgeons in Africa.

Priority number 6: Surgical staff burnout

Surgical staff burnout is common 26 , 27 , 28 and has been reported to be disproportionately high among South African anaesthetists 28 , 29 . The Association of Anaesthetists has published guidelines for wellbeing, including resources on achieving a work/life balance, mindfulness, stress management, and coping with death 30 . Importantly, this priority is vague when referring to ‘surgical staff’. It is unclear which surgical staff members respondents thought were specifically vulnerable to burnout. However, we suspect respondents are referring to surgical staff working in the theatres and perioperative wards, given that this priority was generated from the perspective of nurses working in the perioperative setting. The prevalence of burnout among perioperative nursing staff is unclear. Given the limited resources and staff shortages in low- and middle-income countries, it is likely that burnout among perioperative nurses is common 30 , 31 . Identification of this priority suggests that burnout may be important in nursing in Africa, with further research into nursing staff burnout needed.

Priority number 7: Broad principles of infection control in the surgical ward

As stated above, surgical site sepsis is a major concern in Africa, and intraoperative sterility is a priority. This priority extends effective infection control to the postoperative ward setting. The emphasis on infection control intraoperatively (priority 5) and postoperatively (priority 7) in these 10 priorities may indicate nurses’ experience of poor adherence to aseptic techniques and a high incidence of surgical site sepsis, despite there being numerous national and international standards for infection control. These research priorities are consistent with the observations of high rates of sepsis in low resource environments.

Priority number 8: The role of interprofessional communication to promote clinical teamwork when caring for surgical patients

There is extensive literature to support the benefits of an interdisciplinary team approach to improve patient outcomes 32 and satisfaction with care 33 . Physicians also acknowledged the importance of effective communication and teamwork in our previous work 10 . Given that both nurses and physicians have both prioritised communication and teamwork suggests that ineffective communication may be impeding the teamwork necessary for quality perioperative research and care.

Priority number 9: Effective implementation of the surgical safety checklist and measures of its impact

The use of a surgical safety checklist (SSCL) has been associated with improved postoperative outcomes and decreases mortality 34 – 36 . However, a SSCL is used in only 57% of surgeries in Africa 6 . The importance of the utilisation of a SSCL has also been prioritised by African clinicians 10 , 12 . Further research is needed to identify the barriers to routine implementation of a checklist in Africa.

Priority number 10: Constituents of quality nursing care?

Postoperative mortality is substantially higher among patients in Africa than patients in high-income countries. Mortality rates among adult surgical patients 5 and neonates 7 in Africa are twice that of the global average. Maternal mortality after caesarean section is 50 times higher in African than in high-income countries 7 . Further, an 8 fold and 12 fold variation in outcomes due to the quality of maternal and neonatal care, respectively, has been reported between low-middle-income countries, and high-income countries 37 . These data indicate the importance of improving the quality of perioperative care to successfully decrease mortality among surgical patients in Africa.

Strengths and limitations of the research priority-setting process

We are unaware of any other studies that have reported nurses’ priorities for perioperative research in Africa. This research echoes physicians’ priorities determined in our previous work 2 , 10 , emphasising the importance of a survey of operating theatre and critical care resources, perception of and adherence to sterile field and aseptic techniques among surgeons in Africa, broad principles of infection control in the surgical ward, the role of interprofessional communication to promote clinical teamwork when caring for surgical patients, and how to ensure effective implementation of the SSCL and measure its impact. We would suggest that these common priorities should be addressed early to improve perioperative care in Africa. Limitations to this work are the small sample size and a lack of representation and unequal representation (e.g. 3 of 17 respondents were from Malawi) from all African countries. There is potential selection bias in this current study. Some respondents are involved in research-related activities and therefore could induce a bias related to their current research activities. Importantly, 10 (of 17) respondents have at least 10 years of clinical nursing experience and most (15 of 17) are full-time perioperative nurses. Therefore, these clinicians are well-versed to identify priorities for perioperative research to improve perioperative care.

The top 10 priorities for perioperative research in Africa are presented following a research priority setting process using the Delphi technique. Although there is some overlap in the research priorities among the respondents (nurses) in the current study and the doctors in our previous work 10 , the unique focus on training and education, and quality of care presented by the respondents in this study emphasises the need for ensuring interdisciplinary collaboration in perioperative research. These research priorities provide the structure for an intermediate-term research agenda for perioperative research in Africa. It is hoped that addressing these priorities will significantly improve perioperative outcomes in Africa.

Key points summary

What are nurses’ top 10 priorities for perioperative research in Africa?

Although there is some overlap in the research priorities among the respondents (nurses) in the current study and the doctors in our previous work 9 , the unique focus on training and education, and quality of care presented by the respondents in this study emphasises the need for ensuring interdisciplinary collaboration in perioperative research.

Supplementary Material

This research was supported by a NIHR Development Award Grant (Award number: 129848). GJB was supported by a Scholarship and Postgraduate funding from the University of Cape Town, and Postgraduate Research Grants from Pain South Africa and the South African Society of Physiotherapy, and an unrestricted education grant from Pfizer (2018) with no direct relationship to the current work. GJB is supported by a postgraduate scholarship from the National Research Fund (South Africa) and the Oppenheimer Memorial Trust.

Competing interests

GJB receives speakers’ fees for talks on pain and rehabilitation. All other authors have no competing interests to declare.

Contributor Information

Gillian j bedwell.

1 Department of Anaesthesia and Perioperative Medicine, University of Cape Town, Cape Town, South Africa

Juan Scribante

2 School of Clinical Medicine, University of the Witswatersrand, Johannesburg, South Africa

Tigist D Adane

3 Debre Berhan University, Health Sciences College, Debre Berhan, Ethiopia

Judita Bila

4 Hospital Central de Maputo, Maputo, Mozambique

Caritas Chiura

5 Nurse Educator Association of Zimbabwe, Harare, Zimbabwe

Priscilla Chizombwe

6 Kamuzu Central Hospital, Lilongwe, Malawi

7 Connaught Teaching Hospital, Freetown, Sierra Leone

Lucy Dodoli

8 Kamuzu Central Hospital Surgical Department, Kamuzu college of nursing, University of Malawi, Lilongwe, Malawi

Mahmound MA Elfiky

9 Kasr Al Ainy Faculty of Medicine, Cairo University, Cairo, Egypt

Ifeoluwapo Kolawole

10 Department of Nursing, University of Ibadan, Ibadan, Nigeria

Tina Makwaza

11 Ndola Teaching Hospital, Zambia

Seleman Badrlie M’Baluku

12 Kamuzu Central Hospital, Lilongwe, Malawi

Gaone Mogapi

13 Department of Surgery, Princess Marina Hospital, Gaborone, Botswana

Christine Musee

14 Kenyatta National Hospital; GRASPIT training in Kenya, Nairobi, Kenya

Dominic Mutua

15 Kenyatta National Hospital, Nairobi, Kenya

Worku Misganaw

16 Debre Berhan University, Health Sciences College, Debre Berhan, Ethiopia

Jessy Nyirenda

17 Kitwe Teaching Hospital, Kitwe, Zambia

Lucia Ojewale

18 Department of Nursing, University of Ibadan, Ibadan, Nigeria

Uwayesu Roda

19 King Faisal Hospital, Kigali, Rwanda

Bruce M Biccard

20 Department of Anaesthesia and Perioperative Medicine, Groote Schuur Hospital and University of Cape Town, Cape Town, South Africa

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LIMITATIONS AND DELIMITATIONS IN THE RESEARCH PROCESS

doi: 10.5281/zenodo.2552021 , 10.5281/zenodo.2552022

Introduction: Many authors tempt to balance the recognition of shortcomings and study limitations with the risk of having their paper rejected. Yet, before any attempt to run a study, a researcher needs to recognise the meaning and operational definitions of the terms ‘limitations’ and ‘delimitations’ in biomedical research. Aim: to define, review and elaborate how limitations and delimitations are currently acknowledged in the nursing and biomedical literature and their implications in health care studies. Methods: A critical literature review was undertaken, focusing on papers debating the core essence of research limitations and associated concepts. Initial searches yielded >300 papers of which only 25 were appropriate for this paper’s needs. Results: It is evident that any research attempt inevitably carries limitations and delimitations regarding its underlying theories, study design, replication potential, shortcomings in data collection and questionnaire design, insufficient subgroups or data for robust statistical analysis, narrow time span for data collection, lack of consideration for seasonal differences and missing data, causal relationships, measurement errors, study setting, population or sample, ethical parameters, data collection/analysis, result interpretations and corresponding conclusions. Delimitations require challenging the assumptions of the researchers and openly exposing shortcomings that might have been better tackled. Some authors cite study limitations solely because it is required by journal policy. Under these circumstances, the weakest limitation may be put forward in an attempt to ‘safeguard’ the study’s chance of being published. Researchers need to be aware of the wide range of limitations and delimitations and address them early in the research process Conclusions: Constructive rethinking and restructuring of the global nursing and biomedical research agenda is necessary to upgrade the profession and reassure the public. Thus, authors should openly and extensively report their research limitations, delimitations and assumptions in order to improve the quality of their findings and the interpretation of the evidence presented. On the contrary, when any of these key elements are neglected, overlooked or hushed, the study kudos is jeopardised.

Study Limitations, Methodology, Nursing Research

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Perioperative Nursing - Quarterly scientific, online official journal of G.O.R.N.A.

Issue 3 September-December 2018

Issue 3 September-December 2018

Editorial Article

Evidence based nursing.

Kannelou Efrosini

Saturday, September 1, 2018

Pages: 152-154

Review Paper

Limitations and delimitations in the research process.

Theofanidis Dimitrios , Fountouki Antigoni

Pages: 155-163

Introduction: Many authors tempt to balance the recognition of shortcomings and study limitations with the risk of having their paper rejected. Yet, before any attempt to run a study, a researcher needs to recognise the meaning and operational definitions of the terms ‘limitations’ and ‘delimitations’ in biomedical research. Aim: to define, review and elaborate how limitations

THE CONTRIBUTION OF ENDOSCOPIC LASER COAGULATION IN THE TREATMENT OF THE TWIN-TO-TWIN TRANSFUSION SYNDROME

Katsaras George , Markopoulou Panagiota

Pages: 163-177

Introduction: The twin-to-twin transfusion syndrome is a serious complication which affects 10-15% of monochorionic diamniotic placentation pregnancies. The syndrome is the result of a progressively displayed and chronic imbalance of the communication of the placental shunts, resulting in unequal blood exchange between the fetuses, namely the "transfusion” of

BURN INFECTIONS - MODERN TREATMENT APPROACHES

Karolemea Sevasti , Kelesi Martha , Vasilopoulos Georgios

Tuesday, January 9, 2018

Pages: 178-188

Introduction: Burns are one of the most common and at the same time the most devastating types of trauma related with mortality which is associated, in most cases, with infections that they develop in them. According to estimates, more than 300,000 individuals die each year due to burn-related burns while 6 million people are looking for medical assistance due to burns the world,

THE EFFECT OF RELIGIOUSNESS IN CANCER PATIENTS

Chatzinikolaou Aikaterini

Pages: 189-196

Introduction: Faith in God plays a significant role for patients who encounter chronic and life-threatening diseases. The purpose of this review was to explore the effect of religiousness in patients with cancer. Material and Methods: It was conducted a review in researches in international and Greek databases (Google Scholar and IATROTEK Online)

Original Paper

Ηemodialysis patients' perceptions.

Tsami Athanasia , Maxouris Ioannis , Iliaskou Petroula

Pages: 197-205

Dialysis as the main renal replacement method exerts a significant burden on patients, their families andonthe National Health System of each country. According to estimates, in 2013, 1.500.000 individuals were under hemodialysis. The purpose of this study was to explore perceptions of patients with end-stage renal failure with respect to hemodialysis.  Method and material:  The sample

PSYCHOLOGICAL APPROACH TO CHILDREN AND ADOLESCENTS WITH CYSTIC FIBROSIS

Koutelekos John , Zartaloudi Afroditi , Αthanasiadi Veroniki

Pages: 206-216

Introduction: Cystic fibrosis is a fatal and heritable disease of the white race, which is characterized by the excretion of viscous mucus in various glands of the human body, resulting in their gradual destruction, which eventually leads to death. Purpose: of this study was to focus on psychosocial issues of the disease and especially on the psychosocial approach to children and adolescents with

European Operating Room Nurses Association

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Limitations and Delimitations: The Boundaries and Weakness of Your Research

  • PhD Research

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Every research has it strengths and weaknesses and the limitations of the study addresses these weaknesses, but so does delimitations, yet they are different from each other except on account that both of them explore and explain the factors that limit the questions your research will be able to answer and how these factors can have an impact on your research, this shows that no research is foolproof but the extent to which they affect your research can have a say on the validity of your research outcomes. 

What are research limitations?

Researchers try to find the best possible data for their research to answer a specific question. But no matter how good your research is, it will only provide you with information. The question you ask, the design of your study, and many other factors can limit the amount of information you get from your research. Research limitations are limitations that come from the way you design a study, and they are often due to ethical or methodological reasons. These limitations may make it difficult to draw conclusions and may influence the results. – Sample size: The larger your sample size, the more likely it is that you will find a significant difference between the sample and the control group. – Question: Your results will vary depending on what you ask. – Research design: The validity of your study may be limited by the design of your research. – Data analysis: The way you analyze your data is just as important as the data themselves.

What are research delimitations?

Unlike limitations, research delimitations refer to factors that are not essentially outside of the researcher’s control because delimitations are in essence the limitations consciously set by the authors themselves. They are concerned with the definitions that the researchers decide to set as the boundaries or limits of their work so that the study’s aims and objectives do not become impossible to achieve. Unlike limitations, however, a research delimitation does not mean that the study does not provide some useful information or has been unable to explore something. It simply means that it may not answer all of the study’s research questions. For example, a study may look at the effectiveness of a new treatment, but due to size limitations, it could not determine if the treatment helped patients with all types of cancer or only those with a certain type of cancer. In this case, the study is a delimitation, meaning the researchers did not answer all of the questions about the effectiveness of the treatment.

Importance of Research Limitations and Research Delimitations 

The limitations of a study are important because they can help you understand why certain results happened. For example, if you used only one sample size to test your hypothesis, you would expect to find a significant difference between the sample and the control group. If you did not find this difference, there may be something wrong with your sample size. Limitations also help you learn from your mistakes. If you make a mistake, you can use limitations to correct for that mistake and improve the quality of your research.

In a study that addresses all of the research questions, the results can be very definitive. But in a study that only answers part of the questions, the results may be more like a hypothesis. In a study that only addresses some of its research aims and questions, the results can be even more like a hypothesis. Regardless of the level of the study, the researcher is building an idea of what may be. As researchers build these ideas, they may encounter delimitations, limitations, and other factors that can limit the information they receive. With all of these factors in mind, researchers can still make valuable conclusions from their research.

Wrapping Up 

Researchers should also note that limitations and delimitations are different from another similar restraint on the infallibility of any research – the ‘assumptions’ part. Nonetheless, researchers have an obligation to the academic community to present complete and honest limitations of a presented study and even if they have influenced the outcomes and conclusions you have derived from your research, by describing them in detail and critically evaluating your own study design – you have made a case for your research credibility. 

Theofanidis, Dimitrios, & Fountouki, Antigoni. (2019). Limitations And Delimitations In The Research Process. Perioperative nursing (GORNA), E-ISSN:2241-3634, 7(3), 155–162. http://doi.org/10.5281/zenodo.2552022  

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Research nurse and nurse researcher: differences and similarities

limitations and delimitations in the research process perioperative nursing

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  • Vol. 7 No. 4 (2021): Volume 7 Issue 4 October - December 2021

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COMMENTS

  1. PDF Limitations and Delimitations in The Research Process

    Aim: to define, review and elaborate how limitations and delimitations are currently acknowledged in the nursing and biomedical literature and their implications in health care studies. Methods: A critical literature review was undertaken, focusing on papers debating the core essence of research limitations and associated concepts.

  2. LIMITATIONS AND DELIMITATIONS IN THE RESEARCH PROCESS

    It is evident that any research attempt inevitably carries limitations and delimitations regarding its underlying theories, study design, replication potential, shortcomings in data collection and questionnaire design, and insufficient subgroups or data for robust statistical analysis. 300 papers of which only 25 were appropriate for this paper’s needs. Results: It is evident that any ...

  3. ‪Dimitris Theofanidis‬

    Limitations and delimitations in the research process. Perioperative Nursing, 7 (3), 155-162. D Theofanidis, A Fountouki. 25. 2018. Exploring the experiences of nurses and doctors involved in stroke care: a qualitative study. D Theofanidis, B Gibbon. Journal of clinical nursing 25 (13-14), 1999-2007. , 2016.

  4. ‪Antigoni Fountouki‬

    Nursing staff under heavy stress: Focus on Greece A critical review. F Antigoni, O Pediaditaki, T Dimitrios. International Journal of Caring Sciences 4 (1), 11-20. , 2011. 42. 2011. Limitations and delimitations in the research process. Perioperative nursing (GORNA), E-ISSN: 2241-3634, 7 (3), 155-162. D Theofanidis, A Fountouki.

  5. LIMITATIONS AND DELIMITATIONS IN THE RESEARCH PROCESS

    Introduction: Many authors tempt to balance the recognition of shortcomings and study limitations with the risk of having their paper rejected. Yet, before any attempt to run a study, a researcher needs to recognise the meaning and operational definitions of the terms 'limitations' and 'delimitations' in biomedical research. Aim: to define, review and elaborate how limitations and ...

  6. The Perioperative Patient Focused Model: A literature review

    The literature search identified only 12 articles. After removal of duplicates, and elimination of one article not published in English, only five articles remained (Fig. 1).These articles included a description of how the Model was selected 1; a discussion of the difficulties of determining intraoperative patient outcomes using the Model 2; a personal statement on nursing and how the author ...

  7. Identifying research priorities for improving patient care in the

    to perioperative nursing. 23. With the aim of supporting and encouraging research in perioperative nursing and promoting evidence-based practice, ACORN established a research committee (RC). The primary function of the RC is to guide and coordinate all aspects of research activity for the College. To inform the scope of the committee's purpose

  8. Limitations and Delimitations in The Research Process

    It is evident that any research attempt inevitably carries limitations and delimitations regarding its underlying theories, study design, replication potential, shortcomings in data collection and questionnaire design, insufficient subgroups or data for robust statistical analysis, and narrow time span for data collection. 300 papers of which only 25 were appropriate for this paper’s ...

  9. Nursing Research, Quality Improvement, and Evidence-Based ...

    Nursing Research, Quality Improvement, and Evidence-Based Practice: The Key to Perioperative Nursing Practice. Nursing Research, Quality Improvement, and Evidence-Based Practice: The Key to Perioperative Nursing Practice AORN J. 2017 Jan;105(1):3-5. doi: 10.1016/j.aorn.2016.11.020. ...

  10. Research in peri-operative nursing care

    The most information was available on the post-operative phase, such as recovery, adaptation and the treatment of pain. Peri-operative research is mainly concerned with the quality of nursing care, control of life and ambulatory surgery. The main defects of analysed studies can be characterized as follows: small samples and a single hospital ...

  11. Limitations and Delimitations in The Research Process

    Aim: to define, review and elaborate how limitations and delimitations are currently acknowledged in the nursing and biomedical literature and their implications in health care studies. Methods: A critical literature review was undertaken, focusing on papers debating the core essence of research limitations and associated concepts. Initial ...

  12. Perioperative nursing in public university hospitals: an ethnography

    Perioperative nursing has been explored from different angles for more than a decade []-[].The interaction between nursing care and technology has been discussed in particular detail [],[].This discussion has raised a number of questions about the tendency to view nursing in operating rooms (ORs) as invisible to the patient and as surgical interventions without nursing activities [],[].

  13. Nurses' Priorities for Perioperative Research in Africa

    Results. A total of 17 perioperative nurses representing 12 African Countries determined the top research priorities were: (1) Strategies to translate and implement perioperative research into clinical practice in Africa, (2) Creating a perioperative research culture and the tools, resources, and funding needed to conduct perioperative nursing ...

  14. PDF LIMITATIONS AND DELIMITATIONS IN THE RESEARCH PROCESS

    Aim: to define, review and elaborate how limitations and delimitations are currently acknowledged in the nursing and biomedical literature and their implications in health care studies. Methods: A critical literature review was undertaken, focusing on papers debating the core essence of research limitations and associated concepts.

  15. LIMITATIONS AND DELIMITATIONS IN THE RESEARCH PROCESS

    Aim: to define, review and elaborate how limitations and delimitations are currently acknowledged in the nursing and biomedical literature and their implications in health care studies. Methods: A critical literature review was undertaken, focusing on papers debating the core essence of research limitations and associated concepts.

  16. Issue 3 September-December 2018

    Introduction: Many authors tempt to balance the recognition of shortcomings and study limitations with the risk of having their paper rejected. Yet, before any attempt to run a study, a researcher needs to recognise the meaning and operational definitions of the terms 'limitations' and 'delimitations' in biomedical research.

  17. Evidence based nursing: barriers and challenges for contemporary nurses

    Future Perspectives on Nursing Policy, Technology, Education, and Practice. ... LIMITATIONS AND DELIMITATIONS IN THE RESEARCH PROCESS. D. Theofanidis A. Fountouki. Business. 2018; TLDR. It is evident that any research attempt inevitably carries limitations and delimitations regarding its underlying theories, study design, replication potential ...

  18. Health & Research Journal

    Health & Research Journal Vol 7, No 1 (2021) Volume 7 Issue 1 January-March 2021 Evidence based nursing: barriers and challenges for contemporary nurses Dimitrios Theofanidis doi: 10.12681/healthresj.26093 ... 6. Theofanidis D., A Fountouki A. Limitations and delimitations in the research process. Perioperative Nursing 2018; 7(3):155-163 ...

  19. Limitations and delimitations in the research process

    Abstract: 300 papers of which only 25 were appropriate for this paper's needs. Results: It is evident that any research attempt inevitably carries limitations and delimitations regarding its underlying theories, study design, replication potential, shortcomings in data collection and questionnaire design, insufficient subgroups or data for robust statistical analysis, narrow time span for ...

  20. Limitations and Delimitations: The Boundaries and Weakness of Your Research

    Unlike limitations, research delimitations refer to factors that are not essentially outside of the researcher's control because delimitations are in essence the limitations consciously set by the authors themselves. ... (2019). Limitations And Delimitations In The Research Process. Perioperative nursing (GORNA), E-ISSN:2241-3634, 7(3), 155 ...

  21. Clinical judgement in nursing

    This concept analysis guided the development of an operational definition of clinical judgement, within the context of nursing, articulated as Clinical judgement is a reflective and reasoning process that draws upon all available data, is informed by an extensive knowledge base and results in the formation of a clinical conclusion. Conclusion

  22. LIMITATIONS AND DELIMITATIONS.pdf

    P ERIOPERATIVE N URSING (2018), V OLUME 7, I SSUE 3 LIMITATIONS AND DELIMITATIONS IN THE RESEARCH PROCESS. 2018;7(3) 157 Delimitations are in essence the limitations con-sciously set by the authors themselves. They are concerned with the definitions that the researchers decide to set as the boundaries or limits of their work so that the study's aims and objectives do not become impossible to ...

  23. Research nurse and nurse researcher: differences and similarities

    Health & Research Journal, 7(4), 151-154. https: ... A Fountouki A. Limitations and delimitations in the research process. Perioperative Nursing 2018. 7(3):155-163. ... Article: Values in nursing and the virtues of the profession: a systematic critical review , Issue: Health ...