Swedish Nurse Anesthetists’ Experiences of the WHO Surgical Safety Checklist Linda R€ onnberg, MScN, RNA, Ulrica Nilsson, PhD, RNA Purpose: The World Health Organization (WHO) surgical safety checklist
aims to increase communication, build teamwork, and standardize routines in clinical practice in an effort to reduce complications and improve patient safety. The checklist has been implemented in surgical departments both nationally and internationally. The purpose of this study was to describe the registered nurse anesthetists’ (RNA) experience with the use of the WHO surgical safety checklist. Design: This was a cross-sectional study with a descriptive mixed methods design, involving nurse anesthetists from two different hospitals in Sweden. Methods: Data were collected using a study-specific questionnaire. Findings: Forty-seven RNAs answered the questionnaire. There was a statistically significant lower compliance to ‘‘Sign-in’’ compared with the other two parts, ‘‘Timeout’’ and ‘‘Sign-out.’’ The RNAs expressed that the checklist was very important for anesthetic and perioperative care. They also expressed that by confirming their own area of expertise, they achieved an increased sense of being a team member. Thirty-four percent believed that the surgeon was responsible for the checklist, yet this was not the reality in clinical practice. Although 23% reported that they initiated use of the checklist, only one RNA believed that it was the responsibility of the RNA. Forty-three percent had received training about the checklist and its use. Conclusion: The WHO surgical checklist facilitates the nurse anesthetist’s anesthetic and perioperative care. It allows the nurse anesthetist to better identify each patient’s specific concerns and have an increased sense of being a team member. Keywords: WHO checklist, patient safety, registered nurse anesthetist’s (RNA), compliance, team, research. Ó 2015 by American Society of PeriAnesthesia Nurses
PATIENTS UNDERGOING SURGERY are at risk for complications. Communication, lack of time, and urgent surgical procedures often contribute
Linda R€ onnberg, MScN, RNA, Department of Nursing, Ume a University, Sweden; Department of Anaesthesia, € Ostersunds Hospital, Sweden; and Ulrica Nilsson, PhD, RNA, € is a Professor, School of Health and Medical Sciences, Orebro € University, SE 701 82 Orebro, Sweden. Conflicts of interest: None to report. Address correspondence to Ulrica Nilsson, School of Health € € and Medical Sciences, Orebro University, SE 701 82 Orebro, Sweden; e-mail address: [email protected]. Ó 2015 by American Society of PeriAnesthesia Nurses 1089-9472/$36.00 http://dx.doi.org/10.1016/j.jopan.2014.01.011
468
to these complications.1 While complications during or after surgery are common, most of them are preventable.2 Of the 234 million surgical procedures done annually, seven million patients suffered complications, including one million who died during or immediately after surgery.3 Complications are costly. Structured safety approaches are assumed to benefit both the patient and the health care system.4 The World Health Organization (WHO) developed a surgical safety checklist aimed to improve patient safety and decrease complications.5 The WHO checklist is divided into three parts— ‘‘Sign-in,’’ ‘‘Time out,’’ and ‘‘Sign-out’’—with a
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verbal confirmation of each step. Sign-in takes place before the induction of anesthesia and includes confirmation of the patient’s identity, procedure, site (marked, if appropriate), and consent. Anticipated risk of blood loss, airway difficulty, hypothermia risk, and known allergic reactions are reviewed. A safety check of the anesthesia equipment and oxygen saturation value is monitored. Time-out takes place before the surgical incision and includes presentation of each team member by name and role or confirmation that they are acquainted. The team also confirms that it is the correct operation on the correct patient and site. There is a discussion of anticipated critical events and of the use of antibiotic prophylaxis; essential imaging is displayed if needed. Signout takes place after the procedure, before the patient leaves the operating room (OR), with the completion of an instrument count and the labeling of specimens. Any problems with equipment and postoperative prescriptions and instructions are reviewed.2,5 Previous research indicates that the implementation of a checklist can decrease both the number of communication failures in the OR and the number of complications from surgery.2,6,7 It can also reduce the risk of wrong-site surgery.8 There are some concerns about whether to use the checklist in emergency situations, due to possible delay. However, complications are more common with emergency surgery and could potentially be reduced if the checklist is used.1 It has also been suggested that use of the WHO checklist is associated with the development of a better safety attitude among OR staff.9,10 With the introduction of each staff member, more of a sense of team can be created.9 The purpose of the introductions is to ensure that all personnel know each other and feel included and free to speak about any issues during the surgical procedure. However, the introduction can sometimes seem unnecessary if the members already know each other.11 Surgical departments have implemented the checklist both nationally and internationally. However, despite significant decreases in both postoperative morbidity and mortality,12 there remains low use of the checklist.1,11,13,14 A recent study from Sweden investigated deviations from Time-out and found
469
that it was not always applied as intended and that the component that facilitates communication was often neglected. The study also found that in general, surgeons and nurse anesthetists did most of the talking during the Time-out.14 In Sweden, a nurse anesthetist has an independent responsibility for the anesthetic care of the patient.15 This includes being one step ahead when planning care by identifying each patient’s risk factors as well as being aware of the complications that can arise.16 It is therefore of interest to enlist nurse anesthetists to use the checklist, as well as to know their opinion of it.
Aim The aim of this study was to describe Swedish registered nurse anesthetists’ (RNA) experience with the WHO surgical safety checklist.
Methods Sample and Settings A cross-sectional study with a descriptive mixed methods design was performed at two hospitals in Sweden, a university hospital and a community hospital. The study took place during 3 days in December 2011. The survey was carried out among RNAs who were on duty during the data collection period. A total of 68 RNAs were eligible for participation, and 47 (69%) answered the questionnaire. The Questionnaire The structured questionnaire (see Appendix 1 for details) was constructed by the authors for the purpose of this study and based on a review of the literature concerning implementation of, attitudes towards, and utility of the WHO checklist, as well as their own clinical experience as RNAs. An expert group consisting of two nurse anesthetists and two anesthesiologists with experience in using the checklist evaluated the questionnaire’s validity. The experts suggested some minor revisions, but no changes in the main content of the questionnaire were suggested or made. The experts were not included in the main study. The questionnaire addressed the following issues: compliance with the checklist: the usage of the three different parts, and the RNAs’
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opinion of the value of it, assessed by a numeric rating scale from 0 to10 participation by team members: education on and modification of the checklist assessed by ‘‘yes’’ or ‘‘ no’’ and by open-ended answers profession of the initiator and the person responsible for the usage positive and/or negative effects of the implementation of the checklist assessed by openended answers. The participants’ age, sex, and work experience were also collected. Data Collection Verbal and written information about the study was given during staff meetings and the questionnaire distributed to the OR departments by the researchers. The participants answered the questionnaire anonymously in the OR department. They were given 3 days to answer the questionnaire. No reminder was given. The participants were asked to reflect on their last working day when answering the questions. The questionnaire took approximately 5 minutes to complete. Ethical Considerations The study followed common ethical principles in clinical research including informed consent according to the Ethical Review of Research Involving Humans (2003:460) and was approved by the head of the OR department and the Ethics Committee at Ume a University. The participants were informed that participation was voluntary, that all answers would be treated with confidentiality, and that their participation would not have any impact on their working conditions. Data Analysis Number, percent, mean, and median were calculated for the different variables. For statistical comparisons, the Chi-square test, Mann-Whitney U test, and ANOVA with a Bonferroni adjustment were used. Statistical significance was set to a Pvalue , .05. SPSS 18.0 for Windows software (SPSS, Statistics for Research Methods and Social Science Statistics Inc., Chicago, IL) was used when performing all tests. Analysis of open-ended questions was made based on qualitative content analysis as presented by Graneheim and Lundman.17
Results A total of 47 participants were included in the study, 26 women and 21 men, with a mean age of 44 and with a mean RNA working experience of 14 years (Table 1). The RNAs rated compliance with the checklist in general as 6.0 (range 1 to 10). There was a significant difference between use of Sign-in (3.0) compared with Time-out (7.0) and Sign-out (7.0), P 5 .001 (Table 2). The nurse anesthetists reported that Sign-in was performed by the nurse anesthetist and seldom included the other members of the surgical team. Some also noted that there was no need to confirm all the items in Sign-in as this information had already been checked before the patient entered the operating theatre. ‘‘I think we believe that we generally do not look upon it (Sign-In) as part of the checklist and are therefore not reflecting on it.’’ A majority of the RNAs, 81% (n 5 38), believed that all members of the surgical team were given the same opportunity to confirm their area of responsibility when using the checklist. However the nurse anesthetists noted that the surgeon was not always interested in what the other team members had to say, ‘‘Some think it is something that is unnecessary and inconvenient, especially surgeons’’. Surgeons also sometimes made their own version of the checklist. ‘‘It often happens that the surgeon has their own version of the checklist or are not following the order of the item, as well as they think that the checklist is over and done when they have finished their part of it.’’ Thirty-four percent (n 5 16) of the RNAs believed that the surgeon was responsible for the checklist. This was not the reality in clinical practice, however, as nobody reported that the Table 1. Characteristics of Participants n 5 47 Gender, n (%) Male Female Age (y), mean (min to max) Number of year as RNA, mean (min to max) Hospital, n (%) University Community RNA, registered nurse anesthetist.
21 (45) 26 (55) 44 (30 to 64) 14 (1 to 40)
29 (62) 18 (38)
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Table 2. Registered Nurse Anesthetists Experience With the WHO Surgical Checklist Scale
n 5 47 Median (min to max)
0 5 never to 10 5 always 0 5 low to 10 5 high 0 5 low to 10 5 high 0 5 low to 10 5 high 0 5 low to 10 5 high
6.0 (1 to 10) 3.0 (0 to 10) 7.0 (1 to 10) 7.0 (1 to 10) 9.0 (0 to 10)
Questionnaire issues Compliance to the checklist Use of Sign-in Use of Time-out Use of Sign-out Importance for the RNAs’ work
WHO, World Health Organization; RNA, registered nurse anesthetist.
surgeon was the initiator. Instead, 23% of the RNAs (n 5 11) reported that they initiated use of the checklist, yet only one believed that it was the RNA’s responsibility. Responsibility for the checklist differed as to which profession initiated it and some (9%) noted that it was the nurse assistant (scrub nurse) who initiated the use of it.
sible for it. This could lead to irritation and tension between the members. Some of the RNAs also thought that the checklist was time consuming. ‘‘Extra workload that doesn’t add anything to patients’ safety.’’ It also emerged that some felt that the presentation of all of the team members sometimes wasted time.
All RNAs responded that the checklist was available in their department, but only 43% (n 5 20) had received any education about its use. Twenty-one percent (n 5 10) reported that the checklist had undergone some modification to fit the different specialties or specific surgeries in their departments, for example, to more easily correspond to the usual routines for a caesarian section, ear, nose, and throat surgeries, or neurosurgeries.
Discussion
The nurse anesthetists believed that the checklist was very important to their perioperative care and when conducting anesthesia. A positive outcome of the implementation of the checklist was expressed as the presentation of all team members and the opportunity to confirm each one’s area of expertise, contributing to an increased sense of being on a team. ‘‘Everyone in the operating theater has a specific role and is important for the patient undergoing surgery. It is nice that everyone presents themself for each other in the team because it was not obvious before (the implementation of the checklist), strange enough!’’ They also thought that patient safety had increased due to a more systematic checking of the patient’s identity, the nature of the surgery, and the site marking of paired organs. The nurse anesthetists also noted that the checklist facilitated their anesthetic and perioperative care and highlighted if there were any missed drug prescriptions. A negative aspect of the checklist was the lack of clarity around which team members were respon-
Results showed that nurse anesthetists believed that the checklist was very important for anesthetic and perioperative care and that this could lead to increased patient safety. They also expressed that by confirming their own area of expertise, they achieved an increased sense of being a team member. We believe, and it is also our own experience as RNA’s, that in particular the ‘‘Anticipated critical events’’ in Time-out have contributed to this feeling. ‘‘Anticipated critical events’’ include the surgeon’s critical events, non-routine steps, duration of the surgery, and anticipated blood loss. Before the implementation of the checklist, this was seldom discussed with the nurse anesthetist and the nurse anesthetist seldom had the opportunity to discuss specific patient concerns. In Sweden, the RNA is a registered nurse who has completed specialist education in anaesthesia care at an advanced level. An RNA independently induces, maintains, and ends general anaesthesia for healthy patients (ie, in physical function assessment class I-II as per the American Society of Anesthesiologists, ASA) as prescribed by an anesthesiologist. For patients with severe disease, that is, ASA III-V, the RNA works together with an anesthesiologist.15 This means that the RNA often performs the anaesthesia and perioperative care without an anesthesiologist present. Anesthetic and perioperative care is built on understanding and respect for the patient, confidence, and commitment.18 It implies being
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one step ahead by identifying each patient’s risk factors as well as being aware of the complications that can arise.16 The ‘‘Anticipated critical events’’ are therefore essential to patient safety. Participating in the WHO checklist increases the RNAs’ sense of being on a team.2,6,7,11,13,19 However, the interdisciplinary communication and cooperation seems not to have led to any long-term improvements. It has also been emphasized that although there is a brief improvement in communication and cooperation, the surgeons regarded the quality of interprofessional cooperation as higher than the anesthesiologists and nurse anesthetists.18 In our results, it was surprising that there was a consensus that the RNA thought that the surgeon should be responsible for the checklist. This was not reality in clinical practice as who is in charge of the checklist is unfortunately not clearly stated. It has been argued that surgeons acting as team leaders reject team-based and collaborative practices and many are offended by the notion that someone is ‘‘going to tell me how to run my operating room.’’20 They are thus unwilling to change their behavior and practice,21 even if scientific research suggests otherwise. The character of communication is sometimes a consequence of personal differences and the interpersonal conflicts that arise from these differences, which often occur between physicians and nurses. In the face of this, communication breakdown is one of the leading factors contributing to surgical errors and adverse effects related to patient management, omission, diagnosis, treatment, and commission as well as medication-related errors.22 Despite the checklist being available in both departments and the RNAs in our study believing that its use is important, Sign-in compliance was low. The explanation was that the information had already been checked before the patient entered the operating theater. Mahajan14 asserts that only using parts of the checklist can lead to a false sense of security. It can also lead to tensions between the different staff members on the surgical team if they do not agree on how and when to use the checklist.14 Our study also highlighted a need for checklist education as only 43% of the RNAs had any training.
We can only speculate; however, we think that this low training rate is similar for other team members. It is very important that all OR staff receive an appropriate checklist education including its history and research, outcomes, and use. An annual ‘‘refresher courses’’ should also be implemented. The OR department should address which profession/person on the team is ‘‘in charge’’ of the checklist. Reports show that for successful implementation and longtime adoption, it is important that all team members experience working as a team with a shared task.14 All users should understand that the checklist may not fit every situation and that individualization may be necessary; however, modification should be done collaboratively with all the team members and undertaken with a critical eye.5
Limitations We concede some methodological weaknesses in our study. The sample size was small with an acceptable response rate of 69%. Perhaps the response rate would have been higher if a reminder had been sent out or if the questionnaire had been mailed. Since our aim was to describe the RNAs’ experience of the checklist, we used a study-specific questionnaire, as there was no such questionnaire developed previously. Our questionnaire was not psychometrically tested, but an expert group evaluated its validity. Furthermore, this study could have been improved by adding data that showed if the check-list worked. Regardless of the small sample size and selfconstructed questionnaire, we believe that we captured the nurse anesthetist experiences with the WHO surgical checklist. However, further studies are needed to confirm this.
Conclusion In conclusion, for Swedish nurse anesthetists, the WHO surgical checklist increases a sense of being a team member. It facilitates the nurse anesthetists’ anesthetic and perioperative care, allowing the nurse anesthetist to be one step ahead by identifying each patient’s specific concerns.
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References 1. Weiser TG, Haynes AB, Dziekan G, Berry WR, Lipsitz SR, Gawande AA. Effect of a 19-item surgical safety checklist during urgent operations in a global patient population. Ann Surg. 2010;251:976-980. 2. Haynes AB, Weiser TG, Berry WR, et al. A surgical safety checklist to reduce morbidity and mortality in a global population. N Engl J Med. 2009;360:491-499. 3. Weiser TG, Regenbogen SE, Thompson KD, et al. An estimation of the global volume of surgery: A modeling strategy based on available data. Lancet. 2008;372:139-144. 4. The National Board of Health and Welfare V ardskador inom somatisk slutenv ard. (Swedish). Available at: http://www. socialstyrelsen.se/publikationer2008/2008-109-16. Accessed June 2, 2013. 5. World Health Organization. Implementation Manual WHO Surgical Safety Checklist 2009. Safe Surgery Saves Lives. Available at: http://whqlibdoc.who.int/publications/ 2009/9789241598590_eng.pdf. Accessed April 10, 2012. 6. Lingard L, Espin S, Rubin B, et al. Getting teams to talk: Development and pilot implementation of a checklist to promote interprofessional communication in the OR. Qual Saf Health Care. 2005;14:340-346. 7. Lingard L, Regehr G, Orser B, et al. Evaluation of a preoperative checklist and team briefing among surgeons, nurses and anesthesiologists to reduce failures in communication. Arch Surg. 2008;143:12-17. 8. Makary MA, Mukherjee A, Sexton BJ, et al. Operating room briefings and wrong-site surgery. J Am Coll Surg. 2007;204: 236-243. 9. Bell R. How implementing the surgical safety checklist improved staff teamwork in theatre. Nurs Times. 2010;106:12. 10. Haynes AB, Weiser TG, Berry WR, et al. Safe Surgery Saves Lives Study Group. Changes in safety attitude and relationship to decreased postoperative morbidity and mortality following implementation of a checklist-based surgical safety intervention. Qual Saf Health Care. 2011;20:102-107. 11. Nilsson L, Lindberget O, Gupta A, Vegfors M. Implementing a pre-operative checklist to increase patient safety: A 1-year follow-up of personnel attitudes. Acta Anaesthesiol Scand. 2010;54:176-182.
12. van Klei WA, Hoff RG, van Aarnhem EE, et al. Effects of the introduction of the WHO ‘‘Surgical Safety Checklist’’ on in-hospital mortality: A cohort study. Ann Surg. 2012;255: 44-49. 13. Rydenf€a lt C, Johansson G, Odenrick P, Akerman K, Larsson PA. Compliance with the WHO Surgical Safety Checklist: Deviations and possible improvements. Int J Qual Health Care. 2013;25:182-187. 14. Mahajan RP. The WHO surgical checklist. Best Pract Res Clin Anaesthesiol. 2011;25:161-168. 15. Description of competence for registered nurse with graduate diploma in specialist nursing—anaesthesia care. Riksf€ oreningen f€ or anestesi och intensivv ard & Svensk sjuksk€ oterskef€ orening—SSF. Available at: http://www.swenurse. se/Documents/Komptensbeskrivningar/kompetensbeskrivn% 20anestesi.pdf. Accessed June 2, 2013. 16. Sundquist A-S, Anderzen-Carlsson A. Holding the patient’s life in my hands: Swedish nurse anaesthetists’ perspective of advocacy. Scand J Caring Sci. 2014;28:281-288. 17. Graneheim UH, Lundman B. Qualitative content analysis in nursing research: Concepts, procedures and measures to achieve trustworthiness. Nurse Educ Today. 2004;24: 105-112. 18. Nilsson UG. Intraoperative positioning of patients under general anesthesia and the risk of postoperative pain and pressure ulcers. J Perianesth Nurs. 2013;28:137-143. 19. B€ ohmer AB, Kindermann P, Schwanke U, et al. Longterm effects of a perioperative safety checklist from the viewpoint of personnel. Acta Anaesthesiol Scand. 2013;57: 150-157. 20. Healy G, Barker J, Madonna J. Error reduction through team leadership: Applying aviation’s CRM model in the OR. Bull Am Coll Surg. 2006;91:10-15. 21. Grimshaw JM, Eccles MP, Walker AE, Thomas RE. Changing physicians’ behavior: What works and thoughts on getting more things to work. J Contin Educ Health Prof. 2002;22: 237-243. 22. Sutcliffe KM, Lewton E, Rosenthal MM. Communication failures: An insidious contributor to medical mishaps. Acad Med. 2004;79:186-194.
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Appendix 1 Questionnaire regarding the use of the WHO surgical safety checklist Please make a reflection regarding the use of WHO’s surgical safety checklist in general, and then think about your latest working period when you are answering the following questions. Answer the questions by marking one option and then briefly answer the follow-up issue. 1. Grade your experience regarding the compliance to the checklist in general?
0 1 Very low
2
3
4
5
6
7
8
9 10 Very high
2. How often is Sign-in used?
0 1 2 3 4 5 6 7 8 9 10 Never Always Motivate:............................... 3. How often is Timeout used?
0 1 2 3 4 5 6 7 8 9 10 Never Always Motivate:.............................. 4. How often is Sign-out used?
0 1 2 3 4 5 6 7 8 9 10 Never Always Motivate:.............................. 5. When the checklist is used, are all of the members in the team given the same opportunity to confirm their own parts? , YES , NO
If NO, who and why? ......................
6. Who’s the usual initiator to use the checklist? .................... 7. Have you been given any education about the use of the checklist? , YES , NO 8. Has the checklist been modified to fit your routines? , YES , NO , DONT KNOW
If YES: in what way? .........................
9. Is the checklist available at your place of work? , YES , NO 10. Who is responsible for the use of the checklist, in your opinion?
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11. Do you believe that the checklist is of some value for your work?
0 1 No value
2
3
4
5
6
7
8
9 10 Great value
12. Has the checklist brought something positive? .......... 13. Has the checklist brought something negative? ..........
aims to increase communication, build teamwork, and standardize routines in clinical practice in an effort to reduce complications and improve patient safety. The checklist has been implemented in surgical departments both nationally and internationally. The purpose of this study was to describe the registered nurse anesthetists’ (RNA) experience with the use of the WHO surgical safety checklist. Design: This was a cross-sectional study with a descriptive mixed methods design, involving nurse anesthetists from two different hospitals in Sweden. Methods: Data were collected using a study-specific questionnaire. Findings: Forty-seven RNAs answered the questionnaire. There was a statistically significant lower compliance to ‘‘Sign-in’’ compared with the other two parts, ‘‘Timeout’’ and ‘‘Sign-out.’’ The RNAs expressed that the checklist was very important for anesthetic and perioperative care. They also expressed that by confirming their own area of expertise, they achieved an increased sense of being a team member. Thirty-four percent believed that the surgeon was responsible for the checklist, yet this was not the reality in clinical practice. Although 23% reported that they initiated use of the checklist, only one RNA believed that it was the responsibility of the RNA. Forty-three percent had received training about the checklist and its use. Conclusion: The WHO surgical checklist facilitates the nurse anesthetist’s anesthetic and perioperative care. It allows the nurse anesthetist to better identify each patient’s specific concerns and have an increased sense of being a team member. Keywords: WHO checklist, patient safety, registered nurse anesthetist’s (RNA), compliance, team, research. Ó 2015 by American Society of PeriAnesthesia Nurses
PATIENTS UNDERGOING SURGERY are at risk for complications. Communication, lack of time, and urgent surgical procedures often contribute
Linda R€ onnberg, MScN, RNA, Department of Nursing, Ume a University, Sweden; Department of Anaesthesia, € Ostersunds Hospital, Sweden; and Ulrica Nilsson, PhD, RNA, € is a Professor, School of Health and Medical Sciences, Orebro € University, SE 701 82 Orebro, Sweden. Conflicts of interest: None to report. Address correspondence to Ulrica Nilsson, School of Health € € and Medical Sciences, Orebro University, SE 701 82 Orebro, Sweden; e-mail address: [email protected]. Ó 2015 by American Society of PeriAnesthesia Nurses 1089-9472/$36.00 http://dx.doi.org/10.1016/j.jopan.2014.01.011
468
to these complications.1 While complications during or after surgery are common, most of them are preventable.2 Of the 234 million surgical procedures done annually, seven million patients suffered complications, including one million who died during or immediately after surgery.3 Complications are costly. Structured safety approaches are assumed to benefit both the patient and the health care system.4 The World Health Organization (WHO) developed a surgical safety checklist aimed to improve patient safety and decrease complications.5 The WHO checklist is divided into three parts— ‘‘Sign-in,’’ ‘‘Time out,’’ and ‘‘Sign-out’’—with a
Journal of PeriAnesthesia Nursing, Vol 30, No 6 (December), 2015: pp 468-475
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verbal confirmation of each step. Sign-in takes place before the induction of anesthesia and includes confirmation of the patient’s identity, procedure, site (marked, if appropriate), and consent. Anticipated risk of blood loss, airway difficulty, hypothermia risk, and known allergic reactions are reviewed. A safety check of the anesthesia equipment and oxygen saturation value is monitored. Time-out takes place before the surgical incision and includes presentation of each team member by name and role or confirmation that they are acquainted. The team also confirms that it is the correct operation on the correct patient and site. There is a discussion of anticipated critical events and of the use of antibiotic prophylaxis; essential imaging is displayed if needed. Signout takes place after the procedure, before the patient leaves the operating room (OR), with the completion of an instrument count and the labeling of specimens. Any problems with equipment and postoperative prescriptions and instructions are reviewed.2,5 Previous research indicates that the implementation of a checklist can decrease both the number of communication failures in the OR and the number of complications from surgery.2,6,7 It can also reduce the risk of wrong-site surgery.8 There are some concerns about whether to use the checklist in emergency situations, due to possible delay. However, complications are more common with emergency surgery and could potentially be reduced if the checklist is used.1 It has also been suggested that use of the WHO checklist is associated with the development of a better safety attitude among OR staff.9,10 With the introduction of each staff member, more of a sense of team can be created.9 The purpose of the introductions is to ensure that all personnel know each other and feel included and free to speak about any issues during the surgical procedure. However, the introduction can sometimes seem unnecessary if the members already know each other.11 Surgical departments have implemented the checklist both nationally and internationally. However, despite significant decreases in both postoperative morbidity and mortality,12 there remains low use of the checklist.1,11,13,14 A recent study from Sweden investigated deviations from Time-out and found
469
that it was not always applied as intended and that the component that facilitates communication was often neglected. The study also found that in general, surgeons and nurse anesthetists did most of the talking during the Time-out.14 In Sweden, a nurse anesthetist has an independent responsibility for the anesthetic care of the patient.15 This includes being one step ahead when planning care by identifying each patient’s risk factors as well as being aware of the complications that can arise.16 It is therefore of interest to enlist nurse anesthetists to use the checklist, as well as to know their opinion of it.
Aim The aim of this study was to describe Swedish registered nurse anesthetists’ (RNA) experience with the WHO surgical safety checklist.
Methods Sample and Settings A cross-sectional study with a descriptive mixed methods design was performed at two hospitals in Sweden, a university hospital and a community hospital. The study took place during 3 days in December 2011. The survey was carried out among RNAs who were on duty during the data collection period. A total of 68 RNAs were eligible for participation, and 47 (69%) answered the questionnaire. The Questionnaire The structured questionnaire (see Appendix 1 for details) was constructed by the authors for the purpose of this study and based on a review of the literature concerning implementation of, attitudes towards, and utility of the WHO checklist, as well as their own clinical experience as RNAs. An expert group consisting of two nurse anesthetists and two anesthesiologists with experience in using the checklist evaluated the questionnaire’s validity. The experts suggested some minor revisions, but no changes in the main content of the questionnaire were suggested or made. The experts were not included in the main study. The questionnaire addressed the following issues: compliance with the checklist: the usage of the three different parts, and the RNAs’
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470
opinion of the value of it, assessed by a numeric rating scale from 0 to10 participation by team members: education on and modification of the checklist assessed by ‘‘yes’’ or ‘‘ no’’ and by open-ended answers profession of the initiator and the person responsible for the usage positive and/or negative effects of the implementation of the checklist assessed by openended answers. The participants’ age, sex, and work experience were also collected. Data Collection Verbal and written information about the study was given during staff meetings and the questionnaire distributed to the OR departments by the researchers. The participants answered the questionnaire anonymously in the OR department. They were given 3 days to answer the questionnaire. No reminder was given. The participants were asked to reflect on their last working day when answering the questions. The questionnaire took approximately 5 minutes to complete. Ethical Considerations The study followed common ethical principles in clinical research including informed consent according to the Ethical Review of Research Involving Humans (2003:460) and was approved by the head of the OR department and the Ethics Committee at Ume a University. The participants were informed that participation was voluntary, that all answers would be treated with confidentiality, and that their participation would not have any impact on their working conditions. Data Analysis Number, percent, mean, and median were calculated for the different variables. For statistical comparisons, the Chi-square test, Mann-Whitney U test, and ANOVA with a Bonferroni adjustment were used. Statistical significance was set to a Pvalue , .05. SPSS 18.0 for Windows software (SPSS, Statistics for Research Methods and Social Science Statistics Inc., Chicago, IL) was used when performing all tests. Analysis of open-ended questions was made based on qualitative content analysis as presented by Graneheim and Lundman.17
Results A total of 47 participants were included in the study, 26 women and 21 men, with a mean age of 44 and with a mean RNA working experience of 14 years (Table 1). The RNAs rated compliance with the checklist in general as 6.0 (range 1 to 10). There was a significant difference between use of Sign-in (3.0) compared with Time-out (7.0) and Sign-out (7.0), P 5 .001 (Table 2). The nurse anesthetists reported that Sign-in was performed by the nurse anesthetist and seldom included the other members of the surgical team. Some also noted that there was no need to confirm all the items in Sign-in as this information had already been checked before the patient entered the operating theatre. ‘‘I think we believe that we generally do not look upon it (Sign-In) as part of the checklist and are therefore not reflecting on it.’’ A majority of the RNAs, 81% (n 5 38), believed that all members of the surgical team were given the same opportunity to confirm their area of responsibility when using the checklist. However the nurse anesthetists noted that the surgeon was not always interested in what the other team members had to say, ‘‘Some think it is something that is unnecessary and inconvenient, especially surgeons’’. Surgeons also sometimes made their own version of the checklist. ‘‘It often happens that the surgeon has their own version of the checklist or are not following the order of the item, as well as they think that the checklist is over and done when they have finished their part of it.’’ Thirty-four percent (n 5 16) of the RNAs believed that the surgeon was responsible for the checklist. This was not the reality in clinical practice, however, as nobody reported that the Table 1. Characteristics of Participants n 5 47 Gender, n (%) Male Female Age (y), mean (min to max) Number of year as RNA, mean (min to max) Hospital, n (%) University Community RNA, registered nurse anesthetist.
21 (45) 26 (55) 44 (30 to 64) 14 (1 to 40)
29 (62) 18 (38)
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Table 2. Registered Nurse Anesthetists Experience With the WHO Surgical Checklist Scale
n 5 47 Median (min to max)
0 5 never to 10 5 always 0 5 low to 10 5 high 0 5 low to 10 5 high 0 5 low to 10 5 high 0 5 low to 10 5 high
6.0 (1 to 10) 3.0 (0 to 10) 7.0 (1 to 10) 7.0 (1 to 10) 9.0 (0 to 10)
Questionnaire issues Compliance to the checklist Use of Sign-in Use of Time-out Use of Sign-out Importance for the RNAs’ work
WHO, World Health Organization; RNA, registered nurse anesthetist.
surgeon was the initiator. Instead, 23% of the RNAs (n 5 11) reported that they initiated use of the checklist, yet only one believed that it was the RNA’s responsibility. Responsibility for the checklist differed as to which profession initiated it and some (9%) noted that it was the nurse assistant (scrub nurse) who initiated the use of it.
sible for it. This could lead to irritation and tension between the members. Some of the RNAs also thought that the checklist was time consuming. ‘‘Extra workload that doesn’t add anything to patients’ safety.’’ It also emerged that some felt that the presentation of all of the team members sometimes wasted time.
All RNAs responded that the checklist was available in their department, but only 43% (n 5 20) had received any education about its use. Twenty-one percent (n 5 10) reported that the checklist had undergone some modification to fit the different specialties or specific surgeries in their departments, for example, to more easily correspond to the usual routines for a caesarian section, ear, nose, and throat surgeries, or neurosurgeries.
Discussion
The nurse anesthetists believed that the checklist was very important to their perioperative care and when conducting anesthesia. A positive outcome of the implementation of the checklist was expressed as the presentation of all team members and the opportunity to confirm each one’s area of expertise, contributing to an increased sense of being on a team. ‘‘Everyone in the operating theater has a specific role and is important for the patient undergoing surgery. It is nice that everyone presents themself for each other in the team because it was not obvious before (the implementation of the checklist), strange enough!’’ They also thought that patient safety had increased due to a more systematic checking of the patient’s identity, the nature of the surgery, and the site marking of paired organs. The nurse anesthetists also noted that the checklist facilitated their anesthetic and perioperative care and highlighted if there were any missed drug prescriptions. A negative aspect of the checklist was the lack of clarity around which team members were respon-
Results showed that nurse anesthetists believed that the checklist was very important for anesthetic and perioperative care and that this could lead to increased patient safety. They also expressed that by confirming their own area of expertise, they achieved an increased sense of being a team member. We believe, and it is also our own experience as RNA’s, that in particular the ‘‘Anticipated critical events’’ in Time-out have contributed to this feeling. ‘‘Anticipated critical events’’ include the surgeon’s critical events, non-routine steps, duration of the surgery, and anticipated blood loss. Before the implementation of the checklist, this was seldom discussed with the nurse anesthetist and the nurse anesthetist seldom had the opportunity to discuss specific patient concerns. In Sweden, the RNA is a registered nurse who has completed specialist education in anaesthesia care at an advanced level. An RNA independently induces, maintains, and ends general anaesthesia for healthy patients (ie, in physical function assessment class I-II as per the American Society of Anesthesiologists, ASA) as prescribed by an anesthesiologist. For patients with severe disease, that is, ASA III-V, the RNA works together with an anesthesiologist.15 This means that the RNA often performs the anaesthesia and perioperative care without an anesthesiologist present. Anesthetic and perioperative care is built on understanding and respect for the patient, confidence, and commitment.18 It implies being
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one step ahead by identifying each patient’s risk factors as well as being aware of the complications that can arise.16 The ‘‘Anticipated critical events’’ are therefore essential to patient safety. Participating in the WHO checklist increases the RNAs’ sense of being on a team.2,6,7,11,13,19 However, the interdisciplinary communication and cooperation seems not to have led to any long-term improvements. It has also been emphasized that although there is a brief improvement in communication and cooperation, the surgeons regarded the quality of interprofessional cooperation as higher than the anesthesiologists and nurse anesthetists.18 In our results, it was surprising that there was a consensus that the RNA thought that the surgeon should be responsible for the checklist. This was not reality in clinical practice as who is in charge of the checklist is unfortunately not clearly stated. It has been argued that surgeons acting as team leaders reject team-based and collaborative practices and many are offended by the notion that someone is ‘‘going to tell me how to run my operating room.’’20 They are thus unwilling to change their behavior and practice,21 even if scientific research suggests otherwise. The character of communication is sometimes a consequence of personal differences and the interpersonal conflicts that arise from these differences, which often occur between physicians and nurses. In the face of this, communication breakdown is one of the leading factors contributing to surgical errors and adverse effects related to patient management, omission, diagnosis, treatment, and commission as well as medication-related errors.22 Despite the checklist being available in both departments and the RNAs in our study believing that its use is important, Sign-in compliance was low. The explanation was that the information had already been checked before the patient entered the operating theater. Mahajan14 asserts that only using parts of the checklist can lead to a false sense of security. It can also lead to tensions between the different staff members on the surgical team if they do not agree on how and when to use the checklist.14 Our study also highlighted a need for checklist education as only 43% of the RNAs had any training.
We can only speculate; however, we think that this low training rate is similar for other team members. It is very important that all OR staff receive an appropriate checklist education including its history and research, outcomes, and use. An annual ‘‘refresher courses’’ should also be implemented. The OR department should address which profession/person on the team is ‘‘in charge’’ of the checklist. Reports show that for successful implementation and longtime adoption, it is important that all team members experience working as a team with a shared task.14 All users should understand that the checklist may not fit every situation and that individualization may be necessary; however, modification should be done collaboratively with all the team members and undertaken with a critical eye.5
Limitations We concede some methodological weaknesses in our study. The sample size was small with an acceptable response rate of 69%. Perhaps the response rate would have been higher if a reminder had been sent out or if the questionnaire had been mailed. Since our aim was to describe the RNAs’ experience of the checklist, we used a study-specific questionnaire, as there was no such questionnaire developed previously. Our questionnaire was not psychometrically tested, but an expert group evaluated its validity. Furthermore, this study could have been improved by adding data that showed if the check-list worked. Regardless of the small sample size and selfconstructed questionnaire, we believe that we captured the nurse anesthetist experiences with the WHO surgical checklist. However, further studies are needed to confirm this.
Conclusion In conclusion, for Swedish nurse anesthetists, the WHO surgical checklist increases a sense of being a team member. It facilitates the nurse anesthetists’ anesthetic and perioperative care, allowing the nurse anesthetist to be one step ahead by identifying each patient’s specific concerns.
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References 1. Weiser TG, Haynes AB, Dziekan G, Berry WR, Lipsitz SR, Gawande AA. Effect of a 19-item surgical safety checklist during urgent operations in a global patient population. Ann Surg. 2010;251:976-980. 2. Haynes AB, Weiser TG, Berry WR, et al. A surgical safety checklist to reduce morbidity and mortality in a global population. N Engl J Med. 2009;360:491-499. 3. Weiser TG, Regenbogen SE, Thompson KD, et al. An estimation of the global volume of surgery: A modeling strategy based on available data. Lancet. 2008;372:139-144. 4. The National Board of Health and Welfare V ardskador inom somatisk slutenv ard. (Swedish). Available at: http://www. socialstyrelsen.se/publikationer2008/2008-109-16. Accessed June 2, 2013. 5. World Health Organization. Implementation Manual WHO Surgical Safety Checklist 2009. Safe Surgery Saves Lives. Available at: http://whqlibdoc.who.int/publications/ 2009/9789241598590_eng.pdf. Accessed April 10, 2012. 6. Lingard L, Espin S, Rubin B, et al. Getting teams to talk: Development and pilot implementation of a checklist to promote interprofessional communication in the OR. Qual Saf Health Care. 2005;14:340-346. 7. Lingard L, Regehr G, Orser B, et al. Evaluation of a preoperative checklist and team briefing among surgeons, nurses and anesthesiologists to reduce failures in communication. Arch Surg. 2008;143:12-17. 8. Makary MA, Mukherjee A, Sexton BJ, et al. Operating room briefings and wrong-site surgery. J Am Coll Surg. 2007;204: 236-243. 9. Bell R. How implementing the surgical safety checklist improved staff teamwork in theatre. Nurs Times. 2010;106:12. 10. Haynes AB, Weiser TG, Berry WR, et al. Safe Surgery Saves Lives Study Group. Changes in safety attitude and relationship to decreased postoperative morbidity and mortality following implementation of a checklist-based surgical safety intervention. Qual Saf Health Care. 2011;20:102-107. 11. Nilsson L, Lindberget O, Gupta A, Vegfors M. Implementing a pre-operative checklist to increase patient safety: A 1-year follow-up of personnel attitudes. Acta Anaesthesiol Scand. 2010;54:176-182.
12. van Klei WA, Hoff RG, van Aarnhem EE, et al. Effects of the introduction of the WHO ‘‘Surgical Safety Checklist’’ on in-hospital mortality: A cohort study. Ann Surg. 2012;255: 44-49. 13. Rydenf€a lt C, Johansson G, Odenrick P, Akerman K, Larsson PA. Compliance with the WHO Surgical Safety Checklist: Deviations and possible improvements. Int J Qual Health Care. 2013;25:182-187. 14. Mahajan RP. The WHO surgical checklist. Best Pract Res Clin Anaesthesiol. 2011;25:161-168. 15. Description of competence for registered nurse with graduate diploma in specialist nursing—anaesthesia care. Riksf€ oreningen f€ or anestesi och intensivv ard & Svensk sjuksk€ oterskef€ orening—SSF. Available at: http://www.swenurse. se/Documents/Komptensbeskrivningar/kompetensbeskrivn% 20anestesi.pdf. Accessed June 2, 2013. 16. Sundquist A-S, Anderzen-Carlsson A. Holding the patient’s life in my hands: Swedish nurse anaesthetists’ perspective of advocacy. Scand J Caring Sci. 2014;28:281-288. 17. Graneheim UH, Lundman B. Qualitative content analysis in nursing research: Concepts, procedures and measures to achieve trustworthiness. Nurse Educ Today. 2004;24: 105-112. 18. Nilsson UG. Intraoperative positioning of patients under general anesthesia and the risk of postoperative pain and pressure ulcers. J Perianesth Nurs. 2013;28:137-143. 19. B€ ohmer AB, Kindermann P, Schwanke U, et al. Longterm effects of a perioperative safety checklist from the viewpoint of personnel. Acta Anaesthesiol Scand. 2013;57: 150-157. 20. Healy G, Barker J, Madonna J. Error reduction through team leadership: Applying aviation’s CRM model in the OR. Bull Am Coll Surg. 2006;91:10-15. 21. Grimshaw JM, Eccles MP, Walker AE, Thomas RE. Changing physicians’ behavior: What works and thoughts on getting more things to work. J Contin Educ Health Prof. 2002;22: 237-243. 22. Sutcliffe KM, Lewton E, Rosenthal MM. Communication failures: An insidious contributor to medical mishaps. Acad Med. 2004;79:186-194.
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Appendix 1 Questionnaire regarding the use of the WHO surgical safety checklist Please make a reflection regarding the use of WHO’s surgical safety checklist in general, and then think about your latest working period when you are answering the following questions. Answer the questions by marking one option and then briefly answer the follow-up issue. 1. Grade your experience regarding the compliance to the checklist in general?
0 1 Very low
2
3
4
5
6
7
8
9 10 Very high
2. How often is Sign-in used?
0 1 2 3 4 5 6 7 8 9 10 Never Always Motivate:............................... 3. How often is Timeout used?
0 1 2 3 4 5 6 7 8 9 10 Never Always Motivate:.............................. 4. How often is Sign-out used?
0 1 2 3 4 5 6 7 8 9 10 Never Always Motivate:.............................. 5. When the checklist is used, are all of the members in the team given the same opportunity to confirm their own parts? , YES , NO
If NO, who and why? ......................
6. Who’s the usual initiator to use the checklist? .................... 7. Have you been given any education about the use of the checklist? , YES , NO 8. Has the checklist been modified to fit your routines? , YES , NO , DONT KNOW
If YES: in what way? .........................
9. Is the checklist available at your place of work? , YES , NO 10. Who is responsible for the use of the checklist, in your opinion?
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11. Do you believe that the checklist is of some value for your work?
0 1 No value
2
3
4
5
6
7
8
9 10 Great value
12. Has the checklist brought something positive? .......... 13. Has the checklist brought something negative? ..........
