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1.  Action ethical dilemmas in surgery: an interview study of practicing surgeons 
BMC Medical Ethics  2005;6:7.
The aim of this study was to describe the kinds of ethical dilemmas surgeons face during practice.
Five male and five female surgeons at a University hospital in Norway were interviewed as part of a comprehensive investigation into the narratives of physicians and nurses about ethically difficult situations in surgical units. The transcribed interview texts were subjected to a phenomenological-hermeneutic interpretation.
No gender differences were found in the kinds of ethical dilemmas identified among male and female surgeons. The main finding was that surgeons experienced ethical dilemmas in deciding the right treatment in different situations. The dilemmas included starting or withholding treatment, continuing or withdrawing treatment, overtreatment, respecting the patients and meeting patients' expectations. The main focus in the narratives was on ethical dilemmas concerning the patients' well-being, treatment and care. The surgeons narrated about whether they should act according to their own convictions or according to the opinions of principal colleagues or colleagues from other departments. Handling incompetent colleagues was also seen as an ethical dilemma. Prioritization of limited resources and following social laws and regulations represented ethical dilemmas when they contradicted what the surgeons considered was in the patients' best interests.
The surgeons seemed confident in their professional role although the many ethical dilemmas they experienced in trying to meet the expectations of patients, colleagues and society also made them professionally and personally vulnerable.
PMCID: PMC1182373  PMID: 15996268
JAMA surgery  2013;148(1):29-35.
To examine surgeons’ experiences of conflict with intensivists and nurses about goals of care for their postoperative patients.
Cross-sectional incentivized U.S. mail-based survey.
Private and academic surgical practices.
2,100 vascular, neurological, and cardiothoracic surgeons.
Main Outcome Measures
Surgeon-reported rates of conflict with intensivists and nurses about goals of care in patients with poor post-surgical outcomes.
The adjusted response rate was 55.6%. Forty-three percent of surgeons report sometimes or always experiencing conflict about postoperative goals of care with intensivists, and 43% report conflict with nurses. Younger surgeons report higher rates of conflict than older surgeons with both intensivists (57 vs. 32%, p=0.001) and nurses (48 vs. 33%, p=0.001). Surgeons practicing in closed ICUs report more frequent conflict than those practicing in open ICUs (60 vs. 41% p=0.005). On multivariate analysis, the odds of reporting conflict with intensivists were 2.5 times higher for surgeons with fewer years of experience as compared to their older colleagues (OR: 2.5, 95% CI: 1.6-3.8) and 70% higher for reporting conflict with nurses (OR: 1.7, 95% CI: 1.1-2.6). The odds of reporting conflict with intensivists about goals of postoperative care were 40% lower for surgeons who primarily manage their ICU patients than for those who work in a closed unit (OR: 0.6, 95% CI: 0.4-0.96).
Surgeons regularly experience conflict with critical care clinicians about goals of care for patients with poor postoperative outcomes. Higher rates of conflict are associated with less experience and working in a closed ICU.
PMCID: PMC3624604  PMID: 23324837
3.  Facilitators and Barriers to Adopting Robotic-Assisted Surgery: Contextualizing the Unified Theory of Acceptance and Use of Technology 
PLoS ONE  2011;6(1):e16395.
Robotic-assisted surgical techniques are not yet well established among surgeon practice groups beyond a few surgical subspecialties. To help identify the facilitators and barriers to their adoption, this belief-elicitation study contextualized and supplemented constructs of the unified theory of acceptance and use of technology (UTAUT) in robotic-assisted surgery. Semi-structured individual interviews were conducted with 21 surgeons comprising two groups: users and nonusers. The main facilitators to adoption were Perceived Usefulness and Facilitating Conditions among both users and nonusers, followed by Attitude Toward Using Technology among users and Extrinsic Motivation among nonusers. The three main barriers to adoption for both users and nonusers were Perceived Ease of Use and Complexity, Perceived Usefulness, and Perceived Behavioral Control. This study's findings can assist surgeons, hospital and medical school administrators, and other policy makers on the proper adoption of robotic-assisted surgery and can guide future research on the development of theories and framing of hypotheses.
PMCID: PMC3024425  PMID: 21283719
4.  Current practice of abdominal fascial closure: a survey of Ontario general surgeons 
Canadian Journal of Surgery  2001;44(5):366-370.
To determine the current practice of abdominal fascial closure among provincial general surgeons. The primary objective was to determine the proportion of surgeons choosing absorbable versus nonabsorbable sutures. Secondary objectives included determining knowledge and attitudes of surgeons to evidence-based medicine and concordance of current practice with level I evidence.
A survey.
The province of Ontario.
One hundred general surgeons.
A stratified random sample of community and academic surgeons was assembled and a questionnaire was mailed to them. Common clinical scenarios and questions pertaining to attitudes and knowledge of evidence-based medicine were included.
Main outcome measures
Use of absorbable versus nonabsorbable suture material. Willingness to change current practice on evidence-based level I reports.
Most surgeons (86%) chose an absorbable suture for abdominal fascial closure. Nonabsorbable suture was chosen by 58% of surgeons in the highly contaminated surgical scenario. Eighty-one percent of surgeons indicated they would be willing to change their current practice of fascial closure if there was evidence that the incidence of wound complications was reduced. Polyglactin (Vicryl) was the most commonly chosen suture.
The current practice of abdominal fascial closure among Ontario general surgeons is in disagreement with the findings from a recent meta-analysis, recommending a nonabsorbable suture for a 32% relative risk reduction in the incisional hernia rate. The majority of surgeons employ a continuous absorbable closure in common surgical scenarios. A definitive randomized controlled trial comparing continuous nonabsorbable closure versus continuous absorbable closure is warranted.
PMCID: PMC3692644  PMID: 11603750
5.  Influence of the First Assistant on Abdominal Aortic Aneurysm Surgery 
The hypothesis that the type of first assistant who attends the surgeon influences the course and outcome of graft replacement for abdominal aortic aneurysm was tested. Surgical results were analyzed in 179 consecutive patients (149 men and 30 women; mean age, 69 ± 7.5 years). All the operations were performed by the author—an experienced surgeon with a practice limited to general vascular surgery. The choice of first assistant was based solely on availability; 110 (61%) patients had a board-certified surgeon as the first assistant and 69 (39%) had an experienced registered nurse as the first assistant. Patients with intact aneurysms undergoing elective surgery were in Group 1, and patients with intact aneurysms undergoing urgent surgery were in Group 2. Group 3 patients included those who had ruptured aneurysms but were hemodynamically stable, and Group 4 patients had ruptured aneurysms and were in shock. The distribution of patients was similar in each first-assistant group, as was the use of straight and bifurcated graft reconstructions, associated visceral procedures, and other adjunctive procedures. The hospital mortality was 4% (6/149) for Group 1 patients, 12% (2/17) for Group 2,20% (1/5) for Group 3, and 50% (4/8) for Group 4 patients. The morbidity and mortality rates were independent of the type of assistant, as were the operative time, blood loss, and adjusted blood transfusion volume. These results suggest that the choice of either an MD-surgeon or an experienced RN as first assistant does not influence the course or outcome of abdominal aortic aneurysm surgery. (Texas Heart Institute Journal 1992; 19:4-8)
PMCID: PMC325010  PMID: 15227463
Aneurysm; aneurysmectomy; aorta; aortic surgery
6.  Recapturing the History of Surgical Practice Through Simulation-based Re-enactment 
Medical History  2014;58(1):106-121.
This paper introduces simulation-based re-enactment (SBR) as a novel method of documenting and studying the recent history of surgical practice. SBR aims to capture ways of surgical working that remain within living memory but have been superseded due to technical advances and changes in working patterns. Inspired by broader efforts in historical re-enactment and the use of simulation within surgical education, SBR seeks to overcome some of the weaknesses associated with text-based, surgeon-centred approaches to the history of surgery. The paper describes how we applied SBR to a previously common operation that is now rarely performed due to the introduction of keyhole surgery: open cholecystectomy or removal of the gall bladder. Key aspects of a 1980s operating theatre were recreated, and retired surgical teams (comprising surgeon, anaesthetist and theatre nurse) invited to re-enact, and educate surgical trainees in this procedure. Video recording, supplemented by pre- and post-re-enactment interviews, enabled the teams’ conduct of this operation to be placed on the historical record. These recordings were then used to derive insights into the social and technical nature of surgical expertise, its distribution throughout the surgical team, and the members’ tacit and frequently sub-conscious ways of working. While acknowledging some of the limitations of SBR, we argue that its utility to historians – as well as surgeons – merits its more extensive application.
PMCID: PMC3866005  PMID: 24331217
Surgery; Expertise; Tacit Knowledge; Simulation; Re-enactment; Twentieth Century
7.  Treatment of carpal tunnel syndrome by members of the American Association for Hand Surgery 
Hand (New York, N.Y.)  2012;7(4):351-356.
Carpal tunnel syndrome (CTS) is the most common compressive neuropathy affecting the upper extremity, yet evidence-based guidelines for its diagnosis and treatment are lacking. We set out to expose any potential discrepancies in CTS practice attitudes based on surgeon’s academic background, residency training, clinical experience, and other factors.
This was an online survey-based study. Members of the American Association for Hand Surgery (AAHS) were sent an electronic mail request (n = 817). The online questionnaire consisted of 12 questions that queried surgeons’ approaches to the diagnosis as well as operative and non-operative management of carpal tunnel syndrome.
One hundred twenty-three surgeons responded to the survey (15.1 %). The locations of surgical practices varied within the United States and beyond. Most respondents were either orthopedic or plastic surgeons. With respect to practice duration, 15.4 % had been in practice for 5 years or less, 30.9 % of the respondents had been in practice between 6 and 15 years, 30.9 % had been in practice between 16 and 25 years, and 26.8 % had been in practice for more than 25 years. The most notable interspecialty differences were related to the use of operative antibiotics and the surgical approach. Plastic surgeons were less likely to recommend antibiotic use during surgery and more likely to utilize an open extensile approach during surgical release. Younger surgeons were more likely to employ a mini-open approach for carpal tunnel release.
We conclude that background training and generational differences contribute to the varied approaches observed in the diagnosis and management of CTS.
PMCID: PMC3508019  PMID: 24294152
Carpal tunnel syndrome; Surgeon attitudes; Questionnaire; Survey
8.  Adopting evidence-based practice in clinical decision making: nurses' perceptions, knowledge, and barriers 
Evidence-based practice (EBP) provides nurses with a method to use critically appraised and scientifically proven evidence for delivering quality health care to a specific population. The objective of this study was to explore nurses' awareness of, knowledge of, and attitude toward EBP and factors likely to encourage or create barriers to adoption. In addition, information sources used by nurses and their literature searching skills were also investigated.
A total of 2,100 copies of the questionnaire were distributed to registered nurses in 2 public hospitals in Singapore, and 1,486 completed forms were returned, resulting in a response rate of 70.8%.
More than 64% of the nurses expressed a positive attitude toward EBP. However, they pointed out that due to heavy workload, they cannot keep up to date with new evidence. Regarding self-efficacy of EBP-related abilities, the nurses perceived themselves to possess moderate levels of skills. The nurses also felt that EBP training, time availability, and mentoring by nurses with EBP experience would encourage them to implement EBP. The top three barriers to adopting EBP were lack of time, inability to understand statistical terms, and inadequate understanding of the jargon used in research articles. For literature searching, nurses were using basic search features and less than one-quarter of them were familiar with Boolean and proximity operators.
Although nurses showed a positive attitude toward EBP, certain barriers were hindering their smooth adoption. It is, therefore, desirable that hospital management in Southeast Asia, particularly in Singapore, develop a comprehensive strategy for building EBP competencies through proper training. Moreover, hospital libraries should also play an active role in developing adequate information literacy skills among the nurses.
PMCID: PMC3133901  PMID: 21753915
9.  Perioperative considerations for patient safety during cosmetic surgery – preventing complications 
Maintaining patient safety in the operating room is a major concern of surgeons, hospitals and surgical facilities. Circumventing preventable complications is essential, and pressure to avoid these complications in cosmetic surgery is increasing. Traditionally, nursing and anesthesia staff have managed patient positioning and safety issues in the operating room. As the number of office-based procedures in the plastic surgeon’s practice increases, understanding and implementing patient safety guidelines by the plastic surgeon is of increasing importance.
A review of the Joint Commission’s Universal Protocol highlights requirements set forth to prevent perioperative complications. In the present paper, the importance of implementing these guidelines into the cosmetic surgery practice is reviewed. Key aspects of patient safety in the operating room are outlined, including patient positioning, ocular protection and other issues essential for minimization of postoperative morbidity. Additionally, as the demand for body contouring surgery in the cosmetic practice continues to increase, special attention to safety considerations specific to the obese and massive weight loss patients is mandatory.
After review of the present paper, the reader should be able to introduce the Joint Commission’s Universal Protocol into their daily practice. The reader will understand key aspects of patient positioning, airway management and ocular protection in cosmetic surgery. Finally, the reader will have a better understanding of the perioperative care of unique populations including the morbidly obese, massive weight loss patients and the elderly. Attention to detail in these aspects of patient safety can help avoid unnecessary complication and significantly improve the patient’s experience and surgical outcome.
PMCID: PMC2705307  PMID: 20190907
Body contouring surgery; Cosmetic surgery; Patient safety
10.  Evidence-Based Medicine in Surgical Education 
Evidence-based medicine (EBM) is increasingly important for clinical surgery and for promotion of best practices into surgical decision making. Although barriers exist in the current surgical literature, for certain surgical scenarios, formal efforts to promote evidence-based surgery (EBS) into surgical education are helping to equip future surgeons with these important tools for optimizing patient care. As our evidence-base grows and standards of care evolve, incorporating EBM into everyday practice for trainees and staff surgeons remains an ongoing challenge.
PMCID: PMC3577571  PMID: 23997670
evidence-based medicine; surgical education; appraisal skills
11.  Comparing the results penetrating colon injuries based on intervention by surgeons with different levels of experience in West Indies 
Numerous studies have established the safety of primary repair for civilian penetrating colonic injuries with little data exploring the experience of surgeon performing the procedure. Owing to financial, staff and administrative constraints in the developing world, surgeons-in-training sometimes find themselves faced with having to perform major surgery for penetrating colonic injuries with no experienced surgeon in attendance, but available for advice via phone. With this thought, we collected retrospective data to analyse our outcomes based on this practice.
Materials and Methods:
Over a 10-year period 62 patients with penetrating colonic trauma underwent laparotomies with analysis done on 53 cases. Severity of injury, grade of operating surgical staff and outcome were noted. Outcomes of “inexperienced surgeons” and “experienced surgeons” were compared to determine if a difference exists in outcome based on experience or grade of surgeon.
A total of 53 patients with penetrating colon injures underwent primary repair and/or anastomosis with 18 (34%) performed by “inexperienced surgeons” and 35 (66%) by “experienced surgeons”. There was one death unrelated to colon trauma with an inexperienced surgeon and one anastomotic leak in a patient operated on by an experienced surgeon.
This data supports previous reports on the safety of primary repair for penetrating colonic injuries and raises the point that in cases of lower severity of injury inexperienced surgeons have similar results to experienced surgeons with regard to primary repair.
PMCID: PMC3162698  PMID: 21887019
Colon injury; penetrating colon injury; primary repair
12.  A questionnaire survey on postoperative intermaxillary fixation in mandibular trauma: Is its use based on evidence? 
This questionnaire survey was conducted to ascertain if the practice of the routine use of postoperative intermaxillary fixation (IMF) in mandibular trauma (of the dentate segments only) was based on evidence available in the literature.
Settings and Design:
This study was designed as a questionnaire survey that would be conducted among surgeons operating on mandibular fractures in the state of Gujarat.
Materials and Methods:
A typed questionnaire was sent to oral maxillofacial surgeons and plastic surgeons of Gujarat state for their feedback by post. Approval of the ethical committee of the university was obtained. All the feedback forms received back were included for this survey which included 25 oral and maxillofacial surgeons and 25 plastic surgeons.
Although majority of the surgeons use open reduction and internal fixation (ORIF), 25% of the surgeons still prefer using only IMF as the sole modality of treatment for the said group of mandibular fractures. According to our survey, the majority of surgeons use IMF routinely in the postoperative setting even after using ORIF. Occlusion seems to be the critical factor among 72% of surgeons in deciding on the use of IMF as an adjunct after ORIF. Seventy-eight percent of surgeons vary their period of IMF based on the site of fracture.
The routine use of postoperative IMF in cases of mandibular fractures seems to find favor among surgeons despite lack of sound scientific evidence supporting its use. There is also no evidence to suggest that if IMF is not used, it would have deleterious effects on occlusion or otherwise.
PMCID: PMC3343413  PMID: 22639501
Immediate mobilization; mandibular trauma; postoperative intermaxillary fixation
13.  An evaluation of the knowledge of the surgical treatment of obesity among surgeons 
Surgical treatment of obesity is currently the only effective treatment option for patients with excess body weight, especially morbid obesity and diseases caused by it. There are no studies evaluating the knowledge of surgeons in the field of bariatric surgery.
To assess the knowledge of surgeons regarding bariatric surgery.
Material and methods
An anonymous questionnaire was conducted among 143 surgeons in 2010–2011 during local educational conferences. The survey consisted of 10 questions dedicated to the fundamental problems of the surgical treatment of obesity.
Theoretical and practical knowledge connected to the so-called “epidemiological awareness” in the surgical treatment of obesity was possessed by 25% of the respondents. Knowledge of surgical techniques is known to most surgeons. Reducing the “oncological risk” after bariatric surgery is known to only 27% of surgeons. Almost 80% of surgeons indicated a necessity of their further education regarding the surgical treatment of obesity.
Knowledge of Polish general surgeons in the surgical treatment of obesity is not high, with a high number of surgeons who possess knowledge of the operating technique, whereas only a quarter have a basic knowledge of the indication for surgical treatment. Most surgeons who participated in our study are awaiting educational programmes focused on this issue.
PMCID: PMC3983543
bariatric surgery; knowledge; surgeons
14.  Nursing faculties’ knowledge and attitude on evidence-based practice 
Evidence-based practice (EBP) is one of the main professional competencies for health care professionals and a priority for medicine and nursing curriculum as well. EBP leads to improve effective and efficient care and patient outcomes. Nurse educators have responsibility to teach the future nurses, and an opportunity to promote patient outcomes. Therefore, the aim of this study was to describe nurse educators’ knowledge and attitude on EBP.
Materials and Methods:
This was a descriptive study conducted in nursing faculties of two major universities of medical sciences affiliated to Ministry of Health and Medical Sciences in Tehran, Iran. Data were gathered using a three-section questionnaire. Content and face validity was further enhanced by submitting it to nursing research and education experts. Statistical analysis was carried out using SPSS 11 software.
According the results, nursing faculties’ knowledge of EBP was mainly moderate (47.1%). Significant statistical relationship was found between the level of knowledge with education and teaching experience in different nursing programs. Nurses generally held positive attitudes toward EBP (88.6%) and there was no statistical significant relationship with demographic variables.
Nursing educators are in a position to influence nursing research in clinical practice in the future. Therefore, it is critical to achieve implementation of EBP and be a change agent for a paradigm shift toward EBP.
PMCID: PMC3730454  PMID: 23922597
Attitude; evidence-based practice; Iran; knowledge
15.  Framework of policy recommendations for implementation of evidence-based practice: a systematic scoping review 
BMJ Open  2013;3(1):e001881.
Evidence-based practice (EBP) may help improve healthcare quality. However, not all healthcare professionals and managers use EBP in their daily practice. We systematically reviewed the literature to summarise self-reported appreciation of EBP and organisational infrastructure solutions proposed to promote EBP.
Systematic review. Two investigators independently performed the systematic reviewing process.
Information sources
MEDLINE, EMBASE and Cochrane Library were searched for publications between 2000 and 2011.
Eligibility criteria for included studies
Reviews and surveys of EBP attitude, knowledge, awareness, skills, barriers and facilitators among managers, doctors and nurses in clinical settings.
We found 31 surveys of fairly good quality. General attitude towards EBP was welcoming. Respondents perceived several barriers, but also many facilitators for EBP implementation. Solutions were proposed at various organisational levels, including (inter)national associations and hospital management promoting EBP, pregraduate and postgraduate education, as well as individual support by EBP mentors on the wards to move EBP from the classroom to the bedside.
More than 20 years after its introduction, the EBP paradigm has been embraced by healthcare professionals as an important means to improve quality of patient care, but its implementation is still deficient. Policy exerted at microlevel , middlelevel and macrolevel, and supported by professional, educational and managerial role models, may further facilitate EBP.
PMCID: PMC3563143  PMID: 23355664
Medical Education & Training
16.  Surgical site infection prevention: a survey to identify the gap between evidence and practice in University of Toronto teaching hospitals 
Canadian Journal of Surgery  2012;55(4):233-238.
A gap exists between the best evidence and practice with regards to surgical site infection (SSI) prevention. Awareness of evidence is the first step in knowledge translation.
A web-based survey was distributed to 59 general surgeons and 68 residents at University of Toronto teaching hospitals. Five domains pertaining to SSI prevention with questions addressing knowledge of prevention strategies, efficacy of antibiotics, strategies for changing practice and barriers to implementation of SSI prevention strategies were investigated.
Seventy-six individuals (60%) responded. More than 90% of respondents stated there was evidence for antibiotic prophylaxis and perioperative normothermia and reported use of these strategies. There was a discrepancy in the perceived evidence for and the self-reported use of perioperative hyperoxia, omission of hair removal and bowel preparation. Eighty-three percent of respondents felt that consulting published guidelines is important in making decisions regarding antibiotics. There was also a discrepancy between what respondents felt were important strategies to ensure timely administration of antibiotics and what strategies were in place. Checklists, standardized orders, protocols and formal surveillance programs were rated most highly by 75%–90% of respondents, but less than 50% stated that these strategies were in place at their institutions.
Broad-reaching initiatives that increase surgeon and trainee awareness and implementation of multifaceted hospital strategies that engage residents and attending surgeons are needed to change practice.
PMCID: PMC3404142  PMID: 22617541
17.  Healthcare workers and prevention of hepatitis C virus transmission: exploring knowledge, attitudes and evidence-based practices in hemodialysis units in Italy 
Evidence exists regarding the full prevention of HCV transmission to hemodialysis patients by implementing universal precaution. However, little information is available regarding the frequency with which hospitals have adopted evidence-based practices for preventing HCV infection among hemodialysis patients. A cross-sectional survey has been conducted among nurses in Calabria region (Italy) in order to acquire information about the level of knowledge, the attitudes and the frequencies of evidence-based practices that prevent hospital transmission of HCV.
All 37 hemodialysis units (HDU) of Calabria were included in the study and all nurses were invited to participate in the study and to fill in a self-administered questionnaire.
90% of the nurses working in HDU participated in the study. Correct answers about HCV pattern of transmission ranged from 73.7% to 99.3% and were significantly higher in respondents who knew that isolation of HCV-infected patients is not recommended and among those who knew that previous bloodstream infections should be included in medical record and among nurses with fewer years of practice. Most correctly thought that evidence-based infection control measures provide adequate protection against transmission of bloodborne pathogens among healthcare workers. Positive attitude was significantly higher among more knowledgeable nurses. Self-reporting of appropriate handwashing procedures were significantly more likely in nurses who were aware that transmission of bloodborne pathogens among healthcare workers may be prevented through adoption of evidence-based practices and with a correct knowledge about HCV transmission patterns.
Behavior changes should be aimed at abandoning outdated practices and adopting and maintaining evidence-based practices. Initiatives focused at enabling and reinforcing adherence to effective prevention practices among nurses in HDU are strongly needed.
PMCID: PMC3571883  PMID: 23391009
Evidence-based practices; Hemodialysis; Hepatitis C virus; Italy; Nurses; Prevention
18.  Discrepant perceptions of communication, teamwork and situation awareness among surgical team members 
To assess surgical team members’ differences in perception of non-technical skills.
Questionnaire design.
Operating theatres (OTs) at one university hospital, three teaching hospitals and one general hospital in the Netherlands.
Sixty-six surgeons, 97 OT nurses, 18 anaesthetists and 40 nurse anaesthetists.
All surgical team members, of five hospitals, were asked to complete a questionnaire and state their opinion on the current state of communication, teamwork and situation awareness at the OT.
Ratings for ‘communication’ were significantly different, particularly between surgeons and all other team members (P ≤ 0.001). The ratings for ‘teamwork’ differed significantly between all team members (P ≤ 0.005). Within ‘situation awareness’ significant differences were mainly observed for ‘gathering information’ between surgeons and other team members (P < 0.001). Finally, 72–90% of anaesthetists, OT nurses and nurse anaesthetists rated routine team briefings and debriefings as inadequate.
This study shows discrepancies on many aspects in perception between surgeons and other surgical team members concerning communication, teamwork and situation awareness. Future research needs to ascertain whether these discrepancies are linked to greater risk of adverse events or to process as well as systems failures. Establishing this link would support implementation and use of complex team interventions that intervene at multiple levels of the healthcare system.
PMCID: PMC3055275  PMID: 21242160
patient safety; quality of care; teamwork; communication; surgery
19.  Rules and guidelines in clinical practice: a qualitative study in operating theatres of doctors' and nurses' views 
Quality & safety in health care  2005;14(4):290-294.
Background: The current orthodoxy within patient safety research and policy is characterised by a faith in rules based systems which limit the capacity for individual discretion, and hence fallibility. However, guidelines have been seen as stifling innovation and eroding trust. Our objectives were to explore the attitudes towards guidelines of doctors and nurses working together in surgical teams and to examine the extent to which trusting relationships are maintained in a context governed by explicit rules.
Methods: Fourteen consultant grade surgeons of mixed specialty, 12 consultant anaesthetists, and 15 nurses were selected to reflect a range of roles. Participant observation was combined with semi-structured interviews.
Results: Doctors' views about the contribution of guidelines to safety and to clinical practice differed from those of nurses. Doctors rejected written rules, instead adhering to the unwritten rules of what constitutes acceptable behaviour for members of the medical profession. In contrast, nurses viewed guideline adherence as synonymous with professionalism and criticised doctors for failing to comply with guidelines.
Conclusions: While the creation of a "safety culture" requires a shared set of beliefs, attitudes and norms in relation to what is seen as safe clinical practice, differences of opinion on these issues exist which cannot be easily reconciled since they reflect deeply ingrained beliefs about what constitutes professional conduct. While advocates of standardisation (such as nurses) view doctors as rule breakers, doctors may not necessarily regard guidelines as legitimate or identify with the rules written for them by members of other social groups. Future safety research and policy should attempt to understand the unwritten rules which govern clinical behaviour and examine the ways in which such rules are produced, maintained, and accepted as legitimate.
PMCID: PMC1744048  PMID: 16076795
20.  Governing the surgical count through communication interactions: implications for patient safety 
Quality & Safety in Health Care  2006;15(5):369-374.
Intermittently, the incidence of retained surgical items after surgery is reported in the healthcare literature, usually in the form of case studies. It is commonly recognised that poor communication practices influence surgical outcomes.
To explore the power relationships in the communication between nurses and surgeons that affect the conduct of the surgical count.
A qualitative, ethnographic study was undertaken. Data were collected in three operating room departments in metropolitan Melbourne, Australia. 11 operating room nurses who worked as anaesthetic, instrument and circulating nurses were individually observed during their interactions with surgeons, anaesthetists, other nurses and patients. Data were generated through 230 h of participant observation, 11 individual and 4 group interviews, and the keeping of a diary by the first author. A deconstructive analysis was undertaken.
Results are discussed in terms of the discursive practices in which clinicians engaged to govern and control the surgical count. The three major issues presented in this paper are judging, coping with normalisation and establishing priorities.
The findings highlight the power relationships between members of the surgical team and the complexity of striking a balance between organisational policy and professional judgement. Increasing professional accountability may help to deal with the issues of normalisation, whereas greater attention needs to be paid to issues of time management. More sophisticated technological solutions need to be considered to support manual counting techniques.
PMCID: PMC2565825  PMID: 17074876
21.  Can orthopedic trials change practice? 
Acta Orthopaedica  2010;81(1):122-125.
Background and purpose
The impact of large, randomized trials in orthopedic surgery on surgeons' preferences for a particular surgical approach remains unclear. We surveyed surgeons to assess whether they would change practice based upon results of a large, multicenter randomized controlled hip fracture trial.
We conducted a cross-sectional survey among International Hip Fracture Research Collaborative (IHFRC) surgeons and surgeons who were members of Arbeitsgemeinschaft fuer Osteosynthesefragen - Association for the Study of Internal Fixation (AO/ASIF) to determine the likelihood that they would change practice based on findings of a proposed large, multicenter randomized controlled trial (the Hip Fracture Evaluation with Alternatives of Total Hip Arthroplasty versus Hemi-Arthroplasty (HEALTH) study). We asked surgeons their current preferences for the management of displaced femoral neck fractures and whether a trial that definitively revealed a substantial improvement in function and quality of life with no difference in risk of revision surgery was important and would cause them to change practice.
Of 883 surgeons surveyed, 210 responded from IHFRC and 586 from AO/ASIF (a response rate of 90%). Most surgeons (61%) preferred hemiarthroplasty (HA) for treating displaced femoral neck fractures. 72% of responding surgeons believed that a substantial improvement in patient function with total hip arthroplasty (THA) and no adverse effects on revision surgery would be an important finding. Moreover, of 483 surgeons who preferred hemiarthroplasty, 62% would change their practice based upon the findings of the trial.
Large clinical trials in orthopedics are worthwhile endeavors, as they have the potential to change practice among surgeons. Surgeons seem willing to adopt alternative surgical approaches if the evidence is compelling and sound.
PMCID: PMC2856216  PMID: 20146638
22.  Should surgeons take a break after an intraoperative death? Attitude survey and outcome evaluation 
BMJ : British Medical Journal  2004;328(7436):379.
Objectives To investigate attitudes of cardiac surgeons and anaesthetists towards working immediately after an intraoperative death and to establish whether an intraoperative death affects the outcome of subsequent surgery.
Design Questionnaire on attitudes to working after an intraoperative death and matched cohort study.
Setting UK adult cardiac surgery centres and regional cardiothoracic surgical centre.
Participants 371 consultant cardiac surgeons and anaesthetists in the United Kingdom were asked to complete a questionnaire, and seven surgeons from one centre who continued to operate after intraoperative death.
Main outcome measures Outcome for 233 patients operated on by a surgeon who had experienced an intraoperative death within the preceding 48 hours compared with outcome of 932 matched controls. Hospital mortality and length of stay as a surrogate for hospital morbidity.
Results The questionnaire response rate was 76%. Around a quarter of surgeons and anaesthetists thought they should stop work after an intraoperative death and most wanted guidelines on this subject. Overall, there was no increased mortality in patients operated on in the 48 hours after an intraoperative death. However, mortality was higher if the preceding intraoperative death was in an emergency or high risk case. Survivors operated on within 48 hours after an intraoperative death had longer stay in intensive care (odds ratio 1.64, 95% confidence interval 1.08 to 2.52, P = 0.02) and longer stay in hospital (relative change 1.15, 1.03 to 1.24, P = 0.02).
Conclusion Mortality is not increased in operations performed in the immediate aftermath of an intraoperative death, but survivors have longer stays in intensive care and on the hospital ward.
PMCID: PMC341385  PMID: 14734519
23.  Surgeon-led Initiatives Cut Costs and Enhance the Quality of Endoscopic and Laparoscopic Procedures 
Public perception depicts surgical cost control and quality of care as polar opposites. We describe a program led by practicing surgeons that demonstrates that quality can be maintained, and often improved, while substantial cost reductions are realized.
A set of evidence-based protocols was developed, revised, and followed for 42 procedures in general, otolaryngologic, urologic, and orthopedic surgery. Each protocol consists of surgeon-initiated guidelines on operative indications, preoperative testing, preadmission planning, length of stay, resource utilization, convalescence, and pharmacy services. Information was collected for 24 months from July 1998 to July 2000 by 62 surgeons in Kentucky and Indiana. Data were obtained for 4302 cases, among them colonoscopy (1145), esophagogastroduodenoscopy (714), laparoscopic cholecystectomy (418), endoscopic retrograde cholangiopancreatography (235), and laparoscopic fundoplication (87).
Specific cost reductions occurred in laparoscopic cholecystectomy by limiting the administration of perioperative antibiotics. Sixty-seven percent of patients did not receive antibiotics. Outpatient cholecystectomy was the norm (60%), due primarily to preadmission planning through discussion with the patients and their family. Interestingly, when surgeons were educated on the costs of certain instruments and medications, their practices changed. The avoidance of a particular postoperative antiemetic, which was more than tenfold more expensive than other choices, was rapidly adopted by all surgeons when the costs were discovered. One participating teaching hospital used its own financial data and predicted that if all surgeons at their facility followed the protocols and had similar results, a savings of $1.1 million per quarter would be obtained.
PMCID: PMC3113204  PMID: 14558713
Surgeon-initiated guidelines; Resource utilization; Cost reductions
24.  Nurses’ Perceived Barriers to and Facilitators of Research Utilization in Mainland China: A Cross-Sectional Survey 
The Open Nursing Journal  2013;7:96-106.
Despite the drive towards evidence-based practice, the extent to which research evidence is being implemented in nursing practice is unclear, particularly in developing countries. This study was to assess the levels of perceived barriers to and facilitators of research utilization in practice among Chinese nurses and inter-relationships between these barriers and facilitators and their socio-demographic characteristics. A cross-sectional, descriptive survey was conducted in 2011 with 743 registered nurses randomly selected from four general hospitals in China. They completed the Barriers to Research Utilization and Facilitators of Research Utilization scales. Correlation tests were used to test the relationships between the nurses’ perceived barriers and facilitators, their demographic characteristics and research training and involvement. The Chinese nurses’ level of perceived barriers was moderate on average and lower than that in previous research. Among the 10 top-ranked items, six were from the subscale ‘Organizational Characteristics’. Their perceived barriers were correlated positively with age and post-registration experience and negatively with research training undertaken. Junior diplomatic nurses reported a significantly higher degree of barriers than those senior ones with postgraduate education. Higher and more diverse barriers to research utilization in practice are perceived by Chinese nurses than those in Western countries and they are associated with a few socio-demographic factors. Future research on these barriers/facilitators and their relationships with occupational and socio-cultural factors in Chinese and other Asian nurses is recommended.
PMCID: PMC3731799  PMID: 23919099
Cross-sectional survey; perceived barriers; perceived facilitators; research utilization; registered nurses; Chinese.
25.  Nurse Educators' and Nursing Service Personnel's Knowledge of and Attitudes Toward Computer Use in Nursing Practice 
The purpose of this descriptive study was to assess nurse educators' and nursing service personnels' knowledge of and attitudes toward computer applicability to nursing practice in order to facilitate planning future education in the area of computer-based nursing practice. The data yielded no significant differences between nurse educators' and nursing service personnels' knowledge of and attitudes toward computer use in nursing practice. There were, however, significant differences in knowledge of and attitudes toward computer utilization in nursing practice for both study group and educational level. Suggestions related to educating nurses regarding the benefits of computer use to facilitate nursing practice are provided.
PMCID: PMC2577969

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