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ORIGINAL RESEARCH

Nursing and patient safety in the operating room

Herdis Alfredsdottir & Kristin Bjornsdottir
Accepted for publication 30 July 2007

Correspondence to H. Alfredsdottir: e-mail: herdisal@landspitali.is H. Alfredsdottir MNSc RN CNOR Clinical Coordinator Operating Room, National University Hospital, Reykjavik, Iceland K. Bjornsdottir EdD RN Professor Faculty of Nursing, University of Iceland, Reykjavik, Iceland

A L F R E D S D O T T I R H . & B J O R N S D O T T I R K . ( 2 0 0 8 ) Nursing and patient safety in the operating room. Journal of Advanced Nursing 61(1), 2937 doi: 10.1111/j.1365-2648.2007.04462.x

Abstract
Title. Nursing and patient safety in the operating room Aim. This paper is a report of a study to identify what operating room nurses believe inuences patient safety and how they see their role in enhancing patient safety. Background. Research in health care shows that work experience, communication and the organization of work are key factors in patient safety. This study draws on Reasons denitions of active and latent errors to conceptualize the complex issues that affect patient safety in the operating room. Method. The study reported here is part of an action research project at a university hospital in Iceland. Semi-structured interviews were conducted in 2004 with eight nurses, followed by two focus groups of four nurses each in 2005. Data were analysed using interpretive content analysis. Findings. Securing patient safety and preventing mistakes were described as key elements in operating room nursing by all survey participants. In the interviews, the nurses identied the existing culture of prevention and protection that characterizes operating room nursing as crucial in enhancing safety. The organization of work into specialty teams was considered essential. Increased speed of work in an environment where enhanced productivity is imperative, as well as imbalance in stafng, was identied as the main threats to safety. Conclusion. Operating room nurses have a common understanding of the core of their work, which is to ensure patient safety during operations. The work environment is increasingly characterized by latent error, i.e. system-based threats to patient safety that can materialize at any time. Interventions to enhance patient safety in operating room nursing are needed. Keywords: adverse events, empirical research report, focus groups, incident reporting, interviews, nursing, operating room nursing, patient safety

Introduction
Patient safety has been discussed extensively in both medical and nursing literature in recent years. Enhanced focus on safety is often attributed to ndings from a study on error in health care in the United States of America (USA) in the early

1990s (Brennan et al. 1991), which concluded that mistakes were much more common than previously believed. Subsequently the Institute of Medicine (IOM) in the USA issued a comprehensive report on error and ways to prevent mistakes in health care (Kohn et al. 2000). The IOM report has had a wide impact and its ndings have been addressed in the
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nursing literature by number of authors (Cook et al. 2004, Page 2004, Crigger 2005). Among other things the report calls for a shift in the conceptualization of the sources of mistakes from blaming individuals to analysing system failures, i.e. from a focus on active failures to latent failures.

have emerged in previous studies on safety and its conceptualization was based on Reasons denition of active and latent error.

The study
Study context
The work on which this paper is based took place at a university hospital formed in 2000 when two of the main acute care hospitals in Iceland merged. The merger led to a fundamental reorganization of operating room services, to which the nursing staff needed to adjust. In an attempt to clarify the values and aims of operating room nursing at the hospital, a questionnaire was sent to all operating room nurses. They were asked to describe the main characteristics, goals and nature of their work. Protecting and enhancing patient safety emerged as the core of operating room nursing. Following these ndings, the decision was made to design an action research project with the aim of identifying and developing ways to enhance patient safety during surgery at the hospital (Holter & Schwartz-Barcott 1993, Hampshire 2000). The study presented in this paper is part of that project. Its aim was to identify factors that nurses view as enhancing and threatening to safety, with the intention of using the ndings as a basis for changes in the organization of operating room nursing that the nurses identied as necessary. At both departments that participated in the study, operating room nursing has for a number of years been organized in specialized teams of nurses who work in close collaboration with surgeons in each speciality. This specialization is considered benecial to patient safety. The nurses are experienced and skilled in specic operations and have advanced knowledge of their elds of surgery. The standard working week is 40 hours, but most nurses will be on call some days of the month in addition. It is quite common for nurses to be asked to work extra shifts in addition to the standard work schedule. Following the merger of the operating room services at the two hospitals, some of the nurses had to choose between moving to a new setting or changing specialities, which meant considerable readjustment. In addition, the operating room departments faced a number of challenges. The workforce had been stable for many years and most of the nurses had extensive experience, but many of them were now preparing for retirement. In addition to these changes in the work group, the work environment has changed in fundamental ways. Demands for productivity and efciency have increased and the time for

Background
This shift in conceptualization of the nature of error in the IOM report reects a general trend in addressing safety often attributed to Reason (1990). Reason distinguished errors into two categories, active and latent failure. Active failure is error made by those at the sharp end of practice, i.e. by the employee that performs the task. The effect is felt almost immediately. Latent failures are system-based mistakes, such as decisions that lead to insufcient stafng, excessive workload or faulty maintenance of equipment. Latent failures can lie dormant in the system for some time, becoming active under certain circumstances (Reason 1990). As in other elds the discussion in the nursing literature has been inuenced by the above shift from focusing on the individual practitioner to the organizational context as the source of error (Benner et al. 2002). The Association of periOperative Registered Nurses in the USA has identied how nurses clinical and organizational expertise can help nd and correct system-related errors by simplifying and standardizing work processes as well as improving the work environment (AORN 2005). Incidence reporting has been identied as an important method to nd and analyse system failures (Dunn 2003a,b). Similarly, information technology has been suggested as a helpful way to analyse systems and to nd system errors (Simpson 2005), as well as improving practice by facilitating the sharing of information and the use of checklists and protocols to reduce reliance on memory (AORN 2005). Studies addressing safety and error in health care have been scarce. Most of them attend to both active and latent errors. Lack of communication, as well as reluctance to admit the effect of fatigue on work performance, has been found to be characteristic of the work environment within health care (Sexton et al. 2000). In two studies in Britain nurses identied the most common causes of error to be lack of practice, heavy workload and poor judgement (Meurier et al. 1997, 1998). Silen-Lipponen et al. (2005) studied error and teamwork in operating room nursing in three countries (Finland, the UK and the USA), and concluded that experience, communication and shared responsibility in teams, and the duty of management to address circumstances that lead to error are important factors in patient safety. The study presented in this paper is explorative. It was designed to reect issues that
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staff development and work on developmental projects is more limited. Operations are also larger and more complicated, as smaller procedures are now performed in private clinics outside the hospital. The use of minimally invasive surgery, in addition to progress in anaesthesia, has reduced the risks involved in surgery, allowing more fragile patients to be operated on. As a result, some patients undergoing surgery are older and in poorer health, and need careful monitoring.

were formulated, moving from the general to the more specic. Findings The core of operating room nursing was identied as patient safety and the skilful and knowledgeable work performed by nurses vis-a-vis ensuring a safe transition through sur` gery. Its goal was described as providing patient-centred nursing so that patient safety and a positive outcome were ensured. When asked what characterized their nursing, participants described how a patient undergoing surgery is vulnerable and needs to be taken care of by skilled professionals who use nursing interventions in a preventative manner.

Stage 1. Preliminary survey

Aim The aim of the preliminary survey was to identify how operating room nurses understand the goals, values and characteristics of their work, which may play a critical role in identifying indicators for quality operating room nursing (Norman et al. 1992). Design A survey was designed using a modication of the critical incident technique which stresses clear and concise descriptions (Flanagan 1954, Alfredsdottir 2003). Method Questionnaires were sent to all the operating room nurses (N = 60) who were on call from 25 April until 5 May, 2003. The response rate was 50% (n = 30). Participants were asked to answer three open questions: (1) What do you think ought to be the main goals of nursing care in the operating room? (2) What do you think is most important in the services provided by operating room nurses? and (3) How would you describe the characteristics of operating room nursing in your workplace as currently practised? The questions were ordered so that they led from the general to the more specic and concrete. Ethical considerations Permission to carry out the survey was granted by the Head of Nursing at the division. Letters of introduction were sent with the questionnaires, in which the aim of the survey was explained, anonymity promised and participation encouraged. Completed questionnaires were put in envelopes and given to the unit secretary. Data analysis Data analysis, following the critical incident technique, is inductive, aiming to classify key ndings into categories (Norman et al. 1992). The answers were read and reread to identify factors that indicated what the nurses saw as the essence of operating room nursing. Categories and themes

Stage 2. Interview and focus group study

Based on the ndings of this survey, a qualitative study involving semi-structured interviews and focus group discussions with operating room nurses was designed. Aim The aim of this study was to identify what threatens and enhances patient safety and how operating room nurses see their role in ensuring safety. The research questions in this part of the project were: Which factors in the organization of the operating room do operating room nurses describe as inuencing patient safety? How do operating room nurses describe their contribution to patient safety? Participants Two purposive samples of nurses were recruited, one for the individual interviews and the other for the focus groups. The total number of participants in the study was 14, as two nurses who had previously participated in interviews also took part in the focus groups. These two nurses showed a special interest in the project and requested to be allowed to participate in the whole process. The study was introduced at staff meetings in operating departments, and voluntary participation was requested. Volunteers were asked to contact the head nurse on their unit, who then decided who would participate, based on the inclusion criteria. These were a minimum of 5 years work experience, variation in specialty teams and an interest in participating in the project by sharing knowledge and experience. The age of participants reected the average age (497 years) of nurses working in the departments in question.
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The interview sample was composed of eight Registered Nurses, all certied operating room nurses. Four nurses were recruited from each department. Their age was 4554 years and their length of work experience ranged from 11 to 30 years. The same inclusion criteria were used for participation in the focus groups, although the criterion for years of experience was lowered to include the views of those with less experience to broaden the viewpoints accessed. Two focus groups of four nurses were established, one from each department. Their age range was 4251 years and their length of work experience varied from 3 to 21 years. All were Registered Nurses and all except for two of the focus group participants were certied operating room nurses. The main purpose of the focus groups was: (1) to reinforce our analysis of the interview data and (2) to discuss initiatives to increase patient safety. Data collection The semi-structured interviews took place in the autumn of 2004. Patient safety, work environment and adverse events were the focus of the interviews, which were conducted using an interview guide that was developed based on ndings from the survey and with reference to the literature review (see Table 1). Participants were encouraged to express their views freely. The goal was to chart the situation and identify factors
Table 1 Interview guide 1. How would you describe nursing practice in the department? 2. If you consider the last 5 years, do you see any changes in nursing practice? If so, what kind of changes? 3. How would you dene the aim of teamwork in the department? 4. Are there any changes that need to be done concerning teamwork? 5. How would you describe co-operation in the department? 6. Do you detect any weaknesses in co-operation? 7. How is patient safety in nursing secured in the department? 8. Do you detect any changes in the last 5 years concerning patient safety? 9. Do you ever worry about patient safety at the department? If yes, how? 10. Are there any factors in your work environment that could endanger patients? 11. What is your assessment of nursing skill at the department? 12. What do you consider most important in securing patient safety? 13. Have you experienced or witnessed a mistake or near miss in your nursing environment? a. If yes, was the incident reported? b. How was it handled? c. Were you satised with the handling? 14. If you were involved in a mistake or a near miss, how should it be handled?

in the work environment that inuence patient safety. The interviews were audiotaped and lasted approximately 1 hour each. An interview guide that reected ndings from interview analysis was designed for the focus group discussions that took place in January to February 2005 (see Table 2). Free exchange of opinion was encouraged as well as ideas for interventions to enhance patient safety (Kitzinger 1995, Kidd & Parshall 2000). Ethical considerations The study was approved by the Ethical Review Board at the hospital where the research took place. Before the interviews and the focus group meetings the nurses were handed a letter introducing the purpose of the study. Condentiality was promised, and the right to withdraw from the study was emphasized. Participants were also assured that participation would not have any impact on their working relationships. All participants signed an informed consent form. Data analysis Texts from interviews and focus groups were interpreted separately and characterized by an integrated process of data collection, analysis and interpretation (Sandelowski 1995, Kvale 1996), using interpretive content analysis (Baxter 1994, Graneheim & Lundman 2004).The units of analysis were every audiotaped interview and focus group discussion. Initially, audiotaped interviews were listened to and compared with the transcripts. Then each interview was read and reread with the intention of gaining a sense of underlying key phrases before starting comparison with other interviews. Transcripts from focus group discussions were analysed using the same technique. Quotations from texts that were representative for the ndings were extracted into statements and then condensed into a meaning unit that was compared with other meaning units. Statements that had a common meaning were sorted into 11 main categories constituting the manifest content. Categories that seemed to be related were then

Table 2 Focus group guide 1. Factors that strengthen nursing in the operating room Characterized by preventative measures to protect the patient Expertise in teams Nurses with long experience in operating room nursing 2. Factors that threaten Increased speed and productivity Control of circumstances Stafng and the work environment 3. How can we best deal with errors in a way that supports the victims and will lead to learning and prevention in the future?

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linked together in eight themes expressing the latent content of the text or the underlying meaning of what was said (Graneheim & Lundman 2004). The initial analysis was performed individually by both authors. Minor discrepancies were discussed and a consensus was reached as to the most valid interpretation. An external expert in qualitative research read the interviews and went over the analysis to ensure rigour. The focus groups served a further role in enhancing the rigour. By discussing the ndings from the interview data in the focus groups, it was hoped that the trustworthiness of the analysis would be supported. Rigour and trustworthiness were also sought by the multimethod approach, i.e. a survey that was the initial step of the study, interviews and focus groups (Bellman 2003). Researcher involvement The project was initiated by the rst author, who had been a head nurse at one of the operating departments for 5 years in addition to participating extensively in curriculum development and teaching operating room nursing. At the time of the study, she had leave of absence from her head nurse position. The survey described above provided the base for what has since become a joint effort among operating room nurses at the hospital. Doing research in ones own eld of practice can be difcult and fraught with complicated issues of power and ethics. Many researchers have discussed this and stressed the importance of describing the role of the researcher so that readers can make their own judgement about the rigour of the study being described (Turnock & Gibson 2001). It is our view that this closeness enhanced open communication in the interviews and the researchers knowledge of the eld was a strengthening factor in the study.

thinking, knowledgeable and experienced workers supported by good teamwork, and mutual trust based on many years of co-operation. Thinking ahead: prevention of mistakes the core of operating room nursing All participants described how prevention is always at the core of their work. This means thinking ahead, trying to imagine everything that can go wrong, and taking steps to prevent such occurrences by using guidelines and checklists:
Our nursing aim is prevention, yes, preventing surgical complications. I think thats our main purposeit embraces everything.

They also described how they had to know the background of the patient, and their particular vulnerability and fragility that might increase risk during the operation. Thus, good preoperative patient-centred information that reects individual patients needs and vulnerabilities is essential. They described how they do not interview patients undergoing surgery themselves, apart from doing a standardized admission check, but rely on information from the patients records, particularly from the anaesthesia team. A number of participants said that in some situations they do not have all the information required preoperatively, especially in cases of specic patient needs. They suggested that better preoperative information would ensure patient-centred nursing, continuity of care, and better and more efcient preparation for the surgical operation. Expertise in teams The importance of teams in enhancing patient safety was mentioned by all participants. By dividing the work into teams, operating room nurses develop advanced knowledge of particular operations and a high level of performance. As one of them described:
Its [nursing] more professional, our nursing is better after we introduced teamwork in the operating room. You know the skills and knowledge of your team colleague, everyone knows what to do and things go smoothly. Were just more competent.

Findings
Enhancing patient safety
All the nurses who participated in the interviews described feeling responsible for the well-being of their patients. They often talked about their work as protecting the helpless, with prevention being of key importance in ensuring safety. Creating an environment of warmth, respect and safety for patients was essential to them, and they described how they try to create a quiet, relaxed and friendly atmosphere when greeting a patient. Focusing on the patient is central, and they try to keep conversations between themselves to a minimum while the patient is still awake. Three factors emerged as most important in enhancing patient safety: preventive

Although teams were seen as important for safety, and teamwork was mentioned as one of the strengthening elements of safety in the operating room, focus group participants identied potential weaknesses that needed to be attended to. The teams are often unequally staffed; some are under-staffed and often need support from other teams. Participants felt that this needed to be attended to by managers.
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Mutual trust and co-operation The nurses working in the operating room are in general experienced and represent a stable workforce. Many, although not all, have specialized education in operating room nursing and have worked in this area for many years, even decades. The relationship among the nurses working in both departments was described as supportive. They know each other personally and have developed relationships of mutual trust and co-operation. As one participant described:
You know your colleagues very well and its kind of another family when you have worked together for such a long time.

arrangements because they are scheduled for the operation and its difcult to have to make a decision that changes that schedule.

Many said that they feel addicted to the tension at work. They enjoy the thrill of the pace, and want to be efcient, but at the same time feel that it is at the cost of personal exhaustion. As one said:
Usually I am very, very tired when I get home. I am not tired while at work it is fun to be at work and I like my job and Im very proud of it but I am very tired when I get home.

Many participants described a positive feeling of belonging to a team. They know what to expect from their co-workers and have learned to deal with different personalities. However, it should also be noted that some drawbacks to teamwork were mentioned, such as lack of criticism and reluctance to change work processes.

Constant concentration This leads into the next theme, which reects the nature of operating room nursing. Participants described the work as complicated and demanding full, undivided concentration. Forgetting something can be detrimental, and being tired is cause for alarm:
You have to be alert all the time, being tired isnt an option. This kind of work demands full attention.

Threats to patient safety

A number of issues were identied as threats to patient safety. These relate to the work environment: the fatigue that builds up over time, concentration difculties, lack of control over situations, insufcient stafng and unclear expectations towards staff. The themes discussed in this section give rise to worries that there may be latent failures in the work environment that may lead to active failures (Reason 1990). Worries about demands for increased speed and productivity The hospital portrays itself in terms of productivity, as is reected in the increased number of operations performed and the reduction of waiting lists. The nurses described how, within this environment, they are expected to do more than before, and in less time. The time schedule for operations is tight, and many patients will be waiting for their operations. The pace must be kept up at all costs. The work processes are timed and, while the surgical procedure cannot be rushed, the nurses sense pressure to reduce time for preparation and time between operations. In general, they felt that they were still coping, but they worried about the future and wondered how long they could carry on working like this, i.e. feeling under pressure most of the time. They are always racing against time, so they are mentally exhausted at the end of the shift. One nurse described how difcult it becomes to try to slow down:
You know that there are patients in need of operations and they have been waiting, maybe dreading the procedure, and they have made

The pressure to increase the speed of the work and the number of operations during a shift was often mentioned as a serious threat to the ability to concentrate and to foresee and prevent errors. To withstand the pressure and ensure maximum performance, the nurses have become more cognizant of methods of relieving stress. Many said that they use exercise to reduce the tension that they experience after work and to prepare for the next shift. Staying t is for many of them imperative to cope with the pressure experienced at work. Lack of control of circumstances When asked what they thought causes error or mistakes, the nurses mentioned ignorance, lack of experience, distraction and haste. As one participant described:
When you try to do too many things at once in a short time with little prior experience, you run the risk of making a mistake.

This was experienced most acutely when they were placed in a novel situation. Many of the participants are very experienced, but they also feel that they have become specialized and that their expertise varies greatly depending upon the operations in which they participate. Stafng and the organization of work Sufcient stafng was a topic that emerged repeatedly both in individual interviews and in the focus group discussions. As the following quote from a nurse reects, to function at the speed currently expected, stafng must be adequate and the team must be competent:

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JAN: ORIGINAL RESEARCH The work must be organised. There are some surgical operations that need special stafng and when this happens those resources must be availableyou must have the nurses who are trained for those operations.

Nursing and patient safety in the operating room

Participants described how imbalance in stafng, which may be either under- or over-stafng, may lead to unsystematic preparation or distraction. They stressed that the division of labour and responsibility within the team needs to be clear. Plans must be made for breaks, and special caution is required around changes of shift. Rules on routine procedures such as checking information and counting must be followed at all times.

Addressing adverse events and mistakes

In the literature, incident reporting is commonly identied as a key method in addressing system-based errors. By reporting mistakes, errors are detected, analysed, discussed and attended to. A reporting system for adverse events has been in operation at the hospital for a number of years, although it is believed that incidents are grossly under-reported. Many of the nurses expressed scepticism about the value of formal incidence reporting, and felt that it might easily lead to blaming the victim. However, this does not necessarily mean that incidents are not attended to. The nurses described how incidents are commonly brought up in the teams, where nurses feel they can trust each other. In this way they provide support for each other, while also exploring what went wrong and how it might have been prevented, resulting in a change of task performance.

Discussion
Ensuring patient safety is the main focus of operating room nursing, as described by the participants in this study. The data also gave insight into what nurses see as enhancing and threatening patient safety during operations. To enhance safety, the nurses organize their work with the aim of preventing mistakes from happening. By specializing into teams they develop advanced knowledge of operations in particular areas and develop the skills needed for safe practice. Working in teams was also considered positive for work morale and a sense of mutual trust and co-operation which again was described as enhancing safety. Comprehensive knowledge of each patients individual needs was also seen as highly important. In general, the nurses demand high standards among themselves and practices are designed to detect potential errors before they occur.

Although serious failure or errors that have irreversible consequences have been uncommon at the hospital where the participants work, they discussed changes in the content and organization of their work that raise questions about their ability to ensure safety in the future. They described how the demands for higher productivity and attempts to keep up with waiting lists have increased the speed of work in the operating room, leading to experiences of pressure. Operations have also become more complicated and technically challenging, which has called for new knowledge and skills, while time for staff development has decreased. However, as the demands have increased, the work force, which until recently has been stable, has begun to show signs of vulnerability. Due to lack of trained nurses and an increase in sick leave, imbalance in stafng has increased. All of this was identied as potential sources of risk of mistakes by the participants, or what Reason (1990) refers to as latent error. In many ways, our ndings coincide with those of a recent multinational study carried out in Finland, the USA and the UK (Silen-Lipponen et al. 2005). In both studies, teams function in enhancing safety. The stability of teams is seen as important in advancing skill, which may minimize errors. The nurses in both studies describe working under constant pressure, while at the same time having to be alert and provide quality care and safety for the patient. Occupational-related stressors such as heavy workload, shortage of staff and pressure to work faster have also been shown to affect nurse anaesthetists concern for patient safety. They, like the nurses in our study, link their concern among other things to lack of time for preparing and reviewing patient-centred information before each surgery (Perry 2005). The ndings reported here and from other studies should cause alarm among managers and policy makers. There are strong indications that operating room nursing is under considerable strain, which may in the long run lead to increased errors. Caution must be exercised in attempts to increase productivity. A number of strategies to improve safety were discussed among the participants in this study, some of which have also been described in the literature. Operating room nurses use checklists and many participants mentioned them as helpful when in a constant hurry. However, they felt that the exchange of information at the change of shifts or during breaks had to become more formalized and secure. Incident reporting is a strategy that has been described in the literature as a tool to identify system weaknesses (Dunn 2003a,b). Its purpose is to gather and analyse condential

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What is already known about this topic

Patient safety has received a great deal of attention in health care but there has been relatively little empirical research on this topic. Patient safety has been linked to factors in the work environment such as communication and management decisions. Nurses have identied the most common causes of error as lack of knowledge, information and supervision, heavy workload and poor judgement, which may be lead to both active and latent errors.

Study limitations
The data on which this paper is based came from a sample of operating room nurses working at a university hospital in Iceland. Clearly, this hospital does not reect the organization and performance of operating room nursing universally. In addition, the qualitative research design does not warrant generalization to all operating room nursing. Despite these limitations, the ndings give a valuable insight into the nature of patient safety in the operating room and support ndings from other studies (Silen-Lipponen et al. 2005).

Conclusion What this paper adds

Operating room nurses identify securing patient safety as their most important nursing intervention. Patient safety is strengthened by a culture of prevention and protection and the organization of work into specialty teams, while demands for enhanced productivity and stafng imbalance can threaten patient safety. Nurses clinical and organizational expertise can be used to correct latent errors, avoid active errors and improve the work environment. In light of the main ndings of this study, which indicate that operating room nursing is under considerable strain and that the work environment is increasingly characterized by latent error, it seems imperative to conduct further research on the impact that the demand for increased productivity has on patient safety during operations.

Author contributions
HA and KB were responsible for the study conception and design and the drafting of the manuscript. HA performed the data collection and HA and KB performed the data analysis. HA obtained funding and HA and KB provided administrative support. HA and KB made critical revisions to the paper. KB supervised the study.

information so that future incidents can be prevented. Rather than being used as a method to identify individuals who are incompetent, the focus is on the system as a whole and represents a new way of thinking about nursing error management (Johnstone & Kanitsaki 2006). Incidence reporting has been in operation at the hospital were this study took place for a number of years, but this is not working. Practitioners do not report what happens and, as this study revealed, they are sceptical about condentiality and the purpose of the system. Technical competence and caring for the patient are closely connected elements of everyday work in the operating room, but have sometimes been portrayed as oppositions. Operating room nurses have experienced confusion about their image and the core of their work (Tanner & Timmons 2000, Sigurdsson 2001, Riley & Manias 2002, Bull & FitzGerald 2006). Therefore, it is interesting to note that the nurses who participated in this study had a clearly articulated aim, which was to ensure patient safety during surgery. These ndings seem to suggest that patient safety should be at the centre of operating room nurses conceptualization of their practice.

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