DOCTOR OF NURSING RESEARCH PORTFOLIO

Pressure Ulcer Prevention

in the Perioperative Environment

Ms Judith Berry RN BN MN

Submitted in fulfilment of the requirements

for the Degree of Doctor of Nursing

Department of Clinical Nursing

University of Adelaide

August 2004

TABLE OF CONTENTS

Page

Certificate

Acknowledgments

Portfolio Overview

References

There have been many people who have provided encouragement, support and advice during the
completion of my studies, and I wish to acknowledge them, for without them the road would have
been just that bit more difficult.

Dr. Helen McCutcheon, supervisor and friend for her guidance, encouragement and confidence to
succeed.

Dr. David Evans, always patient, whose assistance through the critical review was invaluable.

Dear Pat, whose keyboard skills have supported me from the very beginning to now my swan
song!

To Marion, friend and fellow student, always calm and rational.

Lastly, my thanks to those nurses who participated in the research and went out of their way to
support the project, and those who simply gave a kind word and had faith in my ability to succeed.

Photograph of Operating Room, Royal Adelaide Hospital reproduced with kind permission by the History & Heritage
Office, RAH.

Portfolio Overview
There are many terms used to describe pressure ulcers: pressure sores, decubitus ulcers, bedsores,
and pressure necrosis or ischaemic ulcers. Essentially they all describe damage to the patients skin
and underlying tissue.

The nursing literature abounds with information about the risk, grading, prevention and treatment of
pressure ulcers. These ulcers are a problem in hospital and long term care facilities, and are a major
cause of morbidity. In the hospital setting they contribute to an extended length of stay and by doing
so block the bed for use by another patient. The ulcers are difficult to treat, are an ongoing cause
for pain and discomfort for the patient and can be a strain on hospital finances.

Pressure ulcers are not unique to modern times, as they have been discovered on the remains of an
Egyptian mummified body (Armstrong & Bortz 2001). This would suggest that the problem dates
back to the Pharoahs, and has continued to be a challenging problem throughout the centuries
(Bridel 1992). The escalating costs of treating these ulcers today, has brought about an emphasis on
the risk factors, prevention and the appropriate interventions, rather than an acceptance of these
ulcers as a tolerable condition (Bridel 1992).

In the operating room, nurses are faced with unique challenges when caring for their patients. This
is due to difficulty in caring for patients under the influence of the anaesthesia required for surgery,
long periods of forced immobility and the inability of the patient to perceive pain and discomfort
from the pressure of the hard surface of the operating room table. These problems are increased by
nurses inability to gain access to the patient because of the sterile drapes required to cover the
patient for surgery. Armstrong and Bortz (2001) present information from one study in which it is
stated that surgical patients have 90% greater chance of developing pressure ulcers than medical
patients. One reason for this may be due to the limited information available in regard to the most
4

effective support surface to place on top of the operating room table. This gap in information is
problematic for operating room nurses as it limits their ability to select the most effective item of
equipment, and determine if the chosen equipment reduces pressure on tissue intra-operatively.

The most effective operating room table mattress used and the skills and knowledge of the
operating room nurse about the aetiology and prevention of pressure ulcer prevention, are important
aspects of nursing care and can influence patient outcomes. The potential for complications to occur
may be dependent on single or combined factors such as the patients age, disease processes,
nutritional status and mobility. Preparatory and supportive nursing interventions for surgical
procedures based on best available evidence, nursing experience and patient preference, can reduce
the incidence of pressure ulcer development in the perioperative environment.

This doctoral portfolio contains four separate sections related and linked together by a common
theme pressure ulcer prevention in the perioperative environment. This first section of the
portfolio situates the topic and provides a brief overview of the portfolio.

The second section is a critical review of the literature pertaining to the most commonly used
operating room table mattresses, and the effectiveness of these mattresses in the prevention of
pressure ulcer development. This review highlighted a lack of quality research in this area, and
while many evaluations have been undertaken to determine the effectiveness of operating room
table mattresses, the results are contradictory concerning the patients, exposures and interventions.
Because of issues related to the methodological quality of published research in this area a
systematic review using meta-analysis was not possible rather a critical review of the research
literature is used.

The third section of the portfolio reports on a hermeneutic ethnography of the perceived skills and
knowledge of nurses in the prevention of pressure ulcer development in the perioperative
environment. This study was designed to determine if pressure ulcer prevention forms an aspect of
the everyday practice of perioperative nurses. This review has highlighted the need for operating
room nurses to review practices when caring for patients in the perioperative environment
particularly in respect of pressure ulcer prevention.

The fourth and final section of the portfolio summarises the research and provides
recommendations for nursing practice and further research in the area of pressure ulcer prevention
in the perioperative environment.

References
Armstrong D., Bortz P. (2001) An Integrative Review of Pressure Relief in Surgical Patients.
American Operating Room Nurses Journal. March 73 (3): 645 674 (p. 5).

Bridel J. (1992) Pressure sores and intra-operative risk. Nursing Standard. October. 21 (7): 28 30.

Pressure Ulcer Prevention in the Perioperative Environment:

A Critical Review of the Literature

INDEX

Page

ABSTRACT

How it all began

Rationale for the Critical Review

Background

Historical Perspective

Aetiology of Pressure Ulcers

Pooled solutions for skin preparation

10

Skin shearing and friction occurring during positioning

10

Intra-operative hypotension

10

Alteration in haemodynamic and circulatory status

10

Tissue Tolerance for Pressure

11

Intrinsic factors

11

Extrinsic factors

11

Intensity and duration of pressure

11

Pressure Ulcer Classification Systems

12

Risk Assessment Tool

12

Incidence and Prevalence of Pressure Ulcers

13

Summary of the Background

14

Introduction

16

Pressure-relieving interventions

17

Critical Review Process

22

Objective

22

Methods

22

Types of studies

24
1

Page

Search Strategy for Identification of Studies

25

Assessment of Methodological Quality

26

Data Collection

27

Data Analysis

28

Results

28

Standard Foam Operating Table Mattress

Findings

31

Results

32

Foam Pads

38
42
46

Gel-filled Pads

51

Results

51

Overlays

53

53

Results

Discussion

37

Results

Results

Gel-filled Mattress

30

56

Implications for Practice

58

Conclusion

62

References

65

Appendix 1

Inclusion Criteria = Elderly Perioperative Patients

71

Appendix 2

Critical Appraisal = Perioperative Patients

72

Appendix 3

Data Extraction Form

73

Appendix 4

Summary of major studies included in the study

76
2

Page
Appendix 5

Excluded studies

82

Appendix 6

Hand searched reference books

84

Appendix 7

Hand searched journals

85

Appendix 8

Hand searched conference proceedings

86

Table 1

Norton Scale Scores of 14 or below, rate the patient as at risk

13

Table 2

Standard Foam Mattress

32

Table 3

Standard Foam Mattress and Dynamic multi-cell mattress

33

Table 4

Standard Foam Mattress and Dry visco-elastic polymer mattress

37

Table 5

Evaluation of Foam Pads

39

Table 6

RCTs - Gel-filled Mattress

44

Table 7

Alternating air device, dry visco-elastic (gel-filled mattress

and standard foam)

50

Table 8

Evaluation of gel-filed pads

52

Table 9

RCTs Overlays

55

Meta-analysis of the micro pulse system

34

Tables

Figures
Figure 1

ABSTRACT
Pressure ulcers are a pervasive problem in hospital environments, causing great distress to the
patient and family and are a major cause of morbidity and prolonged hospital stay. The intraoperative situation is one period of greatest risk of pressure ulcer development for the surgical
patient as body tissues are subjected to pressures which are applied in a non-uniform manner. The
result is often localised tissue damage, and if the unfavourable conditions are prolonged, necrosis,
tissue breakdown, and the development of a pressure ulcer occur.

Unfortunately, operating room tables are designed for utility not comfort and to maximise the
ability of the surgeon to expose and manipulate the surgical wound. Conventional operating room
table mattresses are generally composed of two inches of foam, covered in thick black hard
laminated vinyl fabric, considered as a standard fitting, with little evidence to suggest it assists in
the prevention of pressure ulcer development.

This critical review was conducted to summarise the best available evidence on the most effective
operating room table mattress in pressure ulcer prevention.

How it all began: The Pressure to Bear

A chance conversation between the researcher and a surgical registrar as they discussed the order of
patients for surgical interventions the next day, was the catalyst for the study. When remarking on
the perceived increase in the number of patients scheduled for skin grafting procedures to pressure
ulcers in the past few weeks, the registrar replied this is just the tip of the iceberg, there are
some (patients) out there (ward areas), who are not as bad as these, but do have them! The
researcher continued to question the registrar further, enquiring if the patients had undergone
surgery recently, had been admitted from nursing homes, or had in fact, been admitted from home.
The response was, all following surgery except one. This was a real cause of concern and many
questions arose from that conversation.

was their surgery a long procedure,

what were the patients positioned on for surgery,
had extra equipment been used in an attempt to reduce pressure and had not proven to be
effective,
what steps had the nurses taken, if any to prevent pressure ulcer development,
what did the nurses know and understand about pressure ulcer prevention.

One thing these patients all had in common was the surface of the operating table, the other was
nursing actions.

It was at this stage that the decision to investigate the most commonly used operating table
mattresses used in the study setting, the skills and knowledge of nurses caring for patients in the
environment and their responsibility in pressure ulcer prevention was made. Regardless of the terms
used to describe these ulcers, they remain a significant problem in both hospital and community
settings. The need to reduce the incidence has been well documented; unfortunately there is little
evidence to suggest any major new improvements have been made.

Rationale for the Critical Review

When the literature was searched and read it became clear that few if any of the studies would meet
the inclusion criteria and methodological quality required for a systematic review. Bearing this in
mind and cognisant of the need to present the available research in a rigorous manner, a decision
was made to undertake a critical review of the literature. Mulrow and Cook (1998) consider a
critical review to be the qualitative equivalent of a systematic review. However much debate
continues about levels of evidence and the value of interpretive research that are not within the
scope of this study. Rather the researcher decided to present the research available in the most
suitable way, in this case as a critical review of the literature on pressure ulcer prevention in the
perioperative environment.

Background
Over the years much has been discussed, written and published, about the development and
prevention of pressure ulcers, however a literature review of intra-operative pressure ulcer
development suggests that there is a casual relationship between the events experienced by the
patient during surgery, and the subsequent development of pressure ulcers (Gendron 1980, Stotts
1988, Bridel 1992, Bridel 1993a, Bridel 1993b). Abundant literature spanning health care settings
and various specialties reveals that it is cost-effective to focus on the prevention of pressure ulcers
rather than the treatment of them. Yet despite there being a general consensus that pressure ulcers
are adverse events that on the whole are largely preventable, they continue to be a problem in all
health care settings. The outcome implications of these ulcers should be considered in terms of pain
and discomfort, decreased mobility, a loss of independence, and a potential source of social
isolation for the patient, distress for family and friends in addition to the resource implications.

Armstrong and Bortz (2001) present information from one study, in which it is stated that patients
who undergo surgical procedures have a 90% greater chance of developing pressure ulcers than
3

medical patients. Recommendations for the care of the patient during the intra-operative period are
limited to the provision of equipment for operating room tables which do not impinge upon the
stability of the patients position, safety, anaesthetic or surgical requirements (Horschowsky &
Schraam 1994).

There are a number of inherent risk factors that have direct correlation to pressure ulcer
development, namely the age of the patient, their nutritional status, body temperature, co-morbidity,
mobility status and body size, the most statistically significant intrinsic factor, is the age of the
patient (Armstrong & Bortz 2001). When the age of the patient is combined with at least one other
co-morbidity, conditions such as hypertension, vascular or respiratory disease, or diabetes mellitis,
then the chances of the elderly surgical patient developing a pressure ulcer is greatly increased
(Armstrong & Bortz 2001).

The skin of the elderly patient is relatively easy to damage, and great care is needed when handling
or moving the patient. This is due to the ageing process that causes a thinning of the dermis with a
reduction both of the tensile strength, in tissue perfusion and a lessening of sensation (Dellasega &
Rothrock 1990). For these reasons, the elderly surgical patient presents a challenge to operating
room nurses, who are required to implement all the skill and knowledge they have about pressure
ulcer prevention, in order to minimise the risk of the development of ulcer and skin damage
(Armstrong & Bortz 2001).

Turning patients for pressure and shear relief is common practice in ward areas but is not practical
for patients undergoing surgery because of sterile environment. Special support surfaces for weight
distribution and alternating pressure also face a number of unique difficulties. Some of the newer
surfaces that are conformal enough to provide even moderate pressure reduction risk, create some
patient movement as various pressures are applied to the patient through the contact with members
4

of the surgical team performing surgical manoeuvres (Aronovitch, Wilber, Slezak, Martin & Utter,
1999). Others tend to raise the height of the operating room table and this can make surgery difficult
for the surgeon and those assisting with the procedure, as they may be required to stand on
platforms / stools in order to access the open wound. For these reasons finding surfaces that are
effective in reducing the risks of pressure ulcer development, whilst at the same time providing
stability for both patient and surgeon during the surgical intervention, is difficult (Aronovitch et al
1999).

One of the better materials available is a two-layered polyurethane foam. This is a synthetic
material formed by combining liquid chemicals, which react together to form a long molecular
chain process that ultimately results in polymerisation. A rising agent is then added and results are a
honeycomb effect. An important indicator of foam quality is density and the higher the density the
greater the durability of the item. The end result is a material that is soft, elastic, light and durable,
takes up the contours of the patient and effectively evens out the distribution of the patients weight,
maximising the area over which the body weight is distributed and is reported to prevent ulcer
development. Unfortunately this material is unavailable as a mattress for operating room tables
(Huntleigh Healthcare 2001). Enquiries to the company in April 2003, about the development of an
operating room table mattress in this material have not been answered.

The standard operating room table is generally recognised as being a long, single piece of 1 2
inches of foam confined in a hard, thick non-stretch laminated fabric cover which is easy to clean,
flame resistant and non-allergenic, however it does not reduce capillary pressure therefore does not
prevent the development of pressure ulcers (Armstrong and Bortz 2001).

The life expectancy of the standard foam mattress is limited, due to the constant flattening of the
foam by the weight of the patient. Many types of mattresses have been developed from a variety of
5

materials and purchased by organisations on the recommendations of the manufacturers, often with
little or no evidence that they prevent the development of pressure ulcers. It is unclear to what
extent mattresses currently used in the operating room environment can prevent pressure ulcers and
whether any one system is better than another.

Although a number of assessment tools have been designed to assist in the prevention of ulcer
development, these are on the whole unsuitable for use in the operating room where there is a need
for complete immobility of the patient during surgical procedures. In other environments there is
usually the opportunity to move the patient, albeit for brief periods of time. There is also the
potential to use support surfaces which have the ability to vibrate gently, therefore stimulating skin,
muscle and tissue, preventing stagnation of blood and bringing perfusion to the tissues, however
this is not the case in the Operating Room (OR).

Currently there is lack of nationally accepted guidelines, and evidence, in regard to the most
appropriate operating room table mattress and this is of concern as this deficit allows the use of
personal preferences, myths and traditional practices to determine the type of mattress use in the OR
environment.

A number of quality assurance studies conducted in the operating rooms have concluded that,
Anaesthesia + low blood pressure + immobility + vascular compromise predisposes to tissue
damage because cellular demands are not being met (Aronovitch 1999, p. 131).

Whilst there is a number of publications addressing this issue, there does not appear to be an
attempt to systematically collect, critically appraise and summarise current research. (Neander &
Birkenfield 1991, Horschowsky & Schraam 1994, Aronovitch 1999a, Aronovitch 1999b, Defloor &
deSchnijmer 2000).
6

Historical perspective
Pressure ulcers are not unique to modern times, as they have been discovered on the remains of an
Egyptian mummified body (Armstrong & Bortz 2001). This would suggest that the problem dates
back to the time of the Pharoahs and has been a challenging phenomenon throughout the centuries
(Bridel 1992). Because of the escalating costs of treatment of ulcers, the emphasis is on prevention
and the identification of risk factors, and the implementation of appropriate interventions, rather
than acceptance of pressure ulcers as a tolerable complication (Bridel 1992).

In the operating room environment the registered nurse is responsible for the positioning of the
patient for surgery and the selection of positioning aids. It is therefore essential that the nurse
maintains a current knowledge about the most efficient and effective mattresses and aids to use.
However the operating room environment and its relationship to the prevalence of pressure ulcers
for some patients have received little attention in contemporary research (Harley 2003).

The activities that take place within the operating room environment are a cause for concern in
terms of pressure ulcer development. Examples of this are issues such as pooled solutions, metal
operating room tables, hard mattresses and the shearing and friction that may occur when moving
the patient. Over the years researchers interested in pressure ulcer development have focused their
attention on settings other than the operating rooms (Armstrong & Bortz 2001). The reasons for this
are partly due to the difficulties encountered when attempting to extrapolate the results of studies
conducted in the operating room environment to other areas, because of the specific risk factors
associated with the operating room experience (Armstrong & Bortz 2001). Patients are often placed
on positioning devices that make it difficult to estimate the degree of pressure exerted on parts of
their body, and therefore make it problematic to obtain results that could guide practice. The
Braden Scale (Braden & Bergstom 1987) is one tool used to assess patient risk in terms of pressure
ulcer development and has been tested repeatedly for validity and reliability, but although useful in
7

the clinical evaluation of patients at risk of pressure ulcer development, it is not helpful in guiding
effective interventions to reduce pressure during surgery. This tool and others, however, have not
been tested in the perioperative setting where there is a lack of consistent turning schedule,
immobility and inactivity, due to the requirements of anaesthesia and surgery.

Previously damage to skin sustained in the operating environment was frequently attributed to a
burn and overlooked by ward staff. The ulcer may not be apparent on completion of the surgery,
and 3 to 5 days may pass before there are visible signs of tissue damage, mistakenly attributed to
the procedure rather than to pressure. The subsequent development of lesions thought to be injuries
are actually non-diagnosed pressure ulcers (Defloor & de Schuijmer 2000).

Recently there has been a focus on the operating rooms as an etiological factor in the development
of pressure ulcers. It has been suggested that all patients should be considered at risk for skin
damage because of the risk factors that cannot / or are difficult, to control, such as length of the
operative procedure (Armstrong & Bortz 2001).

Aetiology of pressure ulcers

For patients at risk of pressure ulcer development, compression of soft tissue between a bony
prominence and an external hard surface for even a short time can result in damage to the tissue and
eventually in a pressure ulcer. All levels of body tissue can be involved, epidermis, dermis,
subcutaneous fat, muscle and at worse bone. The manner in which the pressure is applied requires
consideration. If pressure is applied in a uniform manner then there may be little or no impact on
tissue and skin surface. Damage occurs when pressure is applied to local areas such as patients
elbows, sacrum and occipital regions. The duration and intensity of pressure to specific areas of the
body has great variation and is related to other factors such as the individual patients capacity to
tolerate the pressure, whether or not they are thin, their age, oxygen saturation, diet, moisture,
8

physiological and psychological stressors and exposure to shear and friction (Russell & Lichtenstein
2000). Shear and friction occur when patients are not lifted from one surface to another, but
dragged over rough surfaces, usually bed linen, therefore proper lifting and manual handling
techniques are essential for patient transfers.

Pressure ulcers arise over bony prominences, and the common sites include:

Scapula, occiput, sacrum and heels when the patient is placed in the supine position,
Ear, shoulder, trocanter, medial knee, ankle and foot edge when patient placed in the
lateral position,
and nose, forehead, chest, iliac crests, foot edge, and toes when patient placed in the
prone position.
(Armstrong & Bortz 2001, p. 647).

There is an inverse relationship between time and pressure. Patients can usually endure a great
amount of pressure during a short period of time, or minimum amount of pressure over a longer
period without experiencing tissue damage. Neither time nor pressure alone causes damage
(Armstrong & Bortz 2001). Prolonged pressure applied to a localised area of the body results in
occlusion of blood flow causing tissue ischaemia and destruction.

The elements of pressure ulcer development are the intensity and duration of pressure and the
tolerance of the skin and its supporting structures for the pressure. Often damage to deeper
structures may be far more extensive than observed at the skin surface (Pope 1999). Aronovitch
(1999a) believes that many nurses in the ward areas, do not make any connection with surgical time
and the development of ulcers post operatively, and are not familiar with the differences between
traditional and intra-operative pressure ulcers, often describing the latter as unexplained burn like
lesions, that are observed after lengthy surgical procedures that frequently and quickly deteriorate.

Of course there are other contributing factors and these include,

Pooled solutions used to prepare skin
Pooled preparation solutions may cause maceration to the skin, changing the pH of the tissue and in
doing so remove protective oils, making the skin more susceptible to friction and pressure.
Skin shearing and friction occurring during positioning
Shearing and friction occurs when the outer layer of skin slides across a surface and consequently
the tissue situated below the skin becomes damaged. These two factors require specific
consideration in the operating room environment. This also occurs when the anaesthetised patient is
moved on the operating room table without lifting them from the bed; the patient is dragged into
specific positions. The result of this is twisting and tearing of the underlying blood vessels and this
results in ischaemia and eventually necrosis (Waterlow 1996).
Intra-operative hypotension
Armstrong and Bortz (2001) report that in one study, a group of researchers found skin blood flow
decreased by up to one half of the level measured during the preoperative phase of the patients
surgical experience, in patients who developed pressure ulcers. This change was due to the effects
of anaesthetic agents that inherently interrupt and alter blood pressure, tissue perfusion and response
to pressure.
Alteration in haemodynamic and circulatory status related to the patients position and blood loss
An alteration in haemodynamic status and a deficit in perfusion, may lead to tissue hypoxia
and an increase in the risk of pressure ulcer development. The severity of tissue damage is
proportion to blood flow, and the defective response of the skin tissue (Armstrong & Bortz
2001).

10

Tissue Tolerance for Pressure

Tissue tolerance is the ability of both skin and its supporting structures to endure the effects of
pressure without adverse sequelae. It demonstrates how well the tissue acts as a cushioning factor,
transferring pressure loads from the skins surface to the skeleton below. Pressure can be defined as
a perpendicular load or force exerted on a specific area of the body (Australian Wound
Management Association 2001). When prolonged pressure is applied to that area, the tissue can be
denied blood flow causing ischaemia and injury. Perfusion injury and the ischaemic changes, result
in cell destruction and the death of tissue.

If toxic substance removal is hampered this contributes to the tissue necrosis. This is affected by
extrinsic and intrinsic factors. These factors will not cause tissue ulceration in the absence of
pressure.

Intrinsic factors
These factors are inherent among patients undergoing surgical procedures, and exhibit a direct
relationship in the prediction of pressure ulcer development

the age of the patient,

body temperature and
nutritional status.

Extrinsic factors
These factors, when combined with the effects of the intrinsic factors, intensify the risk of
developing a pressure ulcer;

heat and
moisture.

Intensity and duration of pressure

Braden and Bergstrom (1987) believe that the critical elements of pressure ulcer development are:

the intensity and duration of pressure, and

the tolerance of the skin and its supporting structures for pressure.
11

Risk factors that contribute to the patient being exposed to prolonged and intense pressure can be
classified as factors which impede mobility, activity, and sensory perception, with immobility and
diminished activity being considered as primary risk factors in the development of pressure ulcers.

Information from the Australian Wound Management Guidelines (2001) also indicates that any
factor which exposes the skin to intense pressure, or diminishes its tolerance to pressure, is
considered a risk factor. The surgical patient is exposed to all these factors throughout their surgical
experience. There are many risk factors referred to in the literature, but few, such as operating table
mattresses and tissue interface pressures, have been evaluated rigorously, and the operating room as
an etiologic factor is largely undefined (Scott, Mayhew, Harris 1992, Harley 2003).

Pressure ulcer classification systems

Pressure ulcers are generally classified using a system designed to assess the degree of observed
tissue damage. Using a classification tool it is hoped will allow for a universal assessment and
consistent communication of the severity of tissue damage among nursing, medical and allied health
care workers.

Risk Assessment Tool

The purpose of a risk assessment tool is to identify individuals at risk of developing pressure ulcers.
The aim of any risk management strategy is to shift the focus from crisis intervention to
preventative management. The risk assessment tools are based on risk factors known to predispose
an individual to pressure ulcers. They generally utilise a numerical scoring system to weight the
severity of risk into categories. These tools assist health care professionals to identify individual
patients at risk, but they are not designed to replace clinical judgement. An example of an
assessment tool is presented in Table 1. This tool by Norton was one of the first developed for use
in the areas of geriatrics. It is simple, based on five areas, and utilises a scoring system which

12

indicates the level of risk. There have been some criticisms of it over the years, but it still remains
one of the most widely used assessment tools (Bridel 1993).

Table 1

Norton Scale Scores of 14 or below rate the patient as at risk.

Physical
Condition
Good
4
Fair
3
Poor
2
V. Bad
1

Name

Mental
Condition
Alert
Apathetic
Confused
Stuporous

Activity
4
3
2
1

Ambulant
Walk/help
Chairbound
Bedfast

Mobility
4
3
2
1

Full
Sl. Limited
V. Limited
Immobile

Incontinence
4
3
2
1

Not
Occasionally
Usually
Doubly

4
3
2
1

Total
Score

date

Source: Doreen Norton, Rhonda McLaren, and A.N. Exton-Smith 1962. An investigation of geriatric nursing
problems in the hospital. London. National Corporation for the Care of Old People (now the Centre for
Policy on Ageing).

Incidence and Prevalence of Pressure Ulcers

A great variation in reporting both the incidence and prevalence of pressure ulcers serves to
demonstrate the inconsistencies in data collection and how pressure ulcers are classified and
defined. If reliable data were available, the diagnosis and risk factors, incidence and prevalence of
pressure ulcers by stage, and the environment in which the ulcer has arisen could be used to inform
best practice (Pressure Ulcer Interest Sub-committee 2001).

The incidence and prevalence of pressure ulcers is reported by a number of authors as varying
widely according to the population, the clinical environment and research methodology used
(American National Pressure Ulcer Advisory Panel 1989, Aronovitch et al 1999, Bridel 1993,
Cullum, Deeks, Sheldon, Song & Fletcher 2000, Donnelly 2001, Komanestsky 2000, Australian
Wound Management Association, Pressure Ulcer Interest Sub-group 2001).

13

A number of obstacles form the methodological barriers to the interpretation and comparison of
incidence and prevalence of pressure ulcer studies namely:

Difficulties in the comparison of the various patient populations, such as data collected
from acute care facilities and community institutions.

Sources of the data collected ranged from direct observations of patients by

appropriately trained researchers to retrieval of information from medical records.

Study results that may include or exclude ulcers classified as Stage 1, and sections of
populations such as paediatrics and obstetrics.

Study methods often confuse incidence and prevalence.

Operating room table mattresses not covered in a manner that concealed the composition
of the equipment so that true randomisation was not possible.

(Hoshowsky & Schramm 1994, Nixon et al 1998, Cullum et al 2000, Australian Wound
Management Association, Pressure Interest sub-group 2001).

Summary of the Background

Effective patient positioning has been a focal point throughout the history of surgery. Among the
many benefits of proper positioning, preservation of the patients skin is an important factor.
Pressure ulcers are not unique to modern times, and even although there is abundant literature
spanning various practice settings and specialties that reveal it is more cost effective to focus on
prevention rather than treatment of the ulcers, the condition persists. Unfortunately most of the
research focuses on the long-term care setting with little attention given to the operating room
environment.

Surgical patients present a unique challenge in preventing pressure ulcers because the patients are
immobile and unable to perceive discomfort and pain. Operating room tables are designed for
utility, not comfort. During surgery patients are positioned to accommodate the various surgical
positions, and to maximise the ability to expose and manipulate the surgical site. The conventional
operating room table mattress is composed of foam, and there are newer products now available.
14

The table mattress is normally fitted with mattress sections which correspond in size with the head,
torso and foot section of the table. The foot section generally is affected because the patients heels
invariably rest in this area. Pillows and wedges can be used to assist positioning, maintaining body
alignment and protecting direct contact between bony prominences. The protection of the patient
can not be the responsibility of nurses alone, all members of the operating room team have a key
role to play in the reduction of the incidence of pressure ulcers. The team need to be aware of their
role in prevention strategies and the need to constantly review best practice based on research.

15

Introduction
Perioperative nurses are faced with challenges when caring for their surgical patients. Because of
the long periods of immobility and inability to perceive pain and discomfort from the prolonged
pressure on the operating room table mattress, these patients are at risk of developing pressure
ulcers. Whilst many patients in ICU environments may be immobile, nursing staff can re-position
them to relieve pressure; this is unlike patients undergoing operative procedures that demand the
patient remain in pre-determined positions for long periods.

The intra-operative period is a time of greatest risk for the hospitalised surgical patient. Surgery is
one of the few times an individual, who is not normally at risk, is placed at high risk of the
development of pressure ulcers (Stewart 1998).

It is only when preventative interventions,

supported by evidence, are targeted to those patients at greatest risk, can the cost-effectiveness of
preventative measures be realised and quality nursing care of all patients, be introduced.

Nixon, McElvenny, Mason, Brown and Bond (1998) indicate that in the United Kingdom alone, the
extent of intra-operative pressure ulcer development for patients within the National Health Service
(NHS) is unknown, yet many hospital pressure ulcer prevention policies include strategies for
operating rooms. Recommendations for the intra-operative period are limited to the provision of
equipment designed for operating tables which do not impinge on the stability that is required for
the patients position and safety, or anaesthetic and surgical needs (Nixon et al 1998).

There are many products available for use on the operating room table; these include foam
mattresses, dry elastic polymer pads (Action Pads), displacement cell mattresses and silicone fibre
overlays. In 1994 none of the product types had been subjected to any clinical evaluation by
randomised controlled trial (Bridel 1993a). It appears from contemporary literature that very little
has changed since that date, and it remains largely unclear to what extent these surfaces can prevent
16

pressure ulcers, and whether any surface is better than another (Cullum, Decks, Fletcher, Sheldon,
Song 2001). The dry visco-elastic polymer pad and the displacement cell mattress were the only
two that had been evaluated (Nixon, McElvenny, Mason, Brown, Bond 1998). However these
tests were conduced with healthy, non-anaesthetised volunteers, and in a laboratory environment
therefore the results need to be considered and interpreted with caution (Neander & Birkenfield
1991, Moore, Rithalia & Gonsakorale 1992).

Pressure-relieving interventions
The aim of pressure ulcer prevention strategies is to reduce the magnitude and/or duration of
pressure; this includes shear and friction, between a patient and their support surface, or the
interface pressure. This may be achieved by regular manual repositioning for example, two hourly
turning in the ward environment or by using a special bed. Alternatively it may consist of using
pressure-relieving support surfaces, such as cushions, mattress overlays, replacement mattresses or
whole bed replacements. The cost of these interventions varies widely, from as little as $100 to over
$30,000. However there appears to be little information on the relative cost-effectiveness of this
equipment. This information is needed in order to aid in decision-making about the use of some of
the items (Cullum et al. 2001). Nationally accepted evidence about the most cost-effective
equipment for use in the prevention of pressure ulcer development will benefit nurses and patients
by favourably modifying preventative practices, while decreasing vulnerability to litigation. The
continuing threat of fault-based litigation against sub-standard practices and facilities provides an
on-going safeguard of patient rights (Beyer 2000).

Pressure ulcers are expensive to manage, difficult to heal, and demoralising to affected patients
(Komanetsky 2000). The costs associated with this include funding to hospitals to cover the
employment of staff and specific supplies used in the treatment of these wounds (Komanetsky
2000). There is also the potential for legal action to be taken against the hospital, and nursing staff
17

may be called upon to act as a witness to patient care practices within the organisation (Komanetsky
2000).

Price, Bale, Newcombe and Harding (1999) believe that the use of high tech equipment is not
always the most effective equipment for the prevention of pressure ulcer development. Maintenance
of high tech, high cost systems is bound to have an impact on the growing demand for funding in
health care systems.

A national approach towards this problem is necessary in order to resolve the problem. Care and
equipment use based on rigorous research will contribute towards better standards of care and the
potential to save governments funding that could be reallocated for other patient care needs (Price et
al 1999).

In the ward setting there are a number of interventions that can be implemented to reduce the
incidence of pressure such as changing position, massage, and of course a number of supports, from
sophisticated dynamic mattresses to simple items such as pillows. However many of these
interventions are unsuitable for use in the operating room and frequent turning and mattresses that
constantly move are inappropriate as the patient is required to remain motionless for surgery. Any
movement, however slight, may have serious ramifications as the surgeon may inadvertently
damage tissues other than those identified for surgery. Once sterile drapes have been placed on the
patient and sterile field is developed, they become inaccessible to the nurses. The Australian
College of Operating Room Nurses recommends that any handling of the sterile drapes, once
positioned on the patient for surgery, is a breach in aseptic technique in that the sterile field is
contaminated and patient care compromised due to an infection risk (ACORN 2002).

18

Several types of operating table mattresses have been developed to reduce interface pressure. The
required characteristics for these items of equipment are stability, firmness, pressure reduction and
even pressure without flattening, collapsing or bottoming out. The result of the last three
characteristics of the mattress not being available due to damage or wear and tear results in the
patient resting on the underlying hard surface, defeating the purpose of the mattress (Hoshowsky &
Schramm 1994, Schultz, Bien, Drummond, Brown & Myer 1999).

Pressure-relieving cushions, beds and mattresses, called constant low pressure devices, either mould
around the body shape of the patient and distribute the weight of the patient over a larger surface
area or by a mechanical method varies the pressure under the patient. This in turn reduces the
duration of the pressure applied, and is termed an alternating pressure device (Bliss and Thomas
1993). Constant low pressure devices either in the form of overlays, mattresses or replacement beds,
can be grouped together according to the construction and manufacture of them. These items
include materials such as foam, foam and air, foam and gel. There are other devices available that
alternate inflation and deflation of air filled cells, these generate high to low interface pressure
between the patient and the body support surface. All these devices can be used in many and varied
situations and environments, ward areas, high dependency unit and long term care facilities.
However the use of some of these devices in the operating room is problematic due to the need for
the patient to remain in specific, and at times, unnatural positions, for several hours during their
surgical procedure.

The overall aim in the use of pressure reduction surfaces is to reduce the pressure lower than that of
the standard hospital operating room mattress. Devices such as an overlay, placed directly on top of
the mattress, and a replacement mattress, which is used in place of standard foam operating table
mattress are frequently used. The most common composition of overlays is foam, gel, air or water.

19

Prior to the patients surgical experience a thorough assessment by nursing staff is essential that
should focus on the general condition of the patient, eg mobility, pre-existing medical conditions
and risk for pressure ulcer development. This information should assist the nurse to determine
appropriate patient care during surgery.

Pressure ulcer development may be minimised by planning for care. Assessments will provide
information to assist with the management of the patient, and the techniques used may be many and
varied, dependent upon the results of the assessment. It is not that there are major differences in the
care of all patients, but rather that there needs to be an emphasis and greater attention to the various
aspects of care of the elderly patient (Lantz & Wyble 1987).

A lack of risk assessment on patients entering the operating room environment has implications for
both patient care and the nurses responsibility and accountability. Skin assessment pre-operatively
is fundamental to the early identification of skin damage and provides a baseline for the planning
and evaluation of interventions. Russell (1996) asserts that even nurses who are knowledgeable
about risk assessment and prevention, do not necessarily implement these skills in the delivery of
care. Failure to have provided the appropriate care to reduce the incidence of pressure ulcer
development may result in legal action for the hospital (Dimond 1994).

Many aspects should be considered that are equally applicable to other patients, but one specific
area that does require attention in some detail, is that of positioning for surgery. Positioning is a
major area in which adaptations are frequently needed in order to provide individualised care. Stiff
neck, arthritic joints and sore backs may require additional padding (Jackson 1989). Additional
padding to compensate for the loss of subcutaneous tissue, and lifting and moving the patient rather
than sliding or pulling should be considered the better option to prevent skin injury.

20

The Joanna Briggs Institute for Evidence Based Practice Information Sheets (BPIS) Pressure Sores
Part 1 and 2, provides evidence to support changes to practice (Joanna Briggs Institute for
Evidence Based Nursing 1997). The BPIS identifies clinical and cost effective nursing practice
through a critical review process that promotes the use of effective nursing practice and improved
patient outcomes. However they have not produced an information sheet that specifically focuses on
pressure ulcers in the operating room environment.

A review of the literature conducted by the researcher, revealed that although there are a number of
products on the market for pressure area care, few of these are designed for use in the operating
room, and those that are available have limited research to support the claims made by
manufacturers.

Reviews of varying types have been used in the areas of nursing and medicine to summarise and
evaluate treatments and clinical practice. However, no specific guidelines exist on the best methods
and strategies to be employed for the prevention of pressure ulcer development, and reviews very
rarely involve an exhaustive search or a critical review of all studies (Jones & Evans 2000). It is
difficult to assess the validity and comprehensiveness of the reviews conducted about support
surfaces, because the nature and extent of search strategies and selection criteria, are usually not
specified (Jones & Evans 2000). The quality of the studies is often not adequately assessed and,
without pre-determined guidelines, the interpretation and summary of the findings is open to bias
(Jones & Evans 2000). Reviews themselves are a form of research and should, therefore be
conducted as rigorously and methodically in their approach as any primary research conducted
(Droogan & Cullum, 1998).

This critical review was undertaken to identify and summarise research relating to the most efficient
and effective operating table mattress or foam, that can be used to prevent pressure ulcer
development during a patients surgical experience in the perioperative environment.
21

The critical review method was based on the work of the Centre for Reviews and Dissemination at
the University of York (NHS Centre for Reviews and Dissemination 1996) and the Cochrane
Collaboration, York (Mulrow & Oxman 1997), and The Joanna Briggs Institute.

Operating room tables are designed for utility, not comfort. Ideal mattresses should be firm, stable,
and reduce the distribution of pressure evenly without bottoming out, the mattress collapsing or
flattening, leaving the patient on the hard, metal surface of the table. This ideal mattress is
designed for the surgeons convenience, and not for patient comfort. During surgery, patients are
positioned to maximise the ability to expose and manipulate the surgical site. During the surgical
procedure, many parts of the body, which are not designed to bear any weight, are suddenly
subjected to pressures of varying intensity for example the; heels, elbows and sacrum.

Critical Review Process

Objective
The objective of this review was to present the best available evidence related to the most effective
operating room table mattress that can be used for the prevention of pressure ulcer development, the
operating room environment.
Methods
A review of the research literature related to pressure ulcers and surgical patients was conducted to
determine the effectiveness of pressure relieving surfaces on the operating room table. The review
focused on information that indicated a potential connection between the operating room table and
the development of pressure ulcers. The objective of this review was to present the best available
evidence relating to the use of operating table mattresses as an item of pressure reducing equipment
in the operating room. The software programme developed by the Cochrane Collaboration (Rev.
Man. 4.0) was used to graphically present the results from individual randomised controlled trials.

22

Where possible, a graphical summary of results is presented or the findings were summarised in a
narrative form.
Examples of initial search terms used were:

Decubitus
Elderly Surgical Patients
Operation
Perioperative
Perioperative Nursing
Pressure Areas
Pressure Area Care
Pressure Ulcers
Redness / discolourisation of skin
Theatre

Types of Participants
Studies of

Adults who underwent elective surgical procedures requiring them to be positioned on

operating room table mattresses, were included in the reviews. These positions include
but was not limited to, prone, lithitomy, left and right lateral.

Exclusion Criteria

Studies that included paediatric patients. These patients are not part of the population of
the organisation in which the study is conducted.

Studies that included volunteers in a controlled laboratory setting because the volunteers
were healthy and able to move freely and not representative of the ageing population
who are surgical patients.

Studies completed outside of the operating room environment. The critical review is on
the effectiveness of operating room table mattresses, and their contribution to, or
prevention of, pressure ulcers, therefore patients in ICU and long-term health care
facilities were not considered.

Studies not written in English

Inclusion Criteria

Any adult patient over the age of a18 years of age undergoing a surgical procedure.

23

Types of Interventions

All studies that compared any operating room table mattress or positioning aids (pads)
used during surgical procedures.

Types of Outcome Measures

All quantifiable outcome measures related to the effectiveness of the operating room
table mattress or positioning pad in preventing pressure ulcer development were
reviewed.

Definitions

Operating room table mattress was defined as the equipment; pressure relieving devices,
placed on the top of an operating table.

Standard Operating Room Table Mattress

Foam Pads

Gel-filled Operating Room Table Mattress

Gel-filled Pads

Overlays

Types of Studies
This review considered any randomised controlled trials (RCTs) that addressed the effectiveness of
a specific operating room table mattress and padding used to assist positioning and protection.
However in the absence of randomised controlled trials, this review incorporated any other studies
that pertained to the use of operating room table mattress in preventing pressure ulcer development.

It is acknowledged that the inclusion of non-RCTs will limit the strength of any proposed
recommendations from this review, but their inclusion in a narrative summary may help identify
current approaches, and possible future directions in preventing pressure ulcer development in the
operating room environment.

24

Search Strategy for Identification of Studies

The search sought to identify all published and unpublished studies relating to the research
question. The initial search was performed using the electronic databases CINAHL and MEDLINE.
It is important not to limit the search to MEDLINE, as this represents only approximately 23% of
medical type journals. It is essential that the database of CINAHL and EMBASE be included in any
search. The Cochrane Collaboration maintains a database of current and anticipated reviews.
EMBASE lists journals that are not indexed on the other bases but are relevant to this review. In an
attempt to identify new articles, reference lists and bibliographies of relevant articles were also
examined.

The databases searched were:

CINAHL
MEDLINE
Current contents
Cochrane Library
Embase
Expanded Academic Index

In addition, a search of reference lists of all identified studies, review papers; operating room
nursing journals and conference proceedings was conducted to identify any unpublished research.

The search was restricted to research reported in English language only. This strategy has the
potential to limit the results of the review as pertinent research may be excluded on this basis.
Translation of non-English studies was beyond the scope of this review due to time and resource
limitations. Time restrictions also meant that hand searching was limited to journals and books
accessible to the reviewer.

All studies identified during the database search were assessed for relevance to the review based on
the information provided in the title and abstract. A full report was retrieved for all studies that met
25

the inclusion criteria (Appendix 1).

Studies identified from the reference list searches were

assessed for relevance based on study title.

Assessment of Methodological Quality

Initially each study underwent a preliminary review to determine if it met the inclusion criteria for
this critical review (Appendix 2).

Methodological quality of those studies that satisfied the

inclusion criteria after a preliminary review, were then subjected to a more thorough and critical
appraisal using another checklist (Appendix 3). Checklists developed by the Joanna Briggs Institute
(JBI), which are based on those used by the Cochrane Collaboration (Oxman 1994) and Centre for
Reviews and Dissemination at the University of York (National Centre for Reviews and
Dissemination 1996), informed the reviewer when designing the checklist used for critical
appraisal. This checklist was used in order to determine if the randomised control studies identified
through the search process met the critical review inclusion criteria.

The researcher and another person familiar with the critical appraisal process of critical review
piloted the checklist. Not only did this pilot test assess the face validity of the critical appraisal tool
but it also allowed the reviewer to check their assessment for methodological quality against a more
experienced reviewer familiar with the critical review process.

After each initial review the quality of each study was again assessed. Each study varied in regard
to error and bias, studies were excluded from meta-analysis if they were assessed to have

An inadequately defined randomisation technique (selection bias),

The intervention displayed a difference in care within the study groups (performance
bias)

Different treatment groups due to study participant withdrawal or dropping out (attrition
bias) and

Different outcome assessment measures (detection bias).

26

The studies included in the review were catagorised according to the strength of the evidence
reported using a scale published by the Quality of Care and Health Outcomes Committee (Quality
of Care and Health Outcomes Committee Guidelines 1995).

Level I

Evidence obtained from a critical review of all relevant randomised

controlled trials.

Level II

Evidence obtained from at least one properly designed randomised controlled trial.

Level III 1. Evidence obtained from well-designed pseudo-randomised controlled trials (alternate
allocation or some other method).
Level III 2. Evidence obtained from comparative studies with concurrent controls and allocation
not randomised (cohort studies), case control studies or interrupted time sears with a
control group.
Level III 3. Evidence obtained from comparative studies with historical control, two or more
single aim studies, or interrupted time series without a parallel control group.
Level IV

Evidence obtained from case studies.

Data Collection
Data was first collected from individual RCTs using a checklist (see Appendix 3). RCT research
design was found to have been rarely used in the identified studies and therefore, a meta-analysis
was not possible for all the studies included in this critical review. The data extraction tool
facilitated the collection of important and relevant results and allowed the process to be checked for
accuracy. The data extracted from each study included general demographic details of each study
participants; a description of the study institution (s); data related to the specific surgical patient
group, the specific operating room table mattresses being compared and the outcome measures used
to determine the effectiveness of the equipment. The study design, including details relating to the
randomisation and participant numbers was also collected.

Where possible results are graphically presented, or summarised in a narrative form. While the
value of this information is limited because of the potential of bias, the information was considered
27

important in order to present a complete summary of evidence in relation to the nursing

management of patients in the prevention of pressure ulcer development in the operating room
environment. A brief summary of major findings and any other results pertaining to the review
subject was also noted on the data extraction sheet.

Data Analysis
The data extraction tool developed and tested by the Joanna Briggs Institute of Evidence Based
Practice facilitated the collection of important and relevant results and allowed the process to be
checked by others to confirm accuracy. When two or more comparable RCTs were identified, the
results were pooled in a meta-analysis to determine the effectiveness of the support surface. Where
statistical pooling of results was not possible or appropriate and a meta-analysis could not be
undertaken, results are presented graphically as visual presentations of results and in the
communication of the results.

Results
The search uncovered 3 RCTs that addressed some aspect of the management and prevention of
pressure ulcer development in the operating room. They ranged in level of evidence from Level 1
RCTs to Level IV, case studies. Of the papers, 29 retrieved, only 3 were considered to be of an
acceptable standard for inclusion in the review. These were randomised controlled trials and
descriptive studies. The majority of the remaining papers identified were concerned with:

The etiology of pressure ulcers

Pressure ulcer classification systems
Risk factors in surgical patients
Pressure-reduction surfaces

Much of the research available focused on patients and equipment in long-term care settings, with
little attention having been given to the acute care setting, in particular the perioperative
environment.
28

In reviewing the studies, many issues relating to quality or study design were identified:

Rigorous research design was not evident in many of the studies making
replication of the research impossible and making the interpretation and
implementation of the findings into clinical practice difficult.
Reporting of research methods were often inadequate, poorly documented
with no summary of findings provided and the research question unclear.
Reporting of research often incomplete with no statements in regard to the
effectiveness of the study.
Interventions were poorly defined and a wide variety of outcome measures
used to determine the effectiveness of the interventions.
Researchers failed to provide a reasonable description of the research design.

A detailed summary of the papers included in this critical review including the study design,
interventions and level of evidence reported using a scale published by the Quality of Care and
Health Outcomes Committee, are included in Appendix 4, those excluded are documented in
Appendix 5.

It was the intention to extensively hand search articles in a variety of journals and conference
proceedings believed to contain information associated with pressure ulcer prevention and
development in the operating room, to check if any articles met the inclusion criteria. However time
constraints meant that hand searching was limited to those journals and books accessible to the
reviewer, a summary of these are included in Appendices 6, 7, 8.

A two-step searching process was undertaken. This involved an initial search to identify key words
that appeared in titles, abstracts and sub-heading sections of the electronic databases. An example of
useful words was selected as key terms during the electronic database searching process such as
pressure ulcers, pressure sores, bedsores and decubiti. Once key words and search terms were
identified from the initial search, the second step was to conduct a comprehensive search of the
identified databases.

29

A wide search was conducted initially in order to identify all articles that appeared to met the
inclusion criteria. Throughout the search, consideration was given to the possibility of different
terminology and spelling of key words that could occur between different countries.

The search strategy undertaken in this review, identified papers that appeared to meet the inclusion
criteria based on a preliminary review of article abstract or title, these were:
29
2
1
2
4
1
1
3
2
1
4
5
2
4
2
2
6

Randomised controlled trials

Non randomised controlled trials
Uncontrolled clinical trial
Integrative review
Descriptive studies
Descriptive survey
Case study / case series
Reports or general subject overview
Recommendations for practice
Prevalence and incidence studies
Experimental study
Produce review, reports or general subject overview
Evidence Based Practice Documents
Discussion papers
Literature review
Education guidelines
Nursing interventions

The studies included in this critical review satisfied the inclusion criteria for the review (see
Appendix 1) and the inclusion criteria following a critical appraisal for suitability of meta-analysis
or as an inclusion as a narrative summary (see Appendices 2 & 3).

The outcome measure used in the RCTs was which type of operating room table mattress is most
effective in the reduction of pressure ulcer development?
In the next section the findings of the studies included in the review are presented under the
following headings
1. Standard Operating Room Table Mattress
2. Foam Pads
3. Gel-filled Operating Room Table Mattress
4. Gel-filled Pads
5. Overlays
30

1.

Standard Foam Operating Table Mattress

This section reports on comparisons of standard foam operating table mattresses against other
mattress type equipment.

Findings
The literature search identified 3 RCTs evaluating the impact of standard foam operating table
mattress in pressure ulcer development against other methods. The conventional standard operating
table mattress is composed of 1 to 2 inch foam covered with hard, thick, laminated fabric that is
placed on top of the metal surface of the table on which the patient is positioned for surgery. A
summary of the population, intervention and outcome measure of each of these trials is shown in
Table 2. Eighteen of the 29 papers identified contained information about a number of different
materials that are used in the manufacture of operating table mattresses. No paper discussed the
standard foam operating table mattress only, but compared this item in relation to others.

In table 2 the results of the studies demonstrates that the standard foam operating room table
mattress is not effective in preventing pressure ulcers when compared with the dry-visco elastic
mattress or the multi cell dynamic mattress.

31

Table 2

RCTs - Standard Foam Mattress

Study
Russell and
Lichtenstein 2000
Prospective, single
centre randomised
controlled trial

Study Description
Design: RCT
Population: 198
Cardiothoracic
Surgical patients

Study Group
Standard foam
mattress group
n = 100
Multi-cell Dynamic
mattress group
n = 98

Nixon, McElvenny,
Mason, Brown,
Bond 1998

Design: RCT
Population: 446
Elective surgical
patients for vascular
and gynaecological
procedures in prone
or lithotomy
position.
55 years or over

Standard foam
operating table
mattress.
n = 224

Design: SR
Evaluation of 29
RCTs of support
surfaces.
Population:
Patients receiving
care deemed to be
at risk of pressure
ulcer development
in any setting,
including the
operating room.

Standard foam
operating table
mattress.
n = non given
Dry visco-elastic
polymer pad (gelpad).
n = non given.

2 arm trial

Cullum, Decks,
Sheldon, Song,
Fletcher 2001

Dry visco-elastic
polymer pad (gelpad).
n = 222

Outcome Measure
Incidence and severity
of pressure ulcers.
3 low surgery and 3
post-operative stay in
hospital.
proportion of patients
who developed a
pressure ulcer by day
7.
Incidence and severity
of pressure ulcers
skin assessment/
changes pre and post
operatively.
skin grading /
classification of
pressure ulcers 8 day
follow-up.
Incidence and severity
of pressure ulcers.
Secondary outcomes:
comfort, durability of
equipment.

Results
n = 7 patients
developed pressure
ulcers out of 100 (7%)
n = 2 patients
developed pressure
ulcers out of 98 (2.2%)

0.21% of patients on
foam mattress and
0.11% of patients on
visco-elastic polymer
pad developed ulcers.
Disagreement in 2.2%
assessments.
2 disagreements related
to differentiating
between Grade 1 and
2a pressure ulcers.
47% reduction in
pressure ulcer
development associated
with the dry viscoelastic polymer pad, for
patients undergoing
surgery.

Results
All three RCTs were evaluated for their relevance to the question and their methodological rigour
and all were of varying quality from randomisation to lack of replication and poor quality of trials.
The results of the three trials suggest that the equipment evaluated was beneficial in reducing
pressure ulcer incidence in high-risk surgical patients. At present the most effective means of
pressure relief on the operating room table is unclear. The Nixon (1998) trial found a gel-filled
overlay to be significantly better than a standard foam mattress, whilst a gel-filled overlay on the
table less effective than an alternating pressure overlay intra and post-operatively (Micropulse
system). Caution should be used when interpreting this data due to a lack of clarity between the gelpad overlay and mattress. However a gel-filled overlay on the table was less effective than an
32

alternating pressure overlay (Dynamic multi-cell mattress) during operative procedures (Russell &
Lichtenstein 2000).

A single centre, prospective, randomised controlled trial conducted by Russell and Lichtenstein
(2000) in which 200 patients were assigned to be managed either by being placed on the standard
foam operating room table mattress or a multi-cell dynamic mattress, found there were no
differences in patient details that could be detected to be of significant difference, and those that
were recorded were associated with the length of the operative procedure and the health status of
the patient. In the results of the study it is noted that by the seventh day, two patients who had been
placed on the multi-cell mattress had developed ulcers and on the foam mattress seven patients had
developed ulcers. This study presented the results of patients who had cardiovascular procedures
only, and other surgical specialty groups were not considered. This information is presented in
Table 3.

Table 3

Standard Foam Mattress and Dynamic multi-cell mattress

Study
Russell Lichtenstein
2000

Study Description
Design: Single
centre-prospective,
randomised
controlled trial.
Population: 198
patients.
Comparison:
Standard foam
mattress vs dynamic
multi-cell mattress.

Study Group
Standard foam
mattress
n = 100 control
group.
Dynamic multi-cell
mattress
n = 98 treatment
group.
Patients
undergoing
cardiovascular
surgery of at
least 4 hours
duration.

Outcome Measure
Incidence and
severity of pressure
ulcers.
Assessed daily for 7
days post
operatively.

Results
Standard foam
mattress
7 out of 100
patients
7% developed
ulcers
1 patient 3 ulcers
5 patients 1 ulcer
1 patient 2 ulcers
2 Stage I
5 Stage II
3 Stage III
Reduction of 5% in
pressure ulcer
incidence, not
significant in the
population
implications for
clinicians.

33

Where sufficient data was available, the Review Manager software programme (Rev Man 4.0)
developed by the Cochrane Collaboration was used to graphically present the results and pool
statistical data in a meta-analysis. Statistical significance referred to the situation where the results
were due to the intervention and not to random variation. A meta-analysis was undertaken for the
Aronovitch (1998) and Russell (2000) studies and is presented in figure 1.

The results shown in figure 1 indicated that there is no statistically significant difference in the
pressure prevention between the dynamic pressure group and the conventional foam mattress.

Figure 1

The results of the study demonstrated that 198 patients in the dynamic pressure group (n = 198)
were similar at baseline. There was a strong trend of decreased pressure ulcers in those patients
placed on the dynamic multi cell mattress (n = 2) when compared to those patients managed on the
standard foam operating table mattress (n = 7). These results conclude that the multi-cell dynamic
mattress system is safe and effective and decreases risks for pressure ulcer development in patients
who were planned to undergo cardiovascular surgery. Early intervention and the application of the
multi-cell pulsating mattress on the operating table were recommended, as the development of
ulcers begins at the commencement of surgery. Preventing pressure ulcers by early risk reduction
strategies results in cost savings by avoiding the treatment of pressure ulcers and their
complications (Russell & Lichtenstein 2000).

34

A strong point of the study completed by Russell and Lichtenstein (2000), is that it was a
prospective, randomised trial that was blinded. Both groups of patients were well matched for skin
assessment, medical condition, weight and age, and the duration of the surgical procedure
demonstrating that all patients were well matched and at equal risk of developing a pressure ulcer.
The differences in the outcomes between the two groups were attributed to the interventions used.

In the identified RCTs a wide variety of outcome measures were used. The primary one being the
proportion of patients who developed a pressure ulcer at a pre-determined time post operatively,
and up to 3 days of post surgery observation (Nixon et al 1998, Russell & Lichtenstein 2000,
Cullum et al 2001).

Although the difference between these two items of operating room table equipment was not
statistically significantly different, the important information is that each of the 198 patients
assigned to the dynamic multi-cell mattress (n=2) developed only one ulcer; the 7 patients placed on
the standard foam mattress (n=7) developed a total of 10 ulcers. One patient developed one Stage
III ulcer and another patient developed 2 Stage II ulcers.

The findings from the studies demonstrate that the conventional foam operating table mattress
appears to have little or no pressure-reducing effect and therefore cannot contribute to the
prevention of pressure ulcer development in the operating room. It is also suggested that an
operation, which lasts longer than two hours with the patient positioned on a standard foam
mattress, may involve an increased risk for pressure ulcers (Russell & Lichtenstein 2000).

The research conducted by Cullum et al (2001), recommends that using pressure-relieving devices
in the operating room reduces the incidence of ulcer development. They report that although studies
show that this additional equipment is effective, it remains unclear which method or item of
35

equipment, is the most effective. They do however maintain that high specification foam is
preferable to the standard type currently and commonly used.

The results of their study

demonstrate that the standard foam mattress is ineffective in the prevention of pressure ulcer
prevention. They found that two studies conducted using the multi-cell dynamic pulsating mattress
system, one used during surgery and one in the post operative period, both demonstrated a pooled
relative risk of 0.21 in favour of the multi-cell dynamic system, MicroPulse.

In a sequential randomised controlled trial, 446 patients were equally randomised to either a
standard foam mattress or dry visco-elastic polymer mattress. The trial was designed to detect
differences in the incidence and severity of operating room generated pressure ulcers (Nixon et al
1999).

The results of this study demonstrated a statistically significant reduction in the chances of
developing a pressure ulcer if positioned on a dry visco-elastic polymer mattress, as compared to a
standard foam mattress.

The variations in the results of the study were accounted for by differences in pressure sore
definitions, assessments and exclusion criteria. With respect to age, the results are inconsistent with
much of the literature that clearly links increasing age to increased pressure ulcer prevalence and
incidence (Bergstrom & Braden 1992, Waterlow 1998).

In the study conducted by Nixon (et al 1999), the products assessed for efficiency were similar to
those used in other studies, foam mattress, dry visco-elastic polymer pad and a liquid displacement
cell mattress. The main aim of their study was to compare pressure sore incidence in patients
positioned on the standard foam operating room table mattress, and patients positioned on the dry
visco-elastic polymer pad, - the gel-filled mattress. As can be seen in Table 4, 20% of patients
36

placed on a standard foam mattress developed an ulcer. These results are consistent with other
studies of elective surgical patients, which report skin damage and an incidence rate that ranged
from 12 57.4% (Kemp, Keighley, Smith, Moulak 1990, Stotts 1998).

Table 4

Standard foam mattress and dry visco-elastic polymer mattress

Study
Nixon,
McElvenny, Mason,
Brown, Bond 1998

Study Description
Design:
Sequential
randomised
controlled trial.

Study Group
Standard foam
mattress
n = 224 control
group.

Population:
446 patients.
55 years and over.

Dry visco-elastic
polymer mattress
n = 222 treatment
group.

Comparison:
Standard foam
mattress vs dry
visco-elastic
polymer mattress.

Well matched at
baseline, sex, age,
Braden scale score,
type and duration of
surgery.

Outcome Measure
Incidence and
severity of pressure
ulcers.

Results
20% of patients
developed pressure
ulcers.

8-day follow-up.

11% of patients
developed pressure
ulcer.
Disagreement in
differencing
between Grade 1
and 2a of ulcers and
assessments.

Telephone
randomisation.

In this section two RCTs evaluating the use of pressure relieving mattresses demonstrate that
patients should not be placed on ordinary foam mattresses as these have been shown to be little
value in the prevention of ulcer development.

2.

Foam Pads

This section considers foam pads and pads manufactured out of other materials used as protectors
eg elbow, heels. For the purpose of this critical review the pad selected for comparison was gelfilled. The composition of this pad was chosen, as it is one of the commonly used items of
equipment in operating rooms to protect the patient from injury and assist in positioning for
surgery.

Pope (1999) describes the care that is needed to protect patients heels and other sensitive areas of
the body. Heels require additional protection beyond the use of mattresses, and are elevated from
37

the mattress by supports positioned behind the heels that provide continuous suspension (Tymer,
Piepa, Vollman 1997). It is in these circumstances that foam pads are used.

If the patient is placed in the supine position for surgery, the arms are placed at the patients side
and secured, with padding placed between the arm and the support that retains the limbs at the
patients side (Tymer, Piepa & Vollman 1997). This situation is different when the arm(s) need to
be exposed for surgery, and then the arm(s) are rested on padded arm boards or a small table.

Results
The literature search failed to identify any studies that discussed and evaluated the impact of foam
pads used.

Reference to these items was made in articles describing operating room table

mattresses, protection of the patients body and as a positioning aid for surgery.

Stotts (1998, p. 17) presents information about studies that were conducted, but believes that the
published studies for surgery involve small numbers of patients, primary patients with hip fractures,
having cardiovascular procedures, or who are critically ill. She goes on to say she believes many
groups have not been studied. Specific reference to foam pads was rare but there was reference to
heel and elbow protectors, which could be made of foam. The paucity of data collected reinforcing
that there is limited information about pressure ulcers risk in the pre-intra and post-operative
periods.

An experimental study conducted at Maine Medical Centre USA, was designed to evaluate a special
mattress overlay, and heel and elbow protectors in preventing the development of pressure ulcers.
Four hundred and thirteen surgical patients were randomised to receive usual perioperative care or
the new mattress. There were no significant differences in the selected variables between the two
groups. However it was found that the experimental group of patients who had been placed on
38

special egg crate foam mattresses and pads, faired worse than those patients subjected to the
standard foam operating table mattress and padding devices. In this study the composition of the
pads used was foam or gel-filled (Schultz, Bien, Dumond, Brown & Myers 1999).

The results of the study conducted by Schultz et al (1999) (see Table 5) is considered to be the
largest prospective randomised study and reports that whilst the incidence of skin damage was
lower than anticipated, the severe ulcers were not a result of the patients surgical experience. Those
presenting as burns or ecchymosis did not deteriorate further to stage III or IV ulcers during the
six post operative days. This information is somewhat different from the commonly held thoughts
of nurses in the specialty that these ulcers do originate in the operating room.

Table 5
Study
Schultz, Bein,
Drummond,
Brown, Myer
1999

Evaluation of foam pads

Population
Design:
Prospective
randomised study
Post-operative
Population: 413
patients
Comparison:
Standard mattress
and special
mattress

Intervention
General and
cardiac patients.
2 hours surgery or
longer
Control group:
207 = standard
mattress and pads.
n = 34
Experimental
group:
206 = special
mattress overlay
of foam.
n = 55
No statistical
differences in age,
sex, Braden scale
scores on
admission, length
of surgical
procedure.

Outcome
Measure
Incidence and
severity of
pressure ulcers.
Evidence of
friction or shear.
Evaluation of a
special operating
room mattress in
the identification
of the etiology of
pressure ulcers in
surgical patients.

Results
89 patients 21.5%
developed Stage I
ulcers.
n = 34
p = 0.111
2% developed
Stage II and IV
ulcers.
Incidence rate in
experimental
group 26.6%
compared to
16.4% in control
group.
A total of 139
(10.7%) (15)
more severe than
Stage I
9 subjects (2.2%
Stage II)
1 patient Stage
IV ulcer
39

The conclusion is that the usefulness and accuracy of using stage I changes in any calculation of
pressure ulcer development is not reliable, and debate continues about this topic. Schultz et al
(1999) believes it may be misleading and limit ones ability to benchmark across organisations.
These comments contribute towards the difficulties in providing accurate information and
guidelines to nurses seeking to base practice on evidence.

Schultz et al (1999) suggest that there does not appear to have been any major trials or research
studies conducted that specifically investigate the most appropriate composition for the pads used in
patient positioning. Pads of any composition are generally discussed as part of discussions on
positioning aids and operating table mattresses and overlays. In only one instance was the foam pad
referred to specifically, and this was as part of the reference made to the practice of adding
materials such as heating and bath blankets, incontinent pads and turn sheets beneath the patient
(Schultz et al 1999, p. 438). All these items are believed to increase the intensities of pressure by
almost 44mgHg (Schultz et al 1999, p. 438). However this information should be treated with
caution, as the results were only one part of a number of other small studies that collectively
focused on, and examined the intensities of pressure produced over selected bony prominences.
These studies were conducted with or without mattress overlays (Schultz et al 1999). In some
instances the subjects were either healthy non-surgical participants, or surgical participants that
were not adequately followed up during the postoperative period for any evidence of skin damage
(Schultz et al 1999).

From the limited nature of the evidence available, Stotts (1998) suggests that managers of operating
rooms need to be involved in research to see if the equipment used in their environment is the cause
of injuries to patients.

40

Stotts (1998) believes that the findings were that the guidelines proposed by the Agency for Health
Care Policy and Research (AHCPR 1989), were not particularly useful in predicting the patients
considered to be at risk in the study. Schultz et al (1999) agree that further attention needs to be paid
to the variables and the methods used to measure them. Those patients with identified risk factors
such as older age, smaller size, comorbidity of diabetes, need to have special guidelines developed
regarding support padding and positioning.

Stotts (1998) indicates that there were some limitations to the study in that emergency and trauma
surgical patients were excluded, and these could be considered at a high risk of developing skin
damage. The reason for Stotts making this statement is that patients who develop ulcers were older,
had diabetes mellitis, smaller in body mass, and had a lower Braden Scale sore on admission to
hospital, and demonstrated fear about their current situation.
The findings from this study support the literature that the type of operating room table and mattress
and pads, requires further investigation. The risk factors, comorbidity, such as diabetes, small body
size and age, need to have specific guidelines for positioning and support items. Finally, based on
the results of the study, additional padding needs to be applied when patients are placed on the
newer operating room tables. The reasons for this statement remain unclear. All these statements
require further investigation (Schultz et al, 1999).

Pressure-reduction devices may be classified as static or dynamic. Static devices are designed to
provide dry flotation, whilst dynamic devices involve a motor or pump that cycles to provide
constantly changing pressure points beneath the patient. In the operating room dynamic devices
cause problems because of the constant movement from the pump action. The static devices are
however the most suitable and are preferred, because they ensure stability during the operative
procedure (Hochowsky & Schraam, 1994). From the available literature it is difficult to find any
information that specifically focuses on foam pads and their use in the operating room. Whilst they
41

are continuously used in patient positioning, they do not appear to have been evaluated against other
products.

The next section presents information on the most commonly used composition of operating table
mattress after foam, gel filled mattresses and the results of the studies on this second mattress can
be seen in Table 6.

3.

Gel-Filled Mattresses

This section considers comparisons of the gel-filled mattress, against the standard foam operating
table mattress.

Gel-filled mattresses are placed on top of and cover the operating room table mattress. They are
used to protect the patients skin from damage. They are easily cleaned, durable, re-useable, easy to
repair, but can be heavy to transport. The gel may migrate causing creases and folds, which in turn
may predispose to skin damage (Australian Wound Management Association 2001).

The search identified 4 RCTs that evaluated the impact of a gel-filled mattress specifically in
pressure ulcer development (Nixon et al 1998, Aronovitch 1998, Russell & Lichtenstein 2000,
Cullum et al 2001). It is however difficult to separate the information in some studies because of the
variation in terminology.

Two researchers assessed the methodological quality of each trial

independently. For each trial relative risk with 95% confidence intervals was calculated for allimportant dichotomous outcomes, the number of patients or setting. However the quality of the
trials was poor as time randomisation with allocation concealment was evident in only 22% of the
RCTs. Other problems were the sample size used only 10 trials described a prior sample size
calculation, and 27 of the 36 trials involved 100 patients or fewer. Quality was not used to weight

42

the studies in the analysis using any statistical technique, however methodological quality was
drawn upon in the narrative interpretation of the results (Cullum et al 2001).

Table 6 demonstrates that when comparing the gel-filled operating room table mattress against a
standard foam mattress, the incidence of pressure ulcers is reduced significantly in those patients
placed on the gel-filled mattress.

43

Table 6

RCTs - Gel-filled Mattress

Study
Cullum, Decks,
Sheldon, Long,
Fletcher 2001

Study Description
Design: SR Trials

Study Group

Critical Review
3 R.C.T.s

Comparison = Gelfilled mattress Vs

standard foam
mattress

Gel-filled mattress
n = 222

Nixon, McElvenny,
Mason, Brown, Bond
1998

Design = Two centre

double triangular
sequential RCT.
Population = 446
patients

Russell, Lichtenstein
2000

Comparison = Gel
mattress vs foam
mattress
Design = Single
centre RCT.
Population = 198
Cardiovascular
patients
Comparison = Gel
mattress vs foam
mattress

Standard foam mattress

n = 224
General, gynae and vascular patients 4 hours
surgery or longer

Outcome Measure
Incidence and severity of
pressure ulcers.

Results
47% reduction in pressure ulcer development in
majority associated with heel assessments.

Secondary outcome, comfort,

durability of equipment.

Discrepancies in some of the overall results.

Differences in mattresses remain the same.

Incidence and severity of

pressure ulcers

Pressure sore found to be 11% (22 / 205) for

patients on the dry visco-elastic pad, 20% (93 /
211) for patients allocated to a foam mattress.

Gel-filled mattress
n = 98

Incidence and severity of

pressure ulcers.

Standard foam mattress

n = 100

Comparison of the gel-filled

mattress and standard foam
mattress.

For patients allocated to the gel-filled mattress,

the failure rate pressure ulcer development was
11%. This demonstrates a reduction in the
development of an ulcer on the gel-filled mattress
and foam mattress as 0.11 and 0.21 respectively.
Standard foam mattress failure rate 20%
7 out of 100 patients
7% developed ulcers
1 patient 3 ulcers
5 patients 1 ulcer
1 patient 2 ulcers
2 patients developed Stage I ulcer
5 patients developed Stage II ulcers
3 patients developed Stage III ulcers.
Reduction of 5% in pressure ulcer incidence, not
significant in the population implications for
clinicians.

222 = dry visco-elastic polymer pad (gel-pad)

224 = standard foam mattress

44

Study
Aronovitch 1998

Study Description
Design
Single centre, 7-day
comparative parallel
study.
Population = 217
surgical patients age,
sex, weight, history,
type of surgery and
device
analysis
conducted.

Study Group
Gel-filled mattress (action pad)
n = 105

Outcome Measure
Incidence and severity of
pressure ulcers.

MicroPulse
n = 112

Efficiency and safety of

MicroPulse system when
compared to a gel-filled
mattress.

Results
11 patients developed ulcers,
1 patient, 3 ulcers
2 patients, 2 ulcers
4 patients, 1 ulcer.
Of the 11 ulcers
1 was Stage I
4 were Stage II and 6 were unstageable.
In the MicroPulse system 1 patient developed
ulcer because of piece of gel-pad adhered to
patients back.
The ulcer was not considered related to the
support surface.
The difference between the 2 groups significant at
the <0.005 level.
Patients with ulcers remained in hospital for 7
days longer.
MicroPulse surface safe and effective for
reducing pressure in surgical procedures of 3
hours and longer.

45

Results
In the study conducted by Nixon et al (1998), the aim was to compare the post-operative pressure
ulcer incidence in patients positioned on either standard foam or gel-filled operating room table
mattresses. The second objective was to investigate the variables which appeared to be the most
significant in contributing to the problem.

The surgical population was aged over 55 years, and were scheduled for major elective vascular,
gynaecological or general procedures. All patients were positioned for surgery in either the surgical
or lithotomy position. One of the criteria for entry into the study was that the surgical procedure was
estimated to last 90 minutes or longer.

This trial was designed to detect absolute differences in the incidence of operating room generated
pressure ulcers. As can be noted from the results seen in Table 6, there was a decrease in the
incidence of pressure ulcers when the standard foam support surface on the operating room table
was exchanged for gel-filled material.

Nixon et al (1998) suggests that the endpoint failure rate of 15.6% that they found is consistent with
other studies of elective surgical patients that ranged from 12 57% (Gedron 1980, Stotts 1988,
Kemp, Keighley, Smith Moulak1990, Hoshowsky & Schraam 1994 and Tubman, Papantonio,
Wallop, Kolodner 1994). It is thought that the wide variation in the incidence rate can be attributed
to the differences in definitions and assessments of pressure ulcers and the exclusion criteria.

Russell and Lichtenstein conducted their study, a single centre, prospective randomised controlled
trial in 2000, and report that 7% of patients out of every 100 developed an ulcer. This study
included patients having cardiovascular surgery expected to last a maximum of 4 hours. One patient

46

in their study developed 3 ulcers, another 2; these ulcers were rated as being from minor to serious
stage III. These researchers also found that most of the research had been conducted in long-term
settings, with a minimum number of studies conducted in the operating room environment. The
overall results from the studies were found to be consistent with other studies that had been
completed (cited in Armstrong & Bortz 2001). Previous attempts to collect data from the operating
rooms has had problems, due to factors that are difficult to control, such as length of procedure, use
of medications during the procedure. This situation is changing and there is a greater acceptance of
the fact that the operating room is an at risk environment for surgical patients.

From the results of their search, Russell and Lichtenstein (2000) suggest that research clearly
demonstrates that education and development of policies and procedures in institutions should be
initiated and implemented into nursing care. These changes have a positive impact on the reduction
of ulcer development (Russell & Lichtenstein 2000).

The results of three trials evaluating the use of support surfaces conducted by Cullum et al (2001),
who sought information about trials from the Cochrane Wounds Group Specialist Trials Register,
report that the methodological quality of the trials was generally poor as true randomisation was not
evident in 22% of the RCTs because allocation concealment was badly managed. The baseline
comparability could not be guaranteed, and there was a lack of blinded outcome assessment that
further reduced the confidence with which the studies can be regarded. Future trials will need to
address these deficiencies and collect data on aspects of equipment performance such as reliability.
The risk of pressure ulcer development in the operating room consisted of evaluating a gel-filled
mattress with a standard foam mattress. As can be seen from the results presented in Table 6,
patients placed on the gel-filled mattress appeared to have a reduced risk of the development of a
pressure ulcer. The final comment of this critical review was that most of the trials were
47

underpowered and therefore it is difficult to reach the clinically significant differences that could
assist the clinician in changing practice. It is proposed that these deficits should be considered for
future trials.

Whilst it could appear that the results of these studies favoured the use of gel-filled mattresses, the
question of specific recommendations for their use does not appear to be addressed. Many of the
studies encourage further research or investigation. Caution should be exercised when reading the
results of these studies (see Table 6), and consequently no specific conclusions should be made.

Defloor and de Schuijmer (2000) discusses the results of their study in which comparisons of five
mattresses were evaluated for effectiveness in pressure ulcer prevention. In the context of this
critical review the gel-pad has been interpreted to be a full length overlay and not a pad in the
evidence required for discussion in this section.

This study was conducted in a controlled

laboratory setting with health volunteers using a quasi-experimental design. The mattress used and
positions were randomised. Interface pressure was measured using calibrating equipment. The aim
of their study was to ascertain the pressure reducing effects in different positions patients could be
placed in for surgery.

The results of this study suggest that interface pressure measurements using healthy volunteers
provides only a conservative picture of the pressure to which patients are exposed while undergoing
surgery. The researcher made the decision not to include this study in the critical review because it
could be possible for these volunteers to move during the testing, and they had not been subjected to
anaesthetic drugs, injury from trauma and the apprehension of the surgery.

Defloor and de Schuijmer (2000) focused on assessing the pressure-reducing effects of a variety of
gel filled mattresses examined five mattresses commonly in use today. These researchers also
48

evaluated four positions patients are placed in during operative procedures. Their study was
conducted using 36 healthy volunteers in a controlled laboratory environment. It appeared that the
gel-filled mattress and the standard foam mattress have minimal pressure-reducing capabilities,
although the interface pressure of the gel-mattress was significantly lower than on the standard
operating room table mattress, the reduction in the interface pressure was limited. Therefore, only
minimum pressure prevention can possibly be expected. Their conclusions were that patients
undergoing surgery for longer than two hours on the standard foam mattress would probably be at
increased the risk of ulcer development. Therefore in the case of patients being unable to be turned
frequently as in the ward area, the gel-filled mattress did not contribute to an improved outcome,
and in many instances the foam mattress was the better item of choice for patient care, but none of
the mattresses reduced pressure sufficiently to prevent the occurrences of ulcer development.

They concluded that the intended positions in which patients will be placed for surgery, has a direct
impact and should be taken into account and used as a research variable in all research that
investigates pressure ulcer development in the operating room.

One study demonstrated the effectiveness of two types of operating table mattresses (Aronovitch et
al 1999b). This single-centre, 7 day, comparable, parallel study was conducted over an elevenmonth period. The limitations to the study were few, however the limited type of surgery included
was a limitation. The results of the study indicate that the gel-filled mattress often referred to as an
Action Pad performed significantly better than the standard operating room table mattresses,
particularly when surgical procedures lasted longer than 2.5 hours.

In other studies (Aronovitch et al 1995, Armstrong & Bortz 2001 and Cullum et al 2001) a gelfilled mattress was found to be better than the standard operating room table mattress, whilst a gelfilled overlay Action Pad, placed on top of the foam mattress was less effective than other
49

equipment such as an alternating pressure overlay (Nixon et al 1998) intra and post operatively
(Russell & Lichtenstein 2000).

The results of the study involving the multi-cell pulsating dynamic mattress system (Aronovitch
1999 b), demonstrates that the incidence of pressure ulcers was decreased from 7% of patients laid
on the conventional foam mattress to 2% on the new system. This information is substantiated by
other authors (Aronovitch et al 1999, Russell & Lichtenstein 2000, Defloor & de Schuijmer 2000),
who have also completed studies into the problem of pressure ulcer development and prevention.

The gel-filled mattress appeared to protect patients better than those placed on conventional foam
mattresses, but the incidence of ulcer development remains significant (Nixon et al 1998). This
information can be seen in Table 7 where 11% of patients on the gel-filled mattress developed an
ulcer compared to double that number of patients who were placed on the standard foam mattress.

Table 7

Alternating air device, dry visco-elastic (gel-filled) mattress and standard foam.

Study
Aronovitch, Wilber,
Slezak, Martin Utter
1999

Nixon, McEvenery,
Mason, Brown,
Bowd 1998

Study Description
Design: RCT
Population:
217 patients

Study Group
Experimental group
alternating air
device
n = 105 patients

Comparison:
Action Pad on top
of standard foam
mattress vs
alternating air
device.

Control group (gelpad)

n = 11 patients

Design: RCT
Elective surgical
patients over 55
years.

Dry visco-elastic
polymer (gel-filled)
mattress.
n = 222 patients.

446 patients
recruited to 2
centres.

Standard foam
mattress
n = 224

Outcome Measure
Incidence and
severity of pressure
ulcers.

Results
No ulcers in
experimental
group.

Control group
11 ulcers
developed in 7
patients,
8.75% incidence
1 Stage I
4 Stage II
6 unstageable.
Incidence and
severity of pressure
ulcers.

11% of patients on
gel-filled mattress
developed pressure
ulcers.
21% of patients on
foam mattresses
developed pressure
ulcers.

50

Schultz, Bien, Dummond, Brown, Myers (1999), when describing a study that was designed to
identify the etiology and incidence of pressure ulcers in surgical patients, stated that the prevalence
data suggested that the risk of ulcers was associated with the length of procedure, and the operating
table mattress. However the outcome was that the type of operating table and gel-filled mattresses
required further investigation. Similar recommendations are found in a number of other studies
(Aronovitch 1999, Aronovitch et al 1999, Russell & Lichtenstein 2000, Defloor & de Schuijmer
2000). A meta-analysis could not be conducted on the results due to half of the patients being
discharged before the completion of the study (Aronovitch et al 2000). Problems were also evident
in the pressure sensing devices used to measure pressure intensity; therefore the data was not used
in the analysis.

Smaller versions of the gel-filled mattress are available and are used for positioning the patient for
surgery, or for elevating heels and protecting specific parts of the body. The next section discusses
this type of equipment.

4.

Gel-Filled Pads

This section considers comparisons of gel-filled pads, against the standard foam operating table
mattress.

During surgery, vulnerable skin areas such as heels and elbows, and sacrum, which are not designed
to bear weight, are subjected to pressure of varying intensities. Depending on the nursing
assessment, a variety of aids are used to pad the skin over these areas.

Results
A search of the literature failed to find any comparisons of the gel-filled pads and foam pads. Their
use in pressure prevention is briefly discussed in a number of documents but there were no studies
that specifically evaluated their use (Pope 1998, Schultz et al 1999, Donnelly 2001).
51

Studies that were identified contained information about a number of different materials that are
used in the manufacture of operating table mattresses and compared these in relation to the gelfilled pads. However there is limited documentation that describes the use of any pads. A summary
of the population, intervention and outcome measures of those studies that were found are shown in
Table 8. As can be demonstrated from the table, there is difficulty in providing any valuable
information for the use of gel-filled pads (Nixon et al 1998).

Table 8

Evaluation of gel-filled pads

Study
Nixon, McElvenny,
Mason, Brown, Bond
1998

Study Description
Design: RCT 2
Centre

Study Group
Gel-filled pad
n = 222

Population: 446
Surgical patients.
Vascular,
Gynaecological,
and general
surgery.

Outcome Measure
Incidence and
severity of pressure
ulcers.

Results
Difficult
interpretation.
No data.

Gel filled pads are available in a wide variety of shapes, sizes and thickness. The main purpose of
these pads is to assist with the positioning of the patient for a procedure, protect the patient from
contact with any metal on the operating room table, or to elevate the patients heels or other areas
from the standard operating room mattress.

A study conducted by Nixon et al (1998) compared five mattresses for their effectiveness to prevent
pressure ulcer development. It demonstrated that the gel-filled pad reduced the probability of
pressure ulcer development by half. However, although the interface pressure was found to be
significantly lower than on the standard foam operating table mattress, the reduction in pressure was
still limited, therefore the potential for ulcer development could be expected. The difficulty with
this study and similar others (Schultz et all 1999, Armstrong & Bortz 2001) is that the interpretation
of pad and mattress is often difficult to separate and therefore conclusions are subject to individual
interpretation.
52

It was often difficult to judge which item was applicable to be included in the results as terminology
and definitions varied when describing the equipment. The same problems arose when patient
populations were presented, not all were surgical patients, in some instances healthy volunteers, and
environments other than the perioperative environment were used (Stotts 1998, Armstrong & Bortz
2001).

This difficulty with interpretation is one that is common in many articles. Data is found to be
incomplete of baseline comparability, and at times information is missing about the study being
discussed (Cullum et al 2000). Post-operative assessments that have been conducted are completed
in a variety of ways, and therefore make it difficult to present good data with inconsistencies in
recording classifications of skin damage, different pressure-reducing devices on the same patient
and comparisons of each patients results (Armstrong & Bortz 2001). Therefore it is recommended
that in a majority of instances, caution should be exercised when reading the results of these studies,
and consequently, no specific conclusions could be made.

5.

Overlays

Overlays are generally placed on top of the operating room table mattresses to give extra thickness
to the standard foam mattress. They can be composed of either foam or gel-filled. The decision to
include this equipment as part of this study was due to the inconsistency in some of the descriptions
of mattresses and items described as overlays that could, on occasions, be interpreted as a mattress.

Results
The literature search identified three RCTs that included the term overlay and their impact in the
prevention of pressure ulcer development (Table 9). The studies that were identified discussed the
different materials used as overlays. In many instances the term overlay could be interpreted as a
mattress, and for this reason interpretation of data was difficult and subjective, and a meta-analysis
53

was not conducted. A summary of the population, intervention and outcome measurement of these
studies is shown in Table 9.

Overlays are composed of the same materials as many of the other pieces of equipment. However it
appears that many of them offer no assistance in the prevention of pressure ulcer development
(Schultz et al 1999). Vermillion (1990) considers whether any of the products are clinically
effective for patients at greater risk, such as those undergoing vascular and orthopaedic surgery, or
is an effective and practical product yet to be developed?

Overlays are used in conjunction with other items and are generally composed of materials such as
foam, gel, fibre, static air or in the form of alternating pressure devices that work on the principle of
cyclic inflation and deflation of air cells over short periods of time. Foam has been used for many
years as an inexpensive and convenient surface that is easily shaped for the specific bony
prominences of the body. It is lightweight, easily transported and requires a minimum level of
maintenance being resistant to sharp objects. Unfortunately it has some disadvantages in the form of
limited durability, the ability to absorb perspiration, odour and other fluids, stains easily, and is
impossible to clean (Australian Wound Management Association 2001).

54

Table 9

RCTs Overlays

Study
Schultz, Bein,
Dumond, Brown,
Myers 1999

Study Description
Design:
Prospective
randomised
experiment
Population:
413 surgical
patients.
Comparison:
Standard foam
mattress and special
mattress overlay.

Study Group
Cardiac and general
surgery patients.
Control group:
207 = standard
mattress
n = 34

Outcome Measure
Incidence and
severity of pressure
ulcers.
Evidence of friction
and shear. Skin
damage.

Experimental
group:
206 = special
overlay
n = 55
No statistical
differences in age,
sex, Braden Scale
scores etc on
admission, length
of surgery.
Conventional
management in this
study is defined as a
gel-pad.
No international
definition of
conventional.

Nixon, McElveny,
Mason, Brown, Bond
1998

Design:
RCT
Population:
446 surgical
patients over 55
years of age.

Dry-visco elastic
polymer (gel-filled)
overlay
n = 222

Incidence and
severity of pressure
ulcers.

Standard foam
mattress
n = 224

Supine or lithotomy
position.
Cullum, Deeks,
Sheldon, Song,
Fletcher 2001

Design:
RCT 29 Studies
Population:
Patients receiving
care deemed to be
at risk in any
setting.

Pressure relieving
overlays of various
compositions.

Incidence and
severity of pressure
ulcers.

Results
89 patients
(21.5%)
developed
Stage I ulcer.
9 patients (2%)
developed
Stage II and IV
ulcers.
Incidence in
the
experimental
group 26.6%
compared to
16.4% in
control group.
139 (10.7%) of
ulcers more
severe than
Stage I.
No significant
differences
between the
control and
experimental
group in patients
undergoing cardiac
to other surgery or
secondary
diagnosis of
diabetes, length of
surgery.
Significantly more
patients in the
experimental
group (n = 55),
than in the control
group
(n = 34) developed
skin damage
(p=.011)
Reduced the
incidence of ulcer
development by
overlay compared
to standard foam
mattress.
Majority of data
collected,
assessments
completed on heel
assessments.
Not possible to
compare due to
inconsistency in
reporting.
No treatment or
outcomes
presented.

55

These devices are one of a number of specifically manufactured mattresses that are reported to be
useful in pressure ulcer prevention (Schultz et al 1999). Those special items of equipment are
usually referred to as visco-polymer pads, and are considered in the same category as a gel-filled
pad or Action Pad. A full-length overlay covers the entire length of the operating room table.
These pads are usually placed on top of the standard operating room table, and therefore could be
considered as an overlay. Schultz et al (1999) believes that the effect of a gel-overlay needs further
investigation, and concludes that continued difference in protecting the skin of all patients who
come to the operating room is necessary.

Discussion
Pressure ulcers occurring in surgical patients are often attributed to time spent in the operating
room. Initially underlying damage can occur whilst undergoing a surgical procedure but may not
become apparent until hours or days later.

The objective of this critical review of the literature was to identify the most effective composition
of an operating table mattress that can be used to prevent pressure ulcer development during the
patients surgical experience and a review of the literature has highlighted that there is a lack of
rigorous research in this area. Often the researchers have failed to provide a reasonable and
adequate description of any research design that has been used in order to appraise the research.
This lack of critical appraisal, and incomplete description of the study intervention or indeed the
process used to assess the clinical outcome makes replication of the research almost impossible.

When considering the findings of this critical review, it is possible however, to suggest there is a
difference in the effectiveness of the different operating table mattresses and their impact on patient
care but that it is difficult to make recommendations that a particular mattress is more effective than
others in the prevention of pressure ulcer development in the operating room. This is largely due to
56

the fact that a standard mattress is difficult to define, and many different types are in use.
However what is generally recognised from the literature is that the standard operating room
mattress is usually foam with a vinyl or similar outer covering and it is not very good as a pressurerelieving device. Tissue interface pressures depend on the mattress used, but no support surface
relieves pressure for each individual patient. Krouskop, Garber and Noble (1999) cited in Defloor
and deSchuijmer 2000) believe that the best compromise is to select support surfaces that reduce
interface pressures to a minimum. The variability of individual physical conditions makes it
impossible to stipulate one universal interface pressure threshold that could be considered safe
(Burman 1993, cited in Defloor & deSchuijmer 2000). However, when layers of material were
removed between the patient and the operating room table mattress, the social interface pressure
settings were reduced (Campbell 1989 cited in Defloor & deSchuijmer 2000).

Much of the research located dealt with patients in nursing homes and ward environments but
discussion papers were identified which dealt with operating room table mattresses. Some
experimental studies did meet the inclusion criteria for this review and some were rejected due to
deficiencies in the study design, or from insufficient reporting of study design details.

Statistical meta-analysis was confined to those studies that were conducted using the same
intervention, measuring similar outcomes. The use of meta-analysis was limited due to problems
with the intervention details and the method of assessing clinical outcome measures. More often
meta-analysis could not be conducted due to the inadequate reporting of the results. For this reasons
the majority of this report has been presented in a narrative form. Tables and figure formats were
used in the report, whenever possible, to emphasise specific findings.

This review does not include all available compositions of operating room table mattresses, that will
require further research. Of the RCTs reported the dynamic and static air mattresses were superior
57

products, the gel-filled overlays were also effective in reducing pressure ulcer prevention, although
not as effective as the dynamic mattress. The foam mattress commonly used provided the lowest
pressure relief.

Implications for Practice

Pressure ulcers are a real risk for people who are unable to change position regularly. Sustained
pressure on those areas that support the body, leads to reduced blood supply and eventually death of
the skin and underlying tissue and muscles. In the operating room environment moving patients to
relieve and prevent the development of ulcers is difficult, as surgery requires patients to remain
anaesthetised and immobile for long periods of time.

There are two main approaches to preventing pressure ulcers; one is to use a conforming support
surface to distribute the body weight over a large area, and the other is with the use of an alternating
support surface where inflatable cells alternatively inflate and deflate.

There have been few randomised controlled trials (RCTs) on pressure relieving support surfaces
that minimise pressure ulcer development in the operating room environment. Cochrane
Collaboration, (Cullum et al 2001) reviewed 29 RCTs on pressure relieving support surfaces.
Cullum et al (2001), suggest that pressure-relieving overlays on the operating room table are of
benefit in reducing the incidence of pressure ulcers. However the confidence in which firm
conclusions can be made is tempered by the poor quality of many of the trials, a lack of baseline
comparability and of blind outcome assessments.

There is an industry unit of measure used to determine the degree of firmness and the number of
pounds necessary to compress the mattress determines this. Based on these measurements it was
hypothesised that reducing the intensity pressure of a mattress that met the standards would improve
58

tissue tolerance, and decrease the incidence of pressure ulcer development or skin damage (Schultz
et al 1999). Clinch (1996) indicates that mattresses are not routinely tested or audited for condition
and suitability for continual use. This is important given that pressure ulcers are considered adverse
events that can occur in any health care setting.

In the operating room environment minimising the incidence of pressure ulcer development is
difficult due to the immobilisation of patients for surgery but there are some opportunities for
improvement in nursing practice. Quality improvement approaches can provide a framework for
monitoring and evaluating the impact of any preventative management strategy. If any outcomes
are to be measured, it must be able to be demonstrated that the cost exceeds the preventative action
and purchasing of equipment.

Education is crucial in the implementation and maintenance of any pressure ulcer prevention
programme. Education and training workshops and in-service sessions are important to address
deficits in knowledge, increase and maintain competency, and ensure staff remain abreast of new
developments in the prevention of pressure ulcers. Education should be delivered to all levels of
clinicians and as highlighted by this review the operating room environment and staff working in
this area should be involved in ongoing education.

The education programme should include at least the following topics:

Aetiology and risk factors for pressure ulcer development.
Risk assessment tools.
Skin assessment and implementation of an individualised skin care programme.
The importance of the accurate documentation of the patients data.
The skills to assess the status of research evidence.
The knowledge and to record documentation, that should be compatible with clinical
practice.
Prevention of pressure damage and its research priority in the nursing care of patients.
Access to critical review results that will inform nurses of the need to change practice.
Development of a systematic protocol for assessing patients risk of skin breakdown, and for
taking appropriate action when patients are assessed as being at risk of tissue damage, that is
supported by nurses and organisations.

59

Research demonstrates that education and the development and implementation of policies and
procedures have a positive impact on the reduction of pressure ulcer development (Armstrong &
Bortz 2001). Many current practices are not supported by well-conducted research but simply
highlight the variety of procedures and available products.

The development of a policy and risk protocols should demonstrate the commitment a health care
organisation has to the prevention of pressure ulcer prevention. The role and responsibility should
very clearly identify the role and responsibilities of operating room nurses and medical staff
(Bostrom, Mechanic, Lezar, Michelson, Grant, Noumea 1996).

Stott (1998) reports from her literature reviews that generally there is sketchy evidence of the most
effective equipment, and there is a need for further research into what really works and does not.
There are concerns about some of the terminology used to describe the various items of equipment
used on the operating room table. This is of particular importance when differentiating between
operating room mattresses and equipment placed on top of the mattress believed to offer extra
protection for the patient.

Clinical nursing interventions, outcomes of care and adjustments to pressure ulcer prevention
management, are generally the domain and responsibility of the operating room nurse. Therefore
this group of nurses are involved in writing specifications for the purchase or replacement of
operating room tables and mattresses. This involvement should ensure that the most effective
composition for the mattress would be selected.

The perioperative environment offers unique opportunities for investigating and developing
effective pressure relief and reduction devices. Because surgical patients cannot be moved during
surgery, and have been placed in specific positions in order for the surgeon to gain access to the
60

surgical site any product must be firm, stable, able to distribute pressure evenly on the table, and
available in a variety of sizes. Perioperative nurses are in a prime position to offer advice to
manufacturers on the best products. Their knowledge about other items of equipment used during
surgery, which has the potential to cause problems or interfere with the composition of materials
used in the manufacture of mattresses, can be invaluable.

Products should be flame and leak resistant because of the frequent use of electrosurigcal equipment
and lasers. Elimination of cords on the floor will contribute to safer occupational health and safety
issues. Resistance to infections, the ability to disperse moisture and be non allergenic are allimportant points worthy of serious consideration. However support surfaces that reduce tissue and
surface interface pressure below 32mn Hg is of paramount importance (Horshowsky & Schramm
1994). It is important that the support surfaces used in the operating room are evaluated for
performance in reducing interface pressure at bony prominences, durability, ease of use and user
acceptability. Jay (cited in Pope 1998, p. 312), concluded there is a need for objective clinical
evaluation of support surfaces to provide clinicians with improved criteria for selection of
equipment.

Historically research has focused on settings other than the operating room environment. Studies
conducted by researchers indicate that previous attempts to extrapolate results in the operating room
have been unsuccessful, because of the specific risk factors associated to the area. Over time
however, there has been a gradual focusing on the specialty environment as the source of pressure
ulcer development. Evidence based practice is needed about patient care and the equipment used in
this specialty. The knowledge that is unique to this group of nurses requires documenting, this being
another way of promoting the value of the nurse in the perioperative environment.

61

The introduction of a risk management system aimed at preventing and reducing the development
of pressure ulcers should be based on information collected. From the information collected an
organisation should be able to provide costs, variations of practices and the resources available and
to determine the most appropriate assessment tool suited to an operating room.

The promotion of evidence based nursing practice contributes to increasing the effectiveness of the
health service in Australia. Evidence Based Practice is seen today as a fundamental component of
high quality, cost effective, outcome oriented health care by governments and health services. A
reduction in variability of practice is a strategy that educates and involves nurses to refocus nursing
policies and guidelines. This in turn resulting in a positive impact on a wide range of outcomes ie
pressure ulcer amongst many others such as medication use, injury and patient anxiety.

Conclusion
This critical review has highlighted the need for further research into many aspects of the nursing
management of patients at risk of developing pressure ulcers during surgical intervention. In the
operating room environment an important aspect of nursing management it is to be fully conversant
with the most effective equipment and practices that can assist in the prevention of pressure ulcer
development. It is acknowledged that the evidence available for pressure-reducing equipment used
in the operating rooms is limited. This may be due to the limited number of suitable items of
equipment for the table.

It is increasingly apparent that the complex nature of pressure ulcer development means that it is
unrealistic to expect a single discipline to manage the problem effectively. A multidisciplinary team
approach is the most appropriate way to improve the management of this problem.

62

Extended periods of uninterrupted pressure and shear place patients who are undergoing surgical
procedures at an increased risk of skin breakdown. It is easy then to see why support surfaces are
both relied on and heavily utilised in patient care. The major premise is that they reduce pressure on
the patients body. Quality data does exist about this issue, but is limited to areas such as Intensive
Care Units, and the notion that this data will automatically be applicable to the operating room
environment is difficult to substantiate in this complex population. It has been agreed that
controlled clinical studies of pressure-reducing equipment are complex and difficult primarily
because of the diverse number of variables.

There is little evidence that using a pressure ulcer risk score scale is any better than using clinical
judgement, or that it improves patient outcomes.

Considering the findings of this critical review, it is possible to assert that there is a difference in the
effectiveness of the various operating room table mattresses, pads and overlays in the prevention of
pressure ulcer development. Unfortunately it is not possible to make clear recommendations that a
particular mattress is more effective due to the fact that not all compositions of mattresses were
reviewed or evaluated. What this critical review can do is highlight particular studies that may assist
operating room nurses make decisions about the effectiveness of the standard foam mattresses, pads
and gel-filled mattresses commonly used today. A recommendation that can be made is that the
standard foam operating room table mattress does not prevent pressure ulcer development in
surgical patients, and that further investigation is needed to ensure that mattresses used are the most
effective in the continuing fight against pressure ulcers acquired in the operating room.

Theaker (2002) makes the point that manufacturers often use sophisticated marketing strategies to
sell these products and substantiate claims with poor quality evidence such as reports on interface
pressures that may not be applicable. It has often been claimed that controlled trials are difficult and
63

expensive. If this reasoning were applied to pharmaceutical trials, then it would soon be viewed as
superficial and dangerous for the population.

Whilst it is acceptable that support surfaces reduce pressure the evidence that supports this
statement has yet to be confirmed in a majority of cases (Cullum, Deeks, Sheldon, Sing, Fletcher
2001, Scott 200). Quality data exists in some areas but not the perioperative environment. The
notion that data can be automatically transferred from ICU or ward areas to the operating room is
difficult to substantiate in such a fragile and complex group of patients. If the problem of pressure
ulcers is to be managed effectively then it is required to be managed by more than one discipline
whose resources and influences are mandatory in preventing this painful, distressing and perhaps
preventable situation for patients.

64

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70

Appendix 1

Inclusion Criteria : Elderly Perioperative Patients

Author Year Record Number..

Population
Perioperative patients

Intervention
Prevention of pressure areas

Specific interventions

Pressure relieving devices

Education programmes

Care delivery changes

Prevention of pressure area related pain

Maintenance of skin integrity

Outcome

71

Appendix 2

Critical Appraisal : Perioperative Patients

Author Year Record Number..

Question 1 4 must be answered yes for study to be included in the meta-analysis.

1.

Were the recipients randomised to study groups or where intra-individual controls used?
Yes

2.

Not clear

No

Not clear

No

Not clear

Not clear

Not clear

Were the patients comparable at entry?

Yes

5.

Were the outcomes measured in the same manner for all patients?
Yes

4.

No

Were all participants group treated the same?

Yes

3.

No

Was there adequate follow-up of patients.

Yes

No

(Less than 80% followed up)

72

Appendix 3

Data Extraction Form

Author

Record Number

Journal
Year
Reviewer
Method

Setting
Participants

Number of Participants

Group A

Group B

Group C

Interventions
Intervention A

Intervention B

Intervention C

73

Outcome Measures
Outcome Description
Pain

Yes
No

Scale / Measure
Incidence
Pain Scale

Type of scale
Other

Skin discolouration Yes

No

Assessment scale

Yes
No

How ..

Type of scale

Other

74

Results
Dichotomous Data
Outcome

Continuous Data
Outcome

Treatment Group
number / total number

Control Group
number / total number

Treatment Group
mean & SD (number)

Control Group
mean & SD (number)

Authors Conclusions

Comments

75

Appendix 4

Summary of major studies used in review

Study

Method

Population

Setting

Intervention

Hospital operating
rooms

Outcome Measure
Comparisons of
all support
surfaces, all
compositions.
Foam, gel, pads.

Level of Evidence

Findings

Armstrong and
Bortz 2001

Literature review
Integrative
review

Surgical patients

AORN 2001

Assessments /
standards for
positioning

Surgical patients

Hospital operating Patients scheduled Pre-operative and

Post-operative
rooms
for surgical
assessment
procedures

III

Presented as
guidelines for use
by OR nurses.

Aronovitch,
Wilber, Slezak,
Martin and Letter
1999

11 month study.
Parallel
comparative
single centre
study.

Randomised 217
surgical patients
over 18 years of
age.
2 groups
Procedures

Hospital operating Group 1, study

rooms
group patients
placed on
experimental
device (Dynamic
pad)

Comparisons of
the equipment in
the prevention of
pressure ulcer
development.

II

Dynamic pad
(Micropulse)
statistically better
in the prevention
of pressure ulcer
development.

22 patients
developed ulcers
in the pad group,
43 in the foam
mattress group.

II

No significant
differences
between 2 groups.
Use of the pad
statistically
significantly in
lower ulcer
development.

III

Group 2, control
group patients
placed on gel-pad
placed on top of
standard mattress.
Land 1995

Randomised
Controlled Trials.

446 Elective
surgical patients.
222 on viscoelastic polymer
pad vs 224 on
standard foam
mattress.

Operating room.

Comparison
Lithotomy or
supine positions.
90 minute
procedures.
50 years and over.

76

Study

Method

Population

Setting

Intervention

Outcome Measure

Level of Evidence

Findings

Aronovitch 1999

Comparative
parallel study.
Patients
randomised.
2 groups.

217 surgical
patients, 18 years
and over.
4 hour or longer
procedure.

Operating room.

Gel-overlay in the
OR and dynamic
alternating air
mattress.

No difference
between the 2
groups in ulcer
development.

II

No significant
differences found
between both
groups.

Defloor and
deSchuijmer 2000

Laboratory
Pressure
monitoring

36 Healthy
volunteers.
24 females
12 males, ages 2
56 years.
Average weight
72.9 kg.

Laboratory

Interface pressure
measurements on
4 intra-operative
positions;
Supine
Lithotomy
Randomised
Mattress and
Positions.

Standard foam gel

mattress

IV

Interface pressure
highest on the
standard foam
operating room
table mattress
than other types
of mattress.
Visco-elastic
polyther and
polyurethane
mattress most
effective with
most pressure
reducing qualities.
Preferable in the
prevention of
pressure ulcers on
the OR table.

Donnolly 2001

Literature review

All patients.

Hospital

Validity of risk
assessment tool
for reduction of
heel ulcers.

Ineffective use of
sheepskins and
pillows.
Use of cradles and
reduction in the
use of blankets
over feet.

IV

Recommendation
s for further
study.

77

466

Study

Method

Population

Setting

Intervention

Outcome Measure

Level of Evidence

Findings

Brown 2001

Summarised
results of a
systematic review
of RCTs.

Patients in ward
areas and
operating rooms.

Hospital

Hospital bed
mattresses and
operating room
table mattress
pads and overlays.

Comparison of
equipment
available. Cost
and efficiency.

Special pressure
relieving
mattresses should
be used for all
patients at risk for
skin damage.

Cullum, Deeks,
Sheldon, Song,
Fletcher 2001.

Systematic review
RCTs.

Patients in ward
areas and
operating rooms.

Hospital

Bed mattresses,
operating room
table mattresses,
cushions,
overlays.

Comparison of
equipment
available.
19 databases.
29 RCTs of
support surfaces.

Further research
required to
compare, cost
effectiveness of
different types of
pressure-relieving
devices for
patients at various
levels of risk in
different settings.

Clinch 1996

Literature review.
Casenote audit

Surgical patients.

Hospital

Audit of condition
of equipment.
Audit of patient
care plans postoperatively.
All equipment
used compared.

Judgements
documented about
pressure ulcer risk
and precautions
implemented.

IV

Changes to
practice.
Introduction of
Risk Assessment
document for
surgical patients
visco-elastic dry
polymer most
effective than
foam.

78

466

Study

Method

Population

Setting

Intervention

Outcome Measure

Level of Evidence

Findings

IV

Limited data
about the pre-op,
intra-op and postop periods.

Stotts 1999

Review of
scientific data

Elective and
emergency
patients

Retrospective
analysis of case
notes.

Waterlow 1996

Discussion article

Surgical patients.

Testing of a
hypothesis re
operating room
table mattress as
the cause of
ulcers.

Implications of
Intrinsic and
Extrinsic factors.

IV

Costs associated
and factors
contributing.

Vermillion 1990

Nixon 1998

79

466

Prevention trial.
8 day follow-up.
Telephone
conversation
RCT

6 patients with
sacral ulcers postoperatively
following cardiac
and vascular
surgery.

Hospital

Discussions of
pressure ulcer
development
during surgery
and
recommendations.

Pre-disposing
factors length of
time on the OR
table not
predictive of risk.
Risk rating not
particularly
helpful, patients at
risk.

IV

Recommendation
for further study
included in the
document.

Patients 55 years
and over, major
gynae or vascular
surgery.

Operating room.

2 groups
1 Dry viscoelastic polymer
pad.
2 Standard foam
OR mattress plus
heel protection.

Incidence of ulcer
development.

II

Disagreement in
calculations.
Mixed
classification of
overall results.
Difficulty in
determining
overall results.

Study

Schultz, Bien,
Dumon, Brown
and Myers 1999

Method

Experimental
study
RCT.

Bliss, Scrimm
1999

Population

Intervention

Outcome Measure

Level of Evidence

Findings

III

Guidelines needed
to delineate the
best padding
options for
specific
procedures.

Surgical patients
n = 412
randomised post
operative.

Operating room.

Evaluation of
special mattress /
overlays

Identification of
the etiology of
pressure ulcers.
Evaluation of
special mattress /
overlay.

All patients

Hospital

Tissue shear,
pressure, disease
status OR table
mattresses.

Guidelines
required.

Braden, White
1999

Study

10 patients mean
age 84.
7 females,
3 males.

Bridel 1992

Critical literature
review.

Surgical patients

80

466

Setting

Epidural
anaesthesia
warming blankets
increase risk of
ulcer
development.
Post-operative
management
recommended.

Confirmation of
tissue viability
may be comprised
in elderly patients
during surgery.
Need to assess
support surfaces
in the operating
room for the
elderly patient.

Transcutaneous
gas tensions
adjacent to greater
trocanther.

Hospital operating Multi-factoral

room
nature of ulcer
development.

IV

Intrinsic factors
require further
investigation.

Study

Method

Pope 1 and 2
1999

Literature review.

Russell,
Lichtenstein 2000

RCT Single
centre prospective

Richardson,
Gardner, Franz
1998

Comparative,
descriptive study.

81

466

Population

Setting

Intervention

Outcome Measure

Level of Evidence

Findings

Hospital

Outlines the
pathophysiology.
Nursing
interventions.

To reduce the
incidence of
pressure ulcer
development.

IV

Awareness of risk
factors.

Cardio thoracic
patients. Surgery
4 hour duration.
Randomly
assigned.

Hospital

Dynamic mattress
system vs
standard foam
mattress.

Assessed for up to
7 days postoperatively.
Reduction of 7%
for standard
management to
2% for dynamic.

II

Mullti-cell system
decreases
incidence of
pressure ulcers in
patients who
undergo
cardiovascular
surgery.

51 chair or bed
bound residents.

Long term care

setting.

Assessment.
Relationship
between level of
risk and cost of
prevention.

A lack of data
associated with
long term care
setting.

IV

Repositioning the
most frequently
used form of
intervention.
Limitations to the
study. Small
number of
subjects.

Appendix 5

Excluded Studies
CITATION

METHOD

REASON FOR
EXCLUSION

LEVEL OF EVIDENCE

Fletcher 1996

Study

This study described the

main cause of pressure
ulcer development and
prevention strategies. No
operating rooms.

IV

Whillingtom, Patrick
Roberts 2000

Study

A study that sought to

establish national
benchmarks for pressure
ulcer prevalance and
incidence among acute
care health organisations.

IV

Scott 1998

Study

A retrospective analysis
of case notes of patients
who had a surgical
procedure over a 5
month period.
Identification of factors
to be used as part of
assessment tool for
surgical patients.
Preliminary results.

IV

Wild 1991

Study
This study compared the
interface pressure on 6
patient high risk body
areas.
Not operating room.
Water bed.

IV

Parker, Morgan, Clayton,

Gerrish, Nolan 1998

Project

This paper described the

second part of a project
which examined nursing
knowledge, practice and
management to pressure
ulcer prevention.

IV

Richardson, Gardner,
Franz 1998

Comparative descriptive
study

Study conducted in a
long term care facility,
non surgical patients.

IV

Dunford 1994

Department of Health
project, UK

Describing the findings

of an evaluation of
hospital mattresses. Non
surgical areas.

III

82

CITATION

METHOD

REASON FOR
EXCLUSION

LEVEL OF EVIDENCE

Schultz, Bein, Dumond,

Brown, Myer 1999

RCT, Post-operative

This experimental study

designed to identify the
aetiology of pressure
ulcers in a surgical
sample, and evaluate OR
mattress overlay in
preventing pressure ulcer
development.

II

Aronovitch 1999

Multisite, descriptive
study

This study described the

results of an analysis of
104 survey forms, which
sought to determine the
prevelance of surgically
acquired pressure ulcers
associated with
comobidity.

III 3

Price, Berle, Newcombe,

Harding 1999

Prospective Randomised
Controlled Clinical Trial

This study sought to

determine the
effectiveness of a new
low-unit cost support
system in patients at
extreme high risk of
developing a pressure
ulcer.

II

83

Appendix 6

Hand searched reference books

Title
Brown, P.

Year

Title

1994 Communicating with the Older Person, Health

Care and the Aged: A Nursing Perspective.
Dellasega and 1990 The Ageing Patient in Perioperative Nursing
Rothrock
Care Planning
MacIntyre and 2001 Acute Pain Management
Ready

Publisher
MacLennan and Petty
Ltd.
CV Mosley Company
WB Saunders

84

Appendix 7

Hand searched journals

Journal
Advances in Wound Care
American Operating Room Nurses Journal
Applied Nursing Research
Australian College of Operating Room Nurses Journal
Australian Journal of Rural Health
Australian Nursing Journal
Annals of Internal Medicine
British Journal of Theatre Nursing
British Medical Journal
Collegian
International Journal of Nursing Studies
Journal of Advanced Nursing
Journal of Clinical Nursing
Journal of Gerontological Nursing
Journal of Medical Ethics
Journal of Wound Care
Journal of Wound, Ostomy and Continence
Nursing Review
Nursing Times
Primary Intervention
Quality in Health Care
Research in Nursing and Health
Surgical Services Management
The Dissector
Todays OR Nurse

Year
1997 2002
1995 2002
1995 2002
1985 2002
1995 2002
1995 2002
1986 2002
1991 2002
1995 2002
1975 2002
1995 2002
1995 2002
1995 2002
1992 2002
1995 2002
1998 2002
1995 2002
1995 2002
1995 2002
1994 2002
1995 2002
1994 2002
1998 2002
1995 2002
1994 2002

85

Appendix 8

Conference Proceedings

Conference
World Conference of Operating Room Nurses, Germany
World Conference on Surgical Patient Care, Finland
National Association of Theatre Nurses, United Kingdom
Australian College of Operating Room Nurses, National Conference
Australian College of Operating Room Nurses, National Conference
1st Asia Pacific Forum on Quality Improvement in Health Care
American Congress of Operating Room Nurses, California
European Operating Room Nurses Association, Belgium

Year
1995
1999
1994 - 2002
1998
2000
2001
1999
1997

86

A HERMENEUTIC ETHNOGRAPHY
OF THE PERCEIVED SKILLS AND KNOWLEDGE OF NURSES
IN THE PREVENTION OF PRESSURE ULCER DEVELOPMENT
IN THE PERIOPERATIVE ENVIRONMENT

TABLE OF CONTENTS
Glossary of Terms used in the Study

Page
5

Physical Areas

The Surgical Team

Nursing Activities

Introduction

Background

Literature Review

10

Search Strategy for Identification of Studies

11

The Literature

12

The Purpose of the Study

24

Research Design

25

Methodology

25

Ethnography

26

Hermeneutics

29

Hermeneutic Circle

31

Prejudice

31

Truth

32

Methods

34

Conducting Fieldwork

34

Gaining Access to a Study Environment

35

Observation in the Clinical Setting

36

Interviewing Staff

38

Formal Interviews

39

Informal Interviews

40

Page

Field Notes

41

Reflective Journal

42

The Study Setting

43

Ethical Considerations

43

Recruitment

44

Methods of Analysis

45

Domains = development of basic elements

48

Analysis of the Observations

49

Analysis of the Interviews

51

Rigour

53

The adequacy of the definitions

55

Credibility of description accounts

56

The relationship between descriptions and claims

56

Main sources of error of judgement

56

The Participants

62

Analysis

64

The Interviews

Results of Folk Domain Analysis of interview with:

67

Amelia

68

Alice

70

Jennifer

72

Phillip

75

Joanne

77

Joseph

79

Annie

82

Max

84

Page
Patterns and Themes

Analytical Domain Analysis of the Observations

Discussion

87
88
91

Caring

92

Knowledge

93

Involving other health professionals

95

Communication

98

Assessment

99

Nursing Routines

100

Perceived barriers to implementing best practice

101

Meeting the purpose of the research

102

Addressing the research question

102

Effectiveness of the research strategies

105

Ethical dimension of the research

105

Relevance of the research

106

Limitations

106

Evaluation of the Research Process

109

Summary of Research Portfolio

Recommendations

110
112

Where to from here?

114

References

117

TABLES

Page

Table 1

The Observational Process

37

Table 2

Profile of Staff in the Study Setting

43

Table 3

Domains

47

Table 4

Analytical Domains

49

Table 5

Strategies that promote the validity of the research

55

Table 6

Patterns and Themes

87

Table 7

Included terms in each domain

90

Structured analysis of data

50

FIGURES
Figure 1

APPENDICES
Appendix 1

Risk Assessment
Tool 1

Braden Scale for Predicting Pressure Sore Risk

130

Tool 2

Norton Risk Assessment Scale

131

Tool 3

Waterlow Risk Assessment Score

132

Appendix 2

Invitation to be involved in the project

133

Appendix 3

Information Sheet

134

Appendix 4

Contact details for information on project and independent

complaints

135

Appendix 5

Consent Form

136

Appendix 6

Interview Questions

137

Appendix 7

Patient Data Sheet

138

Appendix 8

Demographics of staff interviewed

139

Appendix 9

ACORN Standards
Positioning the Patient for Surgery
Aseptic Technique

140
144

Glossary of Terms Used In The Study

The definitions of the key terms used are drawn from the work of Astbury (1988), Groah (1990),
Hind and Wicker (2000).

Physical Areas
Operating Room Services (ORS), an organisational unit that consists of one or a number of
operating rooms, anaesthetic rooms, post anaesthetic care unit, reception area for patients, changing
rooms for male and female nursing and medical staff, lounge areas, sterile equipment and
consumables rooms, ancillary rooms and disposal areas. This is the setting in which the study was
conducted.

Operating Room: defined as a room where surgical procedures are performed.

Anaesthetic Room: where patients are anaesthetised prior to surgery.
Recovery Ward: this environment receives and cares for patients following surgical interventions.
Monitoring of vital signs, pain management, post operative haemorrhage and patient comfort and
warmth is performed in this environment.

The Surgical Team

Scrub Nurse / Instrument Nurse: a registered nurse who is responsible for the preparation of the
environment, surgical instruments and equipment for the procedure. Assists with and responsible
for positioning the patient.

Circulating Nurse: a registered or enrolled nurse who feeds the consumables to the surgical team.
Assists with the preparation of the environment with positioning, and provides comfort to the
patient.

Anaesthetic Nurse: this nurses main function is to assist the anaesthetist, but they are also a
member of the surgical team. Assists the scrub and instrument nurse if anaesthetic demands permit.

Surgeon: specialist medical officer responsible for the surgical procedure, assisted by junior
medical staff in training.

Registrar: a medical officer enrolled in a training program which may be either in surgery or
anaesthesia.

Nursing Activities
Nursing staff in the operating room perform many tasks when preparing patients and the
environment for surgical procedures.

Reception of the patient and receiving information from patient on ward staff about the
patient.
Checking the identification of the patient, consent, allergies and other relevant
information that may impact on care.
Collection of sterile instruments, and consumables.
Ensuring availability of positioning aids pertinent to the surgical procedure, or to protect
the patients skin from electrosurgical burns or skin trauma.
Co-ordination of the patients transfer from ward bed to the operating room table.
Assisting with anaesthetic induction and monitoring.
Cleaning of the equipment and environment following surgery.

Introduction
Operating room nursing is one of the oldest nursing specialties, with reports suggesting that its
professional development commenced around 1880. There is however a discourse of professional
insecurity pervading its long history, partly due to the nurse cast in the role of a handmaiden to the
surgeon, and lacking any real independent thought or practice (Riley & Manias 2002). All this
stems from the speciality viewed as being outside the accepted role of nursing.

The open-window through which the reader views this study of the operating nurses is via the
performance of their day-to-day practice drawn from interview extracts, observations and from the
field notes taken during the observations.

The operating room environment is unique and challenging. High paced, high risk and frightening
for patients (Wicker 2003). One of the challenges for the perioperative nurse is in the prevention of
pressure ulcers for the surgical patient. These painful, common, expensive to treat and generally
preventable complications are far from a new concept. Evidence can be traced back to the Pharoahs
(Theaker 2003). Today this problem is generally managed by nursing staff with little or no input by
other members of the health care team. For the problem to be managed effectively, all disciplines
need to be committed to preventative strategies (Theaker 2003). Pressure applied to the body during
surgery, the mattress the patient is positioned on, the length of surgery and the plethora of other
factors that contribute to the skin damage, all result in the breakdown of skin and ulcer
development. Operating room nurses need to be knowledgeable and skilled in all aspects of
pressure ulcer prevention and development and should use the best available evidence to inform the
use of the most effective support surfaces for their patients.

In this report the background section situates the study within the area of prevention of pressure
ulcer development in the operating room environment. Despite an abundance of information on the
7

development and prevention of pressure ulcers, they remain a pervasive problem in hospital and
community settings. The intra-operative period is one of great risk for pressure ulcer development
for the surgical patient and one in which little research has been conducted.

A review of the literature is presented that concentrates on the skills and knowledge of the operating
room nurse in relation to pressure ulcer prevention/development, their role and responsibility, risk
factors, preventative strategies and the barriers to good practice.

The methodology and methods used in this research are discussed, followed by analysis of the data,
the findings, and finally recommendations for clinical practice.

Background
In the last twenty years we have witnessed a revolution in the treatment of chronic wounds such as
pressure ulcers. No longer are heat lamps, various lotions and potions mixed and used as packing
for healing and altered skin integrity. Although there is research that makes recommendations
about state-of-the art practice, knowledge of this does not appear to have filtered down to all those
at the bedside providing care (Beitz, Fey & OBrien 1999). This gap between research and practice
must be bridged so that clinicians practice is based on sound evidence to provide quality patient
care. Panagiotopoulou and Kerr (2002) believe that there is little evidence to suggest that there has
been any real change to practice in the area of pressure ulcer prevention.

When patients are transported to the operating room for surgery, they relinquish responsibility for
themselves into the care of the surgical team. The reason for this being that the patients ability to
communicate their needs is compromised. Some members of the surgical team play a greater role in
the care of the patient than others. These team members are generally the nurses who should act in
the patients interest.
8

Gregory-Dawes (1999) and Chard (2000) suggest that it is becoming more difficult for the
operating room nurse to meet patient care requirements adequately in the face of the increasingly
complex and conflicting demands made of them. Mardell (1997) suggests that advocacy is pleading
on behalf of another person. Perioperative nurses believe that acting as an advocate is a nursing
responsibility and a central concern in their practice (Surkitt-Parr 1997). Advocacy appears to have
a cultural definition in this environment, but perhaps different from the norm. Acting as an
advocate for patients is not easy for the operating room nurse, and they may do so covertly seeking
support from the anaesthetic medical staff, who are considered on the same level as surgeons. The
authority in the clinical setting is at a more subtle level, with nurses thinking that something is not
quite right, and allowing the medical staff to make the decision that nurses want. Often the junior
nurse is not experienced or assertive enough, to act as an advocate. These nurses may feel
intimidated and uncomfortable about the scene that is unfolding before them but feel powerless to
intervene. To be an advocate in the perioperative environment takes a great deal of assertiveness,
knowledge and expertise (Lee 2001).

Perioperative nurses should be pro-active in determining best practice and develop care based on
evidence to reduce patient risk for pressure ulcer development in the perioperative environment.
Knowledge of risk factors is essential to provide the perioperative nurse with a basis from which to
implement specific nursing interventions. Included in the knowledge should be information about
positioning aids and operating room table mattresses.

The need for a collaborative approach to the evaluation of research and its integration into nursing
practice, was the impetus for the establishment of the Joanna Briggs Institute for Evidence Based
Nursing and Midwifery (JBIEBNM). The cultural focus of this organisation is the effectiveness of
nursing, with the definition of effectiveness encompassing health outcomes from patients in hospital
and community settings, and from both a clinical and economic aspect. This process of determining
9

effective practice involves a systematic review that is overseen by a multidisciplinary panel. The
topics developed by expert clinicians reflect current nursing practice. Best Practice Information
Sheets, the final stage of the process, are summaries of the best available evidence on a topic. These
information sheets are not complex reports, but easy to read research summaries that are targeted at
those nurses working in the clinical environment. However to date practice which is based on
evidence from rigorous research is minimal, including the perioperative environment.

Nursing in the operating room today bears little resemblance to the original housekeeping role of
many years ago. However there are some lingering echoes of those days that may be found in the
way many people, not employed or familiar with the operating room environment, make sense of
the specialty today. This study seeks to provide some insight into the contribution that operating
room nurses make to patient care management in particular to pressure ulcer prevention whilst
patients are in the perioperative environment. As part of this study, the tension between caring and
technical work, and the invisible nature of the operating room nurses work is explored. Bull
(2002) provides excellent descriptions of the work performed by this group of specialist nurses,
many of which are reflected in this document. The author provides substantive insights into the
world of operating room nursing, and clarifies their contribution to the everyday funding and
management of patients and the environment.

Literature Review
The purpose of this literature review was to establish what research had already been conducted on
the topic. Literature was sought from many sources that focused on the operating room nurses
assessment skills and knowledge in regard to the prevention of the development of pressure ulcers
in the operating room environment. The literature available about the specialty is broad, however in
regard to the assessment skills and knowledge of operating room nurses, there appears to be little.
Riley and Peters (2000) indicate that accounts of nursing practices in the operating room, are largely
10

not research but descriptive. They also suggest that on numerous occasions operating room nurses
have not been asked for their opinions or views about their role in this specialised area of the
profession.

The literature review relating to this study concentrated on operating room nurses understanding of
their role in, and knowledge of, the prevention of pressure ulcer development in patients undergoing
surgical interventions. The information was extracted from publications over the past twenty years
as few articles appear in contemporary literature.

Search Strategy for Identification of Studies

The search sought to identify all published and unpublished studies relating to the research
question. The initial search was performed using the databases CINAHL, MEDLINE and
EMBASE. It is important not to limit the search to MEDLINE, as this represents only
approximately 23% of medical type journals. It should be noted that while there may be some overlap in terms of the journals by the databases, each will present its own unique references (Evans,
1999). For example the Cochrane Collaboration maintains a database of current and anticipated
reviews and this was searched as well as EMBASE which lists journals that are not indexed on the
other databases but are relevant to this review. In an attempt to identify new articles reference lists
and bibliographies of relevant articles were also examined.

The databases searched were:

CINAHL
MEDLINE
Current contents
Cochrane Library
Embase
Expanded Academic Index

In addition, a search of reference lists of all identified studies, review papers, operating room
nursing journals and conference proceedings was conducted to identify any unpublished research.
11

Search was restricted to research reported in English language only. This strategy has the potential
to limit the results of the review as pertinent research may be excluded on this basis. Translation of
non-English studies was beyond the scope of this study due to time and resource limitations. Time
restrictions also meant that hand searching was limited to journals and books accessible to the
researcher.

Examples of initial search terms used were:

Perioperative
Perioperative nursing
Skills and knowledge
Pressure Area Care
Theatre

All studies identified during the database searches were assessed for relevance to the research based
on the information provided in the title and abstract. A full report was retrieved for all studies that
were considered relevant. Studies identified from the reference list searches were assessed for
relevance based on study title.

A large amount of literature was available about a wide variety of issues associated with the
specialty, but a thorough search of the literature in Australia and overseas, revealed few articles on
the topic of operating room nurses knowledge and skills in relation to the prevention of pressure
ulcers in the specialist environment of operating rooms.

The Literature
Patients undergoing surgery are often overlooked for the prevention of pressure ulcers, and yet
anaesthetised patients are at very high risk for pressure injury due to forced immobility which
occurs during surgery. As patient care becomes more and more complex in the acute care setting,
nurses must recognise that injury from pressure may be occurring when patients visit other

12

departments within the organisation. For this reason they should become vigilant about the patients
skin condition immediately post operative and onwards (Blaylock & Gardner 1994).

This deficit in practice is substantiated by the studies conducted by Bostrom and Kenneth (1992),
Wilkes, Bostock, Lovitt and Dennis (1996), Maylor and Torrace (1999) who found that overall the
nurses they surveyed had a sound knowledge of the prevention of the pressure ulcers, however there
were many inconsistencies in their practice. Unfortunately these studies did not include nurses
working in the perioperative environment.

The forced immobility which occurs in the operating room has been reported to contribute to
pressure ulcer occurrence, however the reporting of this has been poorly documented (Vermillion
1990). At times skin damage has mistakenly been reported as a burn. Because prevention of
pressure ulcers has long been a goal of nursing, considerable research has been done to identify
factors relating to pressure ulcer development (Bostrom & Kenneth 1992). However despite the
extensive and consistent findings in this area pressure ulcers remain a significant problem,
particularly in the specialty of perioperative nursing.

Nursing literature abounds with information concerning the risk, grading, prevention and treatment
of pressure ulcers. Norton, McLaren and Exon-Smith (1978), Waterlow (1985), and Braden (1989)
are perhaps the most well known authors of risk assessment guidelines (Appendix 1). While
pressure ulcer prevention is not just a nursing issue, and must involve all members of the surgical
team, it is nurses who should, and generally do, take the lead in managing the prevention strategies.
A recurring theme in the literature is that nurses must take the responsibility for pressure care
prevention (Kelly & Mobily 1991, Wilkes, Bostock, Lovitt & Dennis 1996).

13

One article reported the results of a study conducted in Hong Kong, investigating the practices of
registered nurses in the prevention and treatment of pressure ulcers in elderly patients specifically
(Wilkes, Bostock, Lovitt & Dennis 1996). The authors used a survey to collect the data with an
open and closed-ended questionnaire. Demographic information, age, experience and practice area
were collected, and from the answers it was evident that the nurses were influenced by current and
prior experiences.

Kelly and Mobily (1991), assert that:

Preventative care of a clients skin is within the independent role of the
professional nurse. Nursing must decrease the incidence and prevalence of
pressure ulcers by identifying those persons who are at risk and instituting
preventative treatment measures (p. 25).

A great deal of the literature claims that nurses are failing to address this need (Wilkes et al. 1996).

However it is speculated that nurses have the knowledge to prevent and treat pressure ulcers, but
fail to use that knowledge (Sparks 1992). Sparks (1992), asserts that:
Many patients continue to develop pressure ulcers even though nurses are
thought to have the extensive knowledge base that could lead to the
prevention of many these ulcers! (p. 29).

Other researchers suggest that nurses knowledge of the treatment and prevention of ulcers is
deficient, and are of the opinion that nurses fail to implement the results of research findings for
their patients (David 1981, Vincent 1984, Waterlow 1985, Gould 1986, Hodge, Mounter, Gardner
& Rowley 1990, Wilkes et al 1996). Dunn (1987) indicates that in many instances, nurses advocate
potentially dangerous treatment for pressure ulcers, such as massage which has been shown to cause
trauma to deep tissue.

The elderly are a group particularly at risk and although nurses are aware of the many risk factors
for this group of patients such as changes in mobility, chronic illness and loss of skin elasticity,
incidence of ulcers remains high. This is highlighted in many of the assessment scales used to
identify those patients considered at risk of pressure ulcer development.
14

Bostrom and Kenneth (1992) conducted a survey of 245 nurses from multiple health care settings
and found that although nurses had a good knowledge of risk factors for skin breakdown, there were
a number of environmental and clinical factors that were believed to be an impediment to the ability
of those nurses to maintain patient skin integrity. These authors found that, at the time of their
study, there were limited research findings available about nursings clinical use of research
findings, such as those related to pressure ulcer management. Carlson and Kings (1990) review of
pressure ulcer research identified several factors for skin breakdown; all were reported in medical
research. Whilst these findings by nurses were prominent in health industry literature, there was
limited use of research findings, even although there was a strong agreement that practice should be
evidence based. However, there were other issues of concern in the study conducted by Bostrom
and Kenneth (1992), nurses reported they had limited opportunity to attend conferences or time for
reading journals. It could be concluded that this lack of exposure and information suggests it may
be one of the reasons and major factors in the continuing clinical problems associated with pressure
ulcer development, both in the ward and perioperative environment.

Carlson and King (1999) suggest that in some instances failure to use research findings may be due
to a reluctance of an organisation to change clinical practices, and the attitude of the nursing staff.
Their research revealed that 15% of patients in acute care settings, and 28% of patients in nursing
homes, had pressure ulcers. In their study they provide information that more than one million
patients in hospitals and nursing homes had pressure ulcers. With the number of elderly patients
expected to increase in the future, the care and maintenance of skin integrity is important. Carlson
and King (1999) concluded that the knowledge of risk factors was good, however only 12% of the
245 nurses involved in their study identified a nurse-related factor as a risk of skin breakdown, but
they listed the incorrect use of equipment and procedures and shearing during movement of the
patient. Some risk factors highlighted were a lack of nursing staff, equipment and supplies. The
findings from this study revealed that damage to patients skin due to pressure, was not the result of
15

a lack of knowledge of risk factors and interventions by nurses. It was evident from the answers that
a variety of barriers to the provision of care curtailed their ability to prevent skin damage.
Of concern however, is the information that prevention and skin damage were not considered high
priority activities, particularly during times of staff shortage. Costly interventions and extensive
nursing time, were also a limiting factor. The authors of this study suggested that there is a need for
concrete and practical guidelines for assessing risk and cost-effective strategies for preventing skin
breakdown (Bostrom & Kenneth 1992).

Prevalent studies of pressure ulcers were the catalyst for researchers Maylor and Torrace (1999) to
ask if nurses knowledge of pressure ulcer aetiology and prevention was likely to be a factor in
explaining the prevalence pattern. These authors asked the question Will having carers with
inadequate knowledge of prevention predispose the patient to pressure injury? They considered
that there were two aspects to the problem, the extent of the nurses knowledge and skill in the
prevention of pressure ulcers, and whether or not this knowledge is translated into action (p. 49).

These authors also found a deficit in available literature or studies, that looked specifically at
nurses knowledge and the impact education had on prevention and treatment. They found there
were no commonalities in nursing education about pressure injury, and no defining minimum
acceptable level of competence, skill, or knowledge about the subject (Maylor & Torrace 1999).

A questionnaire based on the literature and the researchers extensive experience in the area of
pressure ulcer prevention, was distributed to 625 nurses, 478 were distributed to registered nurses
with another 147 to unlicensed staff, 439 were returned completed. Of interest was the fact that
nurses who had been in positions for 5 years or more had significantly lower knowledge than newer
graduates. Other questions asked were aimed at demonstrating what nurses knew about equipment
and risk factors. For patients considered high, medium and low risk, nurses were able to provide
recommendations for the use of equipment that would minimise the risk (Maylor & Torrace 1999).
16

The results revealed that overall the awareness and opinions voiced by the nurses was not an
indicator of any deficits in knowledge that would provide a reason for failing to initiate any pressure
ulcer prevention strategies. What was also pleasing was that nurses were aware of the assessment
documents and scores that were available. The conclusions of the researchers were that although
there was significant knowledge and available resources, the knowledge or equipment appeared not
to be utilised. For Maylor and Torrace the problem or obstacles are either, one of reluctance of the
nurse to provide appropriate nursing care, or two, reluctance or some other problems, associated
with organisational motivation towards the problem. This study and its results would appear to
support the results of the study conducted by Bostrom and Kenneth (1992).

Russell (1996), studied a group of nurses to ascertain their knowledge about practices in relation to
pressure ulcer prevention. She also found that little research had been conducted about this
important issue in nursing. During the process of conducting a literature search, Russell found that
in one audit only 52% of patients with existing pressure ulcers had any form of management plan
developed by nurses. Another audit found that if pressure care is entered onto computerised care
plans, the improved documentation appears to lead to a substantially improved quality of patient
care.

Russell also found that even nurses, who were knowledgeable about risk assessment, prevention,
appropriate dressings, and nutritional assessment, did not necessarily implement these skills and
knowledge in the provision of patient care. What was also revealed was the fact that while nurses
were introduced to pressure ulcer prevention during their training, in many instances the
information was never revised or reviewed. Other nurses were notably unfamiliar with the
equipment available for pressure ulcer prevention (Russell 1996).

17

The results of this study were similar to ones described earlier, in that there was considerable scope
for improving nurses use of knowledge of pressure ulcer prevention. The studies seem to suggest
that they have the knowledge but dont use it. Russell suggests that post-basic education would
enable nurses to practice evidence-based nursing, rather than following the myths and rituals of the
individuals, or organisations. Education in her opinion is the most important factor in overcoming
the problem and improving patient care.

Hayes, Wolf and McHugh (1994) found that there were several factors that hindered the use of
pressure ulcer prevention strategies in an elderly population. Factors included a shortage of nursing
staff, a lack of education programmes, limited research and evidence of the cause and prediction of
pressure ulcer development. These authors found that there was reluctance by governments and
insurance companies to reimburse programmes to reduce the incidence. What they did find was that
finance was available for treatment, rather than for prevention (Alvarez, Massac, Brown & Gramer
1990). The major finding of their study was that if nurses were provided with access to an education
programme, or other teaching interventions, that would have direct impact on nursing care of
patients at risk of pressure ulcer prevention. Further, with the introduction of an annual education
programme the incidence and prevalence of pressure ulcers may decrease significantly. They do
suggest however that the retention of knowledge also needs to be tested at least annually.

Beitz, Fry and OBrien (1999) examined the relationship between perceived need for further
education and actual knowledge of pressure ulcer management. This study was conducted in a
community urban hospital. A cross-sectional survey design was used to collect the data, and a
response rate of 100% was noted. It was the researchers views, prior to commencement, that nurses
would have a poor knowledge base about pressure ulcer care and require education about the issue,
and that the results of test would demonstrate this poor knowledge. The correlation between the
perceived need for education and actual need for knowledge was somewhat weak and therefore only
18

partially supportive. Themes of poor knowledge were apparent, with greatest deficits in knowledge
in the areas of aetiological factors, support surfaces and classification systems available (Beitz, Fry
& OBrien 1999, p. 10).

These results differ little from other studies in that there was limited on-going education available
for staff even although they believed they perceived a need for it. No education programmes had
been made available for some considerable time. Importantly the majority of nurses were new
graduates had only been with the organisation for less than one year. These nurses had no ability to
make realistic judgements about pressure ulcer prevention, as they may not have had adequate
information. It was also found that these nurses were not proactive in pressure ulcer management,
believing it to be in the domain of medical staff. They perceived they had no autonomy for critical
thinking about skin breakdown strategies.

The final comments of these authors is the warning that should nurses fail to familiarise themselves
with current information about the topic, and fail to initiate the appropriate care, then they may well
find themselves the target of the legal system. Nurses do have a moral and ethical obligation
towards those in their care.

Panagiotopoulou and Kerr (2002) sought to explore Greek nurses knowledge and practice and
discovered that pressure ulcers remain a significant problem in that country, both in hospitals and
community settings. They also found there was considerable documentation about the need to
reduce the incidence, but little evidence that would suggest any improvement over the years. These
authors found that there was conflicting thoughts about the problem, in so far as, some studies
suggested that nurses do have the skills and knowledge to prevent skin breakdown, but do not use it,
other studies suggest that there are deficits in nurses knowledge of prevention.

19

In order to gather data about this topic, the authors used a questionnaire that was completed by
registered and enrolled nurses working in hospitals in Greece. Of interest was the exclusion of
nurses working in high dependency areas, operating rooms, accident and emergency. The omission
of these areas highlights and supports the limited amount of available evidence on pressure ulcer
prevention in the operating rooms.

At the time of the study it was also discovered that the incidence of pressure ulcers was similarly
high in both Greece and the United Kingdom. The study also sought to identify nurses knowledge
of the risk factors of damage, and recommended preventative strategies. In addition they also
sought to uncover any barriers to good practice or preventative practices (Panagiotopoulou &
Kerr 2002). This exploratory and descriptive research study found that although the knowledgebase of many nurses was good in discussing risk factors, a significant proportion of nurses remained
unaware that some rituals were no longer recommended for use. Rituals such as massage and the
use of donuts were two of the most common.

Other barriers to good practice were reported to be a lack of easy access to research findings, and
those that were accessed were reported to be difficult to understand or read. This is one of the most
important issues to be considered when conducting any form of research. In order to be of most
value to the nurse at the bedside, the information must be written in such a way as to be meaningful
to the majority of nurses who will never conduct research, but it is hoped that after reading, may
change practice, or consider further reading on a subject.

The authors final analysis of the data, suggests that pressure ulcer prevention is an area for
improvement, and that it would be feasible and worthwhile to utilise a modification of the Waterlow
risk assessment tool and incorporate locally-determined risk factors into it. However as the
questionnaire was designed for self-reporting, there was no way that it could be considered that
20

nurses had not discussed the answers collectively or consulted text books, and therefore it could not
be guaranteed that their reported practice reflected their actual practice. The authors considered
that despite the limitations this could be a first step in providing information to the nurses. What is
also of interest, is that they considered there to be a great need to improve the skills of Greek nurses
in the use of research that will better equip them to implement good practice for patients. Finally the
authors believe there to be a real need for observational studies to determine actual rather than
perceived practice. Although there was an agreement about most of the useful methods for ulcer
prevention, there was less agreement about methods which are useful in individual cases or methods
not useful at all.

A similar study involved a mail-out questionnaire containing demographic questions and

preventative methods for pressure ulcer prevention was conducted in Holland (Halfens and Eggnik,
1995). Dutch nurses working in hospitals and universities were investigated about their knowledge
and beliefs regarding the different methods used to prevent pressure ulcers and the usefulness of
them. The authors believing that many of the preventative methods used have never been evaluated
for effectiveness.

In the guidelines the preventative methods were categorised into three parts that encompassed all
the methods that were developed by consensus in the Netherlands. An example of this was
repositioning the patient every three hours. This cannot generally be performed for surgical patients
due to the sterile drapes that cover the patients which would compromise the sterile field. Other
categories included methods advised as useful for individual patients, but not for general use.
Finally the methods advised as not being useful at all such as the use of massage or creams,
supposed to increase blood flow. Too many methods used on the wards were judged by the
consensus committee as not useful, or in individual cases, but risk assessment tools were used in
limited areas. It was therefore concluded that the beliefs and knowledge of nurses concerning the
21

usefulness of pressure ulcer prevention strategies were different from the guidelines in the report.
There were disagreements about the methods most useful, and those not useful at all. It was found
that the knowledge and beliefs of these nurses were comparable with other studies and somewhat
positive, but the implementation or use of these methods in practice is not so positive (Halfens &
Eggnik 1995).

The nurses answers were collated and compared with guidelines developed from a consensus
committee formed following a conference on the topic in 1985 and 1986. This study was conducted
six years after the first publication of the Dutch consensus report (Halfens & Eggnik). These
guidelines were developed in conjunction with Dutch and the United States Department of Health
and Human Services (1992).

Panagiotopoulou and Kerr (2002) found that the number of studies that have explored preventative
practices is relatively small. They did find however, that the results of the study conducted by
Halfens and Eggnik (1995) was similar to theirs, in that despite the fact that nurses were
knowledgeable about particular preventative strategies they did not always appear to translate that
knowledge into practice. Many nurses did not appear to be able to differentiate between the
methods that were generally applicable and those methods that were useful only in individual cases.
This lack of awareness and lack of understanding have also been reported by others (Beitz et al
1999 and Wilkes et al 1996).

Of note and of concern is that the methods known to be detrimental such as massage or using cream
were in common use. It is clear that there is a tendency for nurses to believe these methods are
useful in all, or in individual patients. The conclusion of the authors was that although attention had
been given to the distribution of the guidelines, not sufficient attention had been given to the
availability of the information or the availability of institutional support to adhere to the guidelines.
22

Other reasons for non-compliance was that nurses knowledge about the guidelines was poor, and
another that Dutch and Greek nurses on average, do not read professional journals. Of greater
concern is the problem that there was disagreement in both the beliefs of nurses and those of the
consensus committee. For these reasons there was not a strong basis on which to make
recommendations about a number of issues, the usefulness of massage or creams. Therefore it was
deemed worthwhile to design a randomised clinical trial to evaluate the effectiveness of some of the
practices used as a preventative strategy for pressure ulcers (Halfens & Eggnik 1995). What appears
clear from the literature is that knowledge and skill about pressure ulcer prevention requires
ongoing education and further research in Australia and overseas.

The incidence and management of pressure ulcers in hospitalised patients and in particular, those
scheduled for surgery, is an ongoing concern for nurses. There have been many efforts made to
prevent the development of pressure ulcers, but what is evident from the literature is the
inconsistencies. In one Sydney hospital (Sharp, Burr, Broadbent, Cummins, Casey & Merriman
2000), anecdotal evidence suggests that a range of different approaches are used to assess patients,
identify those patients at risk, to prevent pressure ulcer development, and to treat them. This
resulted in a study which supported the studies described earlier.

These findings were:

Inconsistencies within and across nursing practice domains
That nurses generally do not use a specific pressure score tool to assess patients for the
risk of developing ulcers.
That nurses rely on a range of practice, procedures and risk indicators to determine the
potential for pressure ulcer development
That repositioning patients is the most commonly used approach to preventing skin
damage
Additional measures are diverse
That care provided by some nurses reflected adherence to outdated practices.

23

Patients undergoing surgery are often overlooked for the prevention of pressure ulcers and yet
anaesthetised patients are at very high risk for pressure injury risk due to the forced immobility
which occurs during surgical procedures. Few studies have been conducted which examine the
tissue interface pressure of the operating room table mattress and the products available to reduce
pressure for patients undergoing surgery. Pressure ulcers are known to occur as a result of intrinsic
pressure over bony prominences. Over the years there have been many different methods used to
prevent these ulcers. This review sought to present the literature on operating room nurses
knowledge and practice in respect to pressure ulcer development, but found there was limited
information available on the topic. Collectively, this literature review has highlighted that regardless
of the environment or country, the problem of pressure ulcer development is still of concern and
widespread.

Purpose Of The Study

The purpose of the study was to generate an authentic ethnographic account of the knowledge and
attitude of operating room nurses in relation to pressure ulcers development in perioperative
patients. This was achieved through observation and interview of perioperative nurses.
The aims of the study were to:

Generate insight into the knowledge and attitude of operating room nurses in the
prevention of pressure ulcers.
Produce an ethnographic account that, by reflecting on the understanding of pressure
ulcer development, could increase perioperative nurses awareness of the ways in which
they could contribute to prevention of ulcer development.
Produce an account that would enable the nurses contribution in the operating room to
be more visible and understandable to those not familiar with the environment.

Questions guiding the study:

What is the extent of operating room nurses knowledge and skill in the prevention of
pressure ulcers?
What are the perceptions of their responsibility for the prevention of pressure ulcers?
What in their opinion are the inhibiting factors for pressure ulcer prevention?

24

By generating insights of the knowledge and skills of operating room nurses in the prevention of
pressure ulcers, the study will help clarify what these nurses contribute to patient care with a
particular emphasis on the prevention of pressure ulcers. By doing so this study contributes to the
available information which these nurses can use to enhance their practice. The actions and voices
of nurses are a central part of this ethnographic account, and contribute to the development of nurse
generated arguments, policies and standards for patient care that may have a direct impact on
pressure ulcer prevention in the operating room.

In the next section links are made between the theoretical underpinning and methods of the study
that explain and emphasise their usefulness and relevance to the research. The process of
conducting the ethnography is discussed, and the ethical procedures, data collection and analysis
techniques are outlined.

Research Design
Methodology
This study was concerned with the creation of an interpretive account of operating room nurses
skill and knowledge in regard to pressure ulcer prevention in the operating room setting.
Hermeneutic ethnography was the methodology used to accomplish this. This methodology was
pertinent because it addressed the cultural and interpretive nature of the research purpose, and
acknowledged the relationship between nurses and the culture of the operating room environment.

Nurses opinions collected at interview formed a large portion of the data collected and the
methodology accommodated continuous interpretation of this data (Bowers 1992).

Data was

collected using formal and informal interviews of participants, observations and the maintenance of
a journal that combined a research log, reflective information and notes taken during the fieldwork.

25

Hermeneutics and ethnography are discussed, and the respective development and backgrounds
traced in order to establish links between them. Vidich and Lyman note that lurking behind each
method of research is the personal equation supplied to the setting by the individual observer (1994,
p. 24). As the methodology provides the foundation of the research methods, the personal
equation is implicated in the choice of methodology and thus forms the criterion by which the
evaluation of the research is based. Hammersley (1998) believes that the competence of the
ethnography is evaluated upon its ability to represent a culture truthfully, the justification beginning
with an exploration into the nature of truth.

Ethnography
The methodology on which this study is based is mainly that described by James Spradley (1980)
and deLaine (1997) on ethnography. It was Bruni (1994) and others such as Geertz (1926 present)
a social anthropological ethnographer, who explored the origins of this style of research, and
explained that the concept was a legitimate form of academic research introduced in the 1920s by
the anthropologist Malinowski. Bruni (1994, p. 44) explains that Malinowskis goal for
ethnography was to grasp the natives point of view, his relation to life to realise his vision of his
world. In the view of Malinowski, there were three forms of data that required collection and
consideration in the context of the setting from which it was gathered. These are the rules and
regulations governing the tribal life, the anatomical framework of the society and the subjective
status of the tribe.

Ethnographers ask what do these people see themselves as doing? rather than what do I
see? (Spradley & McCurdy 1972, p. 9). In order to answer this and to understand cultural patterns
it is essential for the researcher to observe actively in the field and openly communicate with the
participants (Schultz 1994). This contributes to a trusting relationship between both parties, and
allows the researcher to enter the hidden culture (Leininger 1985).

26

It is through the work of the cultural anthropologists such as Spradley, that Malinowskis concepts
made their entry into nursing theory. Street is another writer who has made use of ethnography to
explore nursing. One of the better-known publications Inside Nursing: a Critical Ethnography of
Clinical Nursing Practice (Street, 1992) is an example of such an analysis to which frequent
reference is made by her of the culture of nursing.

Spradley (1980) defines culture as the acquired knowledge people use to interpret experience and
generate behaviour (p. 6). According to Spradley (1980), what is known and spoken of, and the
silent, hidden, knowledge that moderates behaviour and the interpretation of the experience can be
uncovered and translated. Cultural knowledge can be inferred rather than observed directly, and the
ethnographer must observe what people do and listen to what they say. This combination allows the
researcher to discover and interpret the implied or inferred knowledge that is embedded in the
particular culture.

The ethnographic component of this study has been guided by the work of Geertz (1973, p. 17) who
suggests that it is through social action that cultural form finds articulation. Ethnography when
informed by Geertz, involves long periods of time in the field observing the ordinary, everyday
lives of the people within the culture. This is reflected in the research methods of this study.

Ethnography is a methodology that can render, and make visible the contribution that perioperative
nurses make to humanity, and emphasises the human interpretation of experiences with using tactic
knowledge.

Sandelowski (1993) believes that the desirability of remaining objective in this type of research is
essential. Failure to do so is counterproductive because truly rigorous enquiring must always be true
to its philosophical assumptions. However it is also known that nothing is value free.

27

The role of the researcher doing ethnography is complex for both researcher and the group
members. Ideally, a strategy should be found that would allow the researcher to fully participate in
all activities as an insider, while consciously and hopefully objectively, describe and analyse the
events as an outsider (Roper & Shapira 2000). It is difficult to be an insider, particularly when
one is unfamiliar with the environment they need to gain access to. This was not a problem in this
study as the researcher is experienced and familiar with the setting. Never the less the researcher
can be viewed as an intruder (Werner & Schoepfle 1987). In this situation the staff may believe that
the researcher is checking on them. This view may arise from the fact that ethnographers ask
what do these people see themselves as doing? (Spradley and McCurdy 1972, p. 6). In order to
answer this and to understand the culture of the group, it is essential for the researcher to actively
observe in the environment, and to be able to communicate freely with the participants (Schultz
1994).

As an experienced nurse within the specialty, and in a position of authority, it is important that the
researcher remain unbiased throughout the process. Objectivity of the researcher is an imperative
part of the ethnography, and provides the open window through which the culture explored is
being interpreted. The impossibility of remaining separate from the social world being observed and
familiar, whilst continuing to study it is recognised (Spradley 1980, Doyal & Harris 1986 and
Hammersley & Atkinson 1995). However ethnographers must rigorously address the impact that
their personal beliefs and values have upon the interpretation of the culture (Koch 1994). The
impact on the beliefs and values of the researcher should not be underestimated as it may negate the
credibility and trustworthiness of their research (Koch 1994). The discipline involved in doing this
also prepares researchers for the complexity of the culture and the co-existence of many
interpretations.

28

The issue of authority and representation is addressed through the inclusion of participants voices
in the final ethnographic account. There is a moral responsibility to present their words in context
and this rests with the researcher. This provides the reader with an opportunity to engage in
conversation with the participants (Koch 1994). Therefore, for the final ethnographic account to
have an authority and authenticity, the voices of the participants must be included.

For the purpose of this study, ethnography is considered as a hermeneutic enterprise. Hermeneutic
ethnography draws upon philosophical hermeneutics, in which the participants and the researcher
enter into a partnership that allows both to verbalise their prejudices and understandings. New ways
of understanding become evident as they seek to reach agreements through dialogue with each
other. It is the hermeneutics of Hans-Georg Gadamer that provided the philosophical foundation for
this study. Gadamer (1975, p. 171) believes that Hermeneutics is an act and not a mechanical
process. Thus it brings its work, understanding to completion like a work of art.

Hermeneutics
Contemporary hermeneutics is a philosophy that is concerned with how people experience
understanding and interpretation (Thompson 1990). The hermeneutic ethnographer is in a position
of authority, and is the single link between the participant and the reader. It is the ethnographer who
has the most authority over what is written, and therefore must accept the greatest share of the
moral responsibility for the accuracy of the written text. It is essential not to misrepresent the
culture otherwise the interpretation can become something of a game of chance. Gadamer (1975)
believes that harmony between all details can only occur when all reach an agreed understanding.

Gadamer (1975) considers hermeneutics to be the foundation of philosophy rather than as a renewal
of practical philosophy. He also sees hermeneutical understanding as historical understanding, a
fusion of horizons, and that hermeneutical experience concerned with tradition, a fusion with the
29

present, the framework remaining clear and transparent (p. 245). The work of Max Weber
influenced Gadamer in some ways and from this Gadamer adapted Webers belief that conditions
for understanding, meaning and interpretation lend themselves to the concept of interpretive
behaviours seen in the disciplines of nursing and anthropology (Allwood 1989). It is the emphasis
on humans rather than on science that makes it most useful for studying these disciplines (Boyne
1988, p. 31).

Gadamer (1975) argues that humans have a linguistic tradition, and that language is the medium for
understanding. For him language can be detached from the speaker and written to form text that can
be later interpreted in order to find hidden meanings. The words belong to the situations not to the
people, and the inquirer must search to find what the words say about the particular context. The
search continues seeking for meanings, and an ongoing structure of questions and answers. The aim
is to open up the text fully for interpretation. The concepts of prejudice and play are also
fundamental to the analysis and this study.

In Roman mythology Hermes is known as Mercury, whose mercurial nature and light heartedness
are characteristics well suited to understanding, integrity, reality and the hazards that accompany
the interpretation of situations and cultural activities.
Hermeneutics is an art and not a mechanical process. Thus it brings its work,
understanding to completion like a work of art.
(Gadamer 1975, p. 191).

Contemporary hermeneutics is a philosophy that is concerned with how people experience

understanding and interpretation (Thompson 1990). Gadamer considers hermeneutics to be the
foundation of philosophy and is based on the linguistic and universal nature of understanding.

30

According to Gadamer (1975, p. 245 and 1989) a horizon encompasses everything that can be seen
from a particular vantage point. If however the vantage point changes then the view will also
change and another perspective will be gained.

The Hermeneutic Circle

Gadamer developed the hermeneutic circle which constantly expands and further context can be
integrated that will effect understanding (Gadamer 1975). This circle enables the inquirer to openly
acknowledge that interpretation is cyclical, uncertain and often profoundly influenced by the
interpreters perspective (Bohman 1991). The inclusion of the interpreter as part of the circle is
significant and re-emphasises the role of the inquirer in the creation of meaning. The lengthy
periods of observation sensitise researchers to the culture and provide them with large quantities of
data upon which to base their interpretations. As Gadamer states hermeneutic work is based on
a polarity of familiarity and strangeness the true focus of hermeneutics is this go-between
(Gadamer 1975, p. 295). He also stresses the importance of pre-understandings of the interpreter
and the required transparency.

Gadamer (1975) believes that it is not possible to be simply a detached observer, as the person is
viewed as inseparable from his or her personal prejudices as suggested by Koch (1994). For him
uncovering and acknowledging prejudice is an integral part of understanding (Gadamer 1975).

Prejudice
Prejudice as defined by Gadamer is a judgement that is rendered before all the elements that
determine a situation have finally been examined (Gadamer 1975, p. 270). By acknowledging
prejudice the inquirer recognises the impact that history can have on the way in which people
experience existence, and it is therefore a condition of knowledge. It is prejudices that are socially
constructed and through which people understand the world in which they live (Koch 1996).
31

According to Gadamer there is a need for self-understanding and a critique of self (Hekman 1990).
This historical reflection on the part of self is fundamental to the process of understanding
(Gadamer 1975). It is however, difficult to separate the researcher and their prejudices due to the
past influences of family and culture.

Gadamer states
In fact history, does not belong to us; we belong to it. Long before we
understand ourselves through the process of self-examination, we
understand ourselves in a self-evident way in the family, society, and state
in which we live. The forms of subjectivity is a distorting mirror. The selfawareness of the individual is only a flickering in the closed circuits of
historical life. That is why the prejudices of the individual, far more than his
judgements, constitute the historical realty of his being.
(1975 p. 277)
Gadamer (1975) in his work Truth and Method explains that in order to experience the fusions
of horizons, one must be able to tolerate the ambiguity of relaxing ones own preconceptions (p.
245). This means that the researcher moves beyond their personal knowledge and explores beyond
it (Whyte 1984).

Truth
The conceptualisation of truth is central to the philosophical paradigms that have guided the
thoughts of humankind, but the nature of truth remains elusive. Greek thinkers and their close
followers were believed to be able to see evidence of universal concepts in the often seemingly
chaotic nature of life. It was this new way of considering what was truth that moved thoughts and
beliefs based in mythology, to that of a more contemporary thinking position. The dominance of
this paradigm holds significance for operating room nursing. This is the paradigm that underpins the
drive to reduce the activities of operating room nurses to discrete skills and tasks upon which a
great deal of literature and research that surrounds the specialty is often based.

32

When conducting hermeneutic ethnography, it demands that the researcher join together
ethnographic methods and the philosophy of hermeneutics. Ethnography can be methodology as
well as method, therefore the essence of culture and the tools required to gather data, blend with the
traditional history and present day fusion of hermeneutics. The research must also balance between
the anti-methodological position of hermeneutic inquiry and the structured methods that are
required when conducting an ethnography. The methods that were used in the study provided for a
workable set of research tools that facilitated engagement with hermeneutic concepts that included
the fusion of horizons, hermeneutic dialogue and prejudice (Spradley 1980, Geertz 1988).

Geertz (1988) and Roper and Shapira (2000) and a number of authors contributed to the
development of the research strategy with several having considerable influence in the final
production of the study. The use of Spradleys (1980) tools for data collection and analysis were
useful, and served as a guide in the initial stages of the project. Burgess (1982) provided some
practical contributions from ethnographers who were actively involved with research that greatly
assisted with the completion of the fieldwork. The work of Morse and Field (1996), Sandelowski
(1993) and Leininger (1985) all provided critical guidance and importantly, did so from a nursing
perspective. In gaining an insight into what an ethnographic research process may look like on
completion, the works of deLaine (1990) and, Roper and Shapira (2000) were of value in the
background reading. Arguments that surround issues of trustworthiness, and central to the way in
which the study was performed are well described by Koch (1996), Lincoln and Guba (1985).

Because cultural knowledge can be implied rather than directly observed, the ethnographer must,
because of this, observe what people do, closely listen to what they say about a topic and what they
think or do. This combination allows the researcher the opportunity to discover and then interpret
the tacit knowledge that is embedded in the particular culture.

33

Ethnography operates from some basic premises (Maggs-Rapport 2000). First, that much cultural
knowledge is tacit and fundamental to the way in which peoples experiences are interpreted.
Secondly, that members of the culture share the same beliefs and meanings. Finally, the third
premise is that exploring these shared beliefs of groups within the culture, the specific cultural
knowledge can then be uncovered and then translated (Maggs-Rapport 2000). Spradley (1980)
believes there are two levels of cultural knowledge, explicit culture what is known and
communicated, and tacit culture the silent, hidden dimension of knowledge that moderates
behaviour and interpretation of personal experiences.

Hermeneutic ethnography provides an interpretive foundation on which to base this study, this
choice of methodology reflecting the belief that it is more likely to be able to represent the
complexity and depth of meaning with human experience. The exploration of nursing activities and
knowledge as they occur when providing patient care is well suited to this methodology.
Hermeneutic ethnography can demonstrate the contribution that perioperative nursing can make in
the world in which they live.

Methods
Conducting Fieldwork
In the literature, conducting fieldwork often receives mixed reviews (Barley 1983, Evaneshko 1985
and Shaffir & Stebbens 1991). However, fieldwork remains the central activity of the ethnographer
to study the culture as it is lived.

It increases the researchers understanding of the culture

(Spradley & McCurdy 1972, Field 1991) an understanding partly achieved by observing individuals
and groups and the dynamics that exist (Whyte 1984). To meet the purpose of the study and conduct
the fieldwork, the use of ethnographic data collection methods were used. These were field notes,
interviews (Appendix 6), observation (Appendix 7) and the researcher keeping a reflective journal.

34

The fieldwork was conducted between March and July 2003. Observation sessions in which field
notes were taken lasted between four and six hours, and totalled thirty hours.

Gaining Access To A Study Environment

Whyte (1984) suggests that the key people who need to give permission for the researcher to gain
entry to specific environments and people in it are called gate keepers. Leininger (1985) indicates
that this access is superficial and will not provide the real information that is sought and that
culture is behind the superficial facade. Burgess (1982) and Whyte (1984) suggest that all
participant observer roles may be used in one piece of fieldwork, as the researcher gradually learns
to be more flexible. In this study the predominant role of the researcher was the observer as
participant. This means that the emphasis was focussed on observation combining a minimum level
of clinical participation with a high level of observation (Burgess 1982 and Whyte 1984).

Gaining access to this environment did not pose a problem, as the researcher was the Nursing
Director of the environment. However there were some constraints in the context of the study, and
these were in the steps of the research process. This was particularly so in the area of conducting the
fieldwork. Of great concern was the issue that the researcher was new to ethnographic research.
Even with the vast amount of experience in the environment, it was sometimes difficult to judge
situations accurately. There was however no problem with staff in the acceptance of the researcher
to conduct the observations.

In ethnographic participant observation, having closeness to the people to be observed is necessary

or this may result in the participants feeling anxious, or even stop talking when in the presence of
the researcher. Feelings of being spied on become real to them even although the real reasons
may have been continuously reinforced. Some initial hesitation from nursing staff may be
encountered and should be expected (Roper & Shapira 2000).
35

Notices were posted for staff information and meetings held to inform staff of the project. At these
meetings an overview of the project was presented and the implications for them during any
observations. The interpretive matters of the project was highlighted and an emphasis on its nonjudgemental nature. The nurses were assured that if any of them did not wish to be observed they
had the right to refuse. No staff objected to the observations at any time during the collection of
data. Meetings were held with the nurses who had volunteered to be interviewed, and assurance
given that they could be assured of anonymity.

For some researchers on-going negotiation for access to some areas may be required (Burgess
1982). For this researcher this was not the case as the researcher is the person responsible and
accountable for the services. The researcher was able to combine a minimal level of clinical
participation with a high level of observation and this assisted with the relationship between the
participants and the researcher (Burgess 1982).

The production of text through observation, ethnographic interviews and subsequent interpretation,
were the central methods of data collection for this study.

Observation in the Clinical Setting

The primary data collection is the responsibility of the researcher, who conducts the observations
and interviews with the participants involved in the study. Gans (1982) notes that participant
observation is a broad term that embraces the various combinations of participation and observation
that occur in ethnographic research. In the literature there are four main types of participant
observation.

These are:

the complete observer (= non participant)

observer as participant
participant as observer
complete participant.
36

In this study a sequence of increasingly focused observations was made using a set of standard
ethnographic data collection methods. For Spradley (1980) the manner in which this is completed is
termed grand tour observations, as the process is driven by questions such as what is going on
here? Focused observations (Spradley 1980), is another type of observation used to collect a large
amount of in-depth data in a range of specific areas identified through these broad categories. It is
the analysis of this data used in conjunction with the data recorded from the interviews that is
termed by Spradley as being selective observations. From this information, rich in-depth data can
be generated. This enables descriptions of the culture to be made. The observation process as
undertaken in this study is shown in Table 1.

Table 1
Observation Process
Check operating lists for precautionary procedures and
Gaining access

changes to order of patients.

Observe patients being received in Reception area.
Observe nursing staff focusing on patient care and

Observation

pressure ulcer prevention strategies.

Answer questions regarding research.
Acknowledge assistance.

End of
observation
period

Exit room via Scrub Room.

Change from OR attire to outdoor clothing.
Leave complex to write up notes and journal entry.

Prior to commencing a period of observation it is essential that the operating lists are checked for
changes as certain disease status in patients may demand that the room where they are to have the
surgical procedure may be closed to all other staff. In those situations nursing staff are allocated
specific roles, with all other staff denied access until the surgery is completed and the room
decontaminated.
37

The observation of nurse patient information in the Reception area provides information about the
relationship that exists between the patient and the nurse. It is primarily one of ensuring patient
safety and well-being, and balancing the technological aspects of the role with the caring elements.
During those observations it will be possible to establish if any formal risk assessment for pressure
ulcer development is conducted as part of routine nursing care.

Many of the focused observations described by Spradley (1980) were not required as the researcher
was very familiar with the environment and culture to be observed. However, writing ethnography
is fundamentally about writing truthfully, and in this study a great deal of care was taken to
represent the skills and knowledge of nurses in the operating room about pressure ulcer prevention.
It is essential that the researcher not pick and choose what will and will not be described (Gadamer
1975). In depth data that generated descriptives was easily collected by using a process of structured
observations (Appendix 7).

Interviewing Staff
Observations were linked to the interviews and therefore formed part of the fieldwork. The
interviews were both formal and informal, and were used to supplement, validate, clarify
observations and the interpretations made during the preliminary analysis of fieldwork (Roper &
Shapira 2000). The inclusion of the participants views (of pressure ulcer prevention) is a
distinguishing feature of ethnography (Hammersley & Atkinson 1995). While participant
observation focussed on the preparation and management of pressure ulcer prevention for patients
the interviews sought to investigate the knowledge nurses had about pressure ulcer prevention. The
interviews sought to add meaning to what had been observed and therefore add a new dimension to
the observation (Lofland & Lofland 1984).

38

The group of eight participants who were interviewed consisted of:

One male nurse working in the area of anaesthetics
Four female nurses working in the area of scrubs / scout
Two male nurses working in the area of recovery
One female nurse working in the area of recovery

Questions to be asked at interview were based on the literature and the researchers extensive
experience in the area (Halfens & Eggnik 1995, Wilkes et al 1996, Harley 2003, Clarke & McLeod
2003). The knowledge and opinions sought from the questions explored the notion that a lack of
knowledge might be a contributing factor to pressure ulcer formation in the operating rooms.
Questions included those that questioned for awareness rather than opinions, mainly to establish
what the participants knew about risk factors and equipment. The questions were designed to elicit
the nurses knowledge, beliefs and use of some of the most common equipment available in the
service.

Initially the researcher intended to interview only nurses employed in the care of patients in the
operating room, but as an interest was shown by nurses working in both anaesthetic nursing and
recovery ward, it was decided to include them in the project. The decision to include these two
groups was also because anaesthetic nurses assist in some of the positioning of patients, and
recovery room nurses provide assistance in the operating room during some emergency surgery, and
often have patients in the recovery ward for extensive periods of time due to post-operative
complications, or because of a shortage of hospital beds. Whatever the reason for the longer length
of stay, some type of pressure prevention strategy may be / should be initiated by the nursing staff,
no matter which context they worked in.

Formal Interviews
Eight formal interviews were conducted, and in addition to asking directed questions, a note was
made of the effects on the participants of the question. Roper and Shapira (2000) encourage the
researcher to pay attention to the shift in conversation that may indicate an issue of significance for
39

the person being interviewed. This may need to be explored, without the participant feeling that
personal details are being searched for, and / or the researcher becoming intrusive.

Recordings were made of the interviews and reviewed shortly after each interview. The interviews
lasted approximately one hour, with an opportunity for the participant to extend the time if wished.
The transcripts were given to the participants who were requested to review the content, and add
anything they considered relevant. Spradley and McCurdy (1972) suggest that working with people
who are excellent informants is considered an integral component of ethnographical fieldwork. To
be considered a potential key informant the following characteristics need to be demonstrated.

A willingness to openly share information

The ability to provide detailed information that is based on experiences in the practice
setting (Spradley & McCurdy 1972, Morse 1991).

Demographic information was also recorded and analysed in order to ascertain if there were
differences in knowledge and skills about the topic associated with age, training and experience of
the participants (Appendix 8). This information permitted the researcher to consider if life
experiences, age and training background demonstrated differences in responses or knowledge.

Informal Interviews
Informal interviews, solicited and unsolicited, arose during the course of the observations. These
interviews or conversations were not always with the key informants, and for that reason many
other issues relating to the topic were captured in this way. Some informal interviews were used to
clarify an observation, or to seek reasons for activities that had been observed. They were also
useful because they highlighted occurrences that were different from normal. An example of this
would be specific requests from the surgeon in regard to positioning of the patient that would not be
done for many others. Nursing staff with little or no assistance from surgical staff, would generally
perform the task of positioning the patient for surgery. However when patients are required to be
positioned in specific positions for surgery, sitting for neurosurgery, prone for spinal surgery or
40

procedures on a fractured pelvis, surgeons play a large role. These actions opened up a line of
enquiry into decisions and were viewed as ones in which to observe the behaviour of the nurses
more closely.

Field Notes
Initially the field notes were made at the time of the observations, but this caused a change in
behaviour of those being observed and did attract some attention from the medical staff. For these
reasons only very brief notes were made during observation, and were completed in greater detail
away from the study environment. Field notes are a traditional means of recording data in
ethnographic studies and are filled with an enormous number of cover terms and included terms.
This process is central to the research activity. They are concrete descriptions of what occurs in the
day to day activities of the life of specific cultures being explored, in this case, operating room
nursing (Hammersley & Atkinson 1995). This text converts to descriptions of the behaviours
demonstrated throughout the observations in the practice setting (Geertz 1973), and comments in
the researchers reflective journal support and enhance the data and text.

Three levels of field notes were used in this study. Initially the preliminary handwritten notes made
at the time of the observations in the operating room and reception area, were further developed in
private. Whilst recall is maximised, if the preliminary notes can be expanded immediately, it is
impractical because it attracts attention and changed the behaviour of the participants involved.

These notes are transferred to the computer, and further expanded to provide a more detailed
account of the observations and conversations. As text, this now enabled the events observed and
conversations to be reviewed and read many times for the purpose of analysis. This process of
expanding the field notes and their analysis is described by Webb (1982) as, an instrument of
actual discovery (p. 196).
41

Finally a third set of field notes was created through the analysis of the substantive notes, and then
used for cross-referencing with the literature (Burgess 1982). These notes were kept separated from
the substantive field data and interview notes, in order that a re-examination of the data could be
conducted (Hammersley & Atkinson 1995). The result of this exercise was the development of the
suggested themes to be used for the ethnographic account compiled from the collective analytical
field notes.

Reflective Journal
The ethnographer is intricately involved in the collection of data from the field and then shaping the
study through their personal beliefs and ideas (Glaser & Straus 1967, Hammersley & Atkinson
1995). Throughout the study a reflective journal was maintained. This allowed the researcher to
keep an account of the personal impact of beliefs and ideas on the study (Koch 1996). This journal
was divided into three sections for ease of use, a reflective section, procedural section, or fieldwork
journal and the research log. A combined journal allowed for links between the development of
thoughts in the reflective section, the research decisions in the procedural notes and the research
activities in the research log.

The reflective sections of the journal helped to synthesis and sequence the study (Leininger 1985),
and facilitated clarification about personal bias and understanding of the context and process of
interactions and reactions to observations. Importantly, it encouraged explanations of the prejudices
of the researcher (Gadamer 1975).

In the procedural section the decision process that related to the data collection and analysis
methods were documented. Reasons for changes to the way in which observations or interviews
were conducted were reported. The research log was contained within the third section of the

42

journal. This was written in the form of a diary with dates, times and length of any observations,
some non-identifying patient details and staff present at the time.

The Study Setting

The study was conducted in the operating room services of a large metropolitan hospital in South
Australia. Approximately 18,000 elective and emergency surgical procedures are performed each
year. All specialties are involved except elective paediatrics and obstetrics (the exception of this are
those arising from road trauma). The service is involved in teaching medical and nursing staff and
other health professionals seeking operating room experience or up-skilling. The profile of the
operating room staff is presented in Table 2.

Table 2
Profile of Staff in the Study Setting
Designation
Registered Nurse Level 4
Registered Nurse Level 3
Registered Nurse Level 2
Registered Nurse Specialist Level 1
Registered Nurse Level 1
Enrolled Nurse
Orderlies Transport only
Surgeons
Surgical Registrars
Anaesthetists
Anaesthetic Registrars

Total
1
9
16
19
83
25
3
90
20
40
30

Ethical Considerations
Approval for conducting the research was granted from the hospital that was to participate in the
project. A formal discussion with the Director of Nursing and Patient Care Services also took place.
As the nurse in charge and responsible and accountable for the Operating Room Services, there was
no requirement to discuss the study with any other senior nursing personnel.

43

In discussions concerning the responsibility of the researcher and the need to promote the safety and
anonymity of the participants, Lofland and Lofland (1984, p. 29) state their goal, as researchers,
should be neither moral judgement nor immediate reform, but understanding. This has been one of
the goals of this research and has had this ethical principle at its core!

Expressions of interest were sought from nurses willing to be involved in this project (Appendix 2).
Those who did so were on a voluntary basis. An information sheet (Appendix 3) explaining the
study, and who to contact for information on the project and independent complaints procedure
(Appendix 4) together with a consent form (Appendix 5), was provided to the participants. In
addition the study was discussed with each participant prior to the interview. Anonymity was
assured through the use of pseudonyms, which also were used in the transcripts. At all times
confidentially was maintained. Data of any sort, field notes, interview tapes and the research journal
has been retained in a secure place and accessible only to the researcher and supervisor.

Ethical issues in interpretive research are frequently less visible and more solvable than the issues
that arise in survey or experimental research method (Lipson & Marsh 1994). These issues are
related to the characteristics of this method of research, and include long-term and close personal
involvement, interviewing and often participant observation (Lipson in Morse 1994).

Recruitment
Details of the project were available on information sheets (Appendix 3, 4 and 5) provided to the
participants. The telephone numbers provided by them on initial contact were used to arrange
interview times, and as soon as feasible the purpose of the project was reiterated. During the initial
meeting it was explained to the participants that although they may be present during observations,
they had been recruited for interview purposes only. To minimise any confusion an overview of the
study was provided at a staff meeting. Recruiting participants for the interviews was undertaken by
44

advertising for volunteers to be involved in the research project (Appendix 2). The advertisement
was placed on notice boards in the operating room environment and sought the involvement of staff
interested in the study topic. In addition to a desire to be involved, the volunteers had to be
practising nurses in the study setting. The nurses who were interviewed presented a broad range of
experiences and specialisation in the area. Nurses were given a pseudonym to protect their identify.
The participants who were interviewed were volunteers and represented a cross section of nurses
from the operating room environment. This is important because working with people who are
excellent key informants is integral to strong ethnographic fieldwork (Spradley & McCurdy 1972).

Methods of Analysis
This ethnography is based on the belief that it is not possible to represent a culture from any other
standpoint than that of difference (Maanen 1988). The ethnographer is set apart from the
participants, simply by the acts of observing, interpreting and the need to explore and illuminate the
culture. No matter if the emphasis is placed on the voices of these within the culture, the
ethnographers voice is the predominant one (Maanen 1988). In the final analysis all its implicit
limitations represents the authors construction of the culture explored. It is therefore the
responsibility of the researcher to demonstrate the soundness of these judgements by providing an
audit trail of the research process (Koch 1994). Of course the authenticity of the account does not
merely rest on how plausible it all sounds, but in the way in which the final account is
accomplished.

Writing an ethnography, according to Street (1992), demands that the ethnographer pay attention to
not only what is written, but how it is written. Geertz (1988) believes that ethnography is
fundamentally the result of the imagination, but is not imaginary. For this reason it is considered
fiction and a story of a culture. The ethnography becomes a still life, and all the colours and textures
of it become vivid. By fixing speech and action in text, the transient nature of human endeavour is
45

irrevocably lost (Geertz 1988). Geertz (1988) considers that the approach taken to writing an
ethnographic account, is a choice between playing pilgrim and playing cartographer. The
ethnographer does not however, have the same objectives as the cartographer, they seek to convince
the reader that the author was immersed in the culture and was at the scene.

Spradleys (1980, p. 88) concept of cultural domain analysis forms the foundation of analysis of
this work. Cultural domain is a category of cultural meaning that includes other smaller categories.
This is therefore suitable for this specific study as the study seeks to explore a small group culture
as found in an operating room complex. For Spradley (1980) the concept of cultural domain
analysis, involves the observation and analysis of social situations in order to discover social
scenes, culture existing as a framework composed of given definitions of situations varying from
group to group. Spradley advises that in order to discover patterns of cultural meaning prior to
organising them into patterns and themes, the elements or parts of cultural meaning need to be
identified (p. 85 99). Cultural themes are simply the elements in the pattern that make up a
culture. This fits with Street (1992) and Geertz (1988) concept of writing the ethnography. Rigorous
and systematic reading and coding of transcripts allows major themes to emerge.

Spradley (1980), describes how every culture creates innumerable categories of cultural meaning
(cultural domains). In this all things unique to that culture are grouped together. Anything may be
used to create such a domain, but they always include three elements, a cover term, included terms,
and a semantic relationship:

Cover term is the name of the main grouping (operating room nurses)
Included terms are names for the smaller categories (enrolled, student nurses)
Semantic relationship forms the links between the two.

This can be illustrated by the example in table 3.

46

Table 3 - Domains
Cultural Domain

Smaller Categories

Nurses

Cover term

are kinds of

Semantic relationship

Clinical Nurse Consultants

Clinical Nurses

Included terms

Nurse Specialists
Registered Nurses
Enrolled Nurses

Domains consist of groups of items that fit together, express a particular theme, or constitute a
predictable and consistent set of behaviours (LeCompte & Schensul 1999). Spradley believes that
these are all words and phrases that define and give meaning to the objects, events and activities
observed by the researcher. Numerous bits of the conversations of the participants provide the folk
terms for the construction of the cultural domains (Spradley 1980).

The folk domains occur when all the items come from the language used by participants in the
social situation. Sometimes however an analytical term will be used to complete the domain. These
come from the additional existing things that need a label.

Many analytic domains are manoeuvrable and are inferred from what people say, do or the
instruments and equipment used or made. The researcher selects their own term when consistent
patterns of behaviour emerge and there is an absence of an appropriate folk term to attach (Spradley
1980). Examples of this may been seen in Table 4.

Taxonomy is a set of categories organised on the basis of a simple semantic relationship, similar to
that of a cultural domain. However taxonomy shows more of the relations among the things inside
47

the cultural domain, it includes all the terms in the domains and the manner in which they related
(Spradley 2002). Each domain is stated with a cover term and a semantic relationship, the included
terms are discovered from the cultural setting. The beginning steps to making domain analyses with
semantic relationships are to review fieldnotes and search for themes that may fit the semantic
relationship. It is suggested by Spradley (1980) that which terms could be a kind of something?
or could there be a different kind of those (p. 95).

Discrete categories are arranged into broader ones on the basic similarities or differences. From the
arguments developed by the researcher, it is possible to include or exclude categories into each of
the thematic areas of the ethnography and the relationships between and within each thematic area
(Bull 2002).

The researcher needs to systematically move from simply observing the culture to discovering a
cultural scene, both of these concepts are related but different. The parts or elements of cultural
meaning are discovered and subsequently organised into a cultural domain, this involves a search
for the attributes of terms in each domain and then considering the themes and how they are linked
to the cultural scene as a whole (Spradley 1980, p. 88).

Domains = development of basic elements

In order to begin the process of analysis, a systematic examination of the data to determine the
relationships among parts, and the whole (Spradley 1980, p. 85) is required. This generally
involves searching through the fieldnotes to discover cultural patterns. A cultural domain is a
category of meaning where unique things are classified together. All these make up the basic
elements cover term, included terms and semantic relationship.

The size of each domain will demonstrate how prominent specific terms feature as part of the
individual participants analysis. Each participant may have varying numbers of terms; this indicates
48

the importance given by the participants to the question of pressure ulcer prevention. It is from this
information that an index of pressure ulcer prevention behaviours was compiled.

Table 4 Analytical Domains

Patient advocates
Operating room

are links of

nurses

Helpers
Technicians
Surgical Assistants

Analysis of the Observations

Notes taken during the observations of nursing staff were studied to see if concepts and terms could
be matched to the cover terms. From the observation of patients in the reception area the nurse
did not ask the patient, or ward nurse, about skin damage or soreness (FN 16 18), could form a
basis of an included term in a domain that could be associated with communication. Included terms
were grouped together to form cultural domains that will be related to the chosen cover terms. From
this concept it revealed aspects of skill and knowledge related to the selected cover terms that were
considered important aspects of patient care. An indication of how prominently specific cover terms
featured in any individual analysis were by the size of each domain.

Some participants may generate a domain for specific cover terms that include one term, whereas
others may have five included terms. The result of this will be that the participants with multiple
included terms could be believed to be able to demonstrate more pressure ulcer prevention
strategies than those with only one or two. This analysis of data allowed comparisons of the
different ways participants have fulfilled the domains.

The analysis of data was continuous and commenced on the completion of the first field visit. The
moving between the roles of interpreting and playing a part is a characteristic of the method of
research chosen for the study. This notion of interpretation as play may hold great appeal to the
49

ethnographic project because it reflects the drama into which the ethnographer enters the
theatre (Gadamer 1975).

A preliminary analysis of the data was made during the initial phases of the working with the
information. This was achieved through the structured analytical process represented in Figure 1.

Figure 1

Structured Analysis of Data

ETHNOGRAPHIC PROCESS

FIELDWORK
Collection of the data

CODING
Comparisons of the data

SELECTION OF THE SMALL CATEGORIES

DEVELOPMENT OF THE BROAD CATEGORIES

DEVELOPMENT OF THE CULTURAL THEMES

50

The text was continuously searched for words, phrases and behaviours that frequently occurred.
Once highlighted they were organised into codes for easy management, and retrieval of information
(Roper & Shapira 2000). Using the principles of inclusion and exclusion outlined by Spradley
(1980), the similarities and differences between the data elements were formed into codes. Themes
were then verified or re-established accordingly. Themes will be drawn together in a manner that
reflected the central questions that the data inspired.

From the descriptions obtained during the fieldwork, and the interview scripts, the text for this
study were developed. The rich descriptions allowed the reader to experience the event being
described (Geertz 1973). The information documented in the reflective journal also serves to
support the text.

Analysis of the Interviews

Cultural domain analysis of the participant interviews revolved around searching the transcripts of
the interviews for any broad concepts they contained and concepts referred to by the participants.
These concepts were required to describe common territories for all of them to a larger or smaller
degree. The most significant of these were used as a basis for cover terms. These cover terms were
collated and then used to form anchors which were then used to collate folk included terms,
statements or terms actually used and understood by the participants, ultimately large folk domains
were cultivated in this manner for each participant. These domains were described in narrative,
using dialogue from the interviews where appropriate.

Data obtained from interviewing the participants was categorised into folk domains, the cover terms
identified for domains from the expressed culture of the participants, and extrapolated to the
expressed culture of the participants, which sought to identify culturally relevant included terms to
complete these domains.
51

The included terms were sought from the field notes through the use of a semantic relationship to
the relevant cover terms. This provided an indication of the frequency and prominence of that
particular aspect of pressure ulcer prevention in each participants clinical practice. From this
information was possible to perform an appraisal of how those aspects of that nurses practice
relates to the specific component of pressure ulcer prevention in the perioperative environment. An
appraisal of how these aspects of individual nursing practice relates to that specific component of
pressure ulcer prevention will also be possible.

Thomas (2003) proposes that the researcher condense extensive and varied raw text data into a
summary format, and allow the research findings to emerge from frequent, significant or dominant
themes. The manner in which this is done is to rigorously read transcripts, identify themes and
categories, the emerging themes were studied and possible meanings formulated. Transcripts were
read and segments of text grouped by theme. By continuously re-examining these themes, in time a
final conclusion was reached. This technique was used in analysing the data.

From categories of cultural domain analysis, the grouping of unique things together created a
domain. Each domain consisting of three basic elements, a cover term, included term and a
semantic relationship. The cover term indicates the main grouping which in this case is nurses, the
included terms are the names of smaller categories, enrolled, registered, student and the semantic
relationship the one that forms the links, kinds of nurses.

Cover terms were selected and judged to be an important component of the nurse-patient
relationship which would promote care and facilitate pressure ulcer prevention in the operating
room. They are suggested by the many different studies conducted over the years (Ismail 1983,
MacLeod-Clark, Wilson-Barnett, Latter & Maber 1993, Long & Irving 1993).

52

For this study these will be:

Communication
Nurse-patient relationship
Empowerment / disempowerment
Nursing tasks
Involving other health professionals in pressure ulcer prevention
Education and knowledge.

Finally, each type of domain analysis was followed with a search for themes and patterns of
meaning, from the information given by the participants at their interview. For Spradley (1980, p.
141) cultural themes are a principle recurrent in a number of domains, tactic or explicit, and
serving as a relationship among sub-systems of cultural meaning. An example would be social
conflict, maintaining status and solving problems (p. 153).

Patterns that appeared in data was distilled from any part of the interview and influenced by the
nature and direction of the interviewers lines of enquiry. Unstructured interview format may help
to minimise this tendency, but the fact is that the answers were simply fulfilments of the questions
asked. The interviewer remained aware of the patterns and concepts that perhaps become
implanted into the process, and those emerging from the descriptive statements of the
interviewees. An understanding of the themes that emerged were compared to an understanding of
those uncovered by the description of the domain analysis of the participant observations previously
described, in an attempt to enhance the validity of the conclusions. This made it more difficult to
influence the nature of a pattern simply as an observer.

Rigour
In writing an ethnographic account, the ethnographer is called upon to make many analytical and
ethical decisions. The researcher is called upon to convince the reader that the author was totally
immersed in the culture being studied and leaving the reader no doubt that they were actually
observing behaviours and listening to conversations at the time they took place. An ethnography is
the final account of the collective judgements made by the researcher. In order to do this accurately,
53

the researcher must be able to provide a clear, and easily followed process of the research
conducted. Some of the strategies used to facilitate the authenticity of the account are presented.
That which has been sanctioned by tradition and custom has an authority that is
harmless, and our finite historical being is marked by the fact that the authority of
what has been handed down to us and not just what is clearly grounded always
has power over our attitudes and behaviour.
(Gadamer 1975, p. 280).

The production of text through ethnographic interview and observation and its interpretations were
central methods of the study. In order to ensure rigour in the research four main areas must be
considered:

the adequacy of the definitions

the credibility and plausibility of the disciplines
the relationship between description and the claims made, and
the attention to the main sources of error in judgement.
(Hammersley 1998).

The authenticity of the account does not rest with how plausible it all sounds, but in the manner in
which the final account was achieved. Gadamer (1975, p. 271) says that the only thing that
gives a judgement dignity is its having a basis, a methodological justification and not fact that it
may actually be correct! The experienced ethnographer Martyn Hammersley (1998), Professor of
Education and Social Research, suggests that the adequacy of ethnographic research must be
considered from the perspectives of validity and relevance. He constructed criteria to ensure that a
comprehensive evaluation of the research can be achieved. In adopting the term validity,
Hammersley uses it in the sense of how trustworthy the ethnography is (Hammersley, 1998). The
issues that have a bearing on the validity of the research and informed the conduct of this research
are presented in table form (Table 5).

Geertz (1988, p. 143 4) emphasises that it is upon its authenticity that anything else
ethnography seeks to do analyse, explain, amuse, disconcert, celebrate, edify, excuse, astonish,
subvert-finally rests. The question for ethnographers to ask is what do these people see
54

themselves as doing? rather than what do I see? (Spradley & McCurdy 1972, p. 9). To answer
these questions the researcher must actively observe people in their every-day activities and
communicate with them in an open, honest manner (Schultz 1994).

Table 5

Strategies that promote the authenticity of the research (and adopted for this
research)

Strategy
Definitions
Credibility of the descriptions

Relationship between descriptions and claims

Sources of error in judgement

Misconception of something observed

Constraints faced by the researcher

Use in this study

Frequently used terms, and theoretical concepts
through description and evidence from the fieldwork.
Descriptive accounts taken from filed verbatim
interview transcripts. Attention to the occurrences
not included in the data as reflections of everyday
work. Participant checking.
Data management procedures, analytical processes
and referrals to data to ground theoretical constructs
and theories.
Reactivity, - the extensive period of observation, the
effect that the research and the researcher have on
what is being observed. Misrepresentation, attention of unfamiliar acts, participants
representation of the truth, and prejudices of the
researcher. Constraints, - access to the setting,
presentation of self as the researcher, attention to the
weight of evidence and saturation of data.
Unfamiliar acts consisting of rigorous field
documentation reiteration of the purpose of the
research to the researcher and other participants,
transcripts verification, the use of interview, research
journal and observations, pre understandings of the
researcher and the communication between
researcher and participants, maintenance of journals.
Access to the environment permission to observe
communication between participants and researcher.
Respect for the culture and awareness of being
researcher, clinician and boss reflection on feelings
and actions of the researcher. Analysis of data
collection processes. Attention to the degree of
evidence and data.

The adequacy of the definitions

The definitions of frequently used terms were from text books that described perioperative nursing
and surgical procedures, the Australian College of Operating Room Nursing Standards, Policy
Statements and Guidelines. Every effort was made to state the definitions in a clear and simple
manner that was designed to be easily understood by those people who had no concept or
55

experience of the specialty area or a limited understanding of the patient care that is provided within
the confines of this specialty environment.

Credibility of descriptions accounts

Descriptive accounts of day-to-day nursing practice were taken from field notes that were
documented during the observations. Other comments taken from the extracts of the participant
interviews supported the descriptions and strengthened and authenticated them. Some descriptions
were not included as they did not reflect day-to-day clinical practice. The decision to follow this
process was when behaviour was observed only once or infrequently.

The relationship between descriptions and claims

The process of data management and analytical procedures are described in the section Research
Methods. These were designed so that the relationships that existed between the descriptions and
the claims could be easily interpreted and also acknowledged as credible. The importance to ensure
that the descriptions had credibility was critical to the efficacy of these processes. Constant referral
was made to the data, to ground the processes of theorising the observed behaviours and comments
of the perioperative nurses.

Main sources of error in judgement

Hammersley (1998) believes that there are a number of main sources of error when conducting
ethnography. These are presented here separately.

reactivity which concerns the effect that both researcher and the research have on what is
being observed.

Van Maanen (1991, p. 31) believes that the success of any fieldwork endeavours depends
inherently on the results of the unofficial study the observer. Observing and interviewing in the
perioperative environment meant that the perceptions and perspectives of participants and the
56

researcher are shaped by the study process (Vidich 1969, p. 86). The presence of the researcher in
the field has an impact on those being observed. This can be a paradoxical situation, with potential
for the researcher to not only change the scene, by their presence, but by acting inappropriately, also
change the scene (Schatzman & Strauss, 1973). A balance between participation and observation
arose during the conduct of the study and can be demonstrated from the excepts contained in the
research journal:
Today a very large patient was transported to the operating room. It was obvious that
extra staff would be required to assist to move the patient from the bed onto the table. I
could see them looking at me, perhaps wondering if I was going to help. It took a lot of
restraint on my part. I know if the group appeared to be in trouble, I would have been
compelled to do so (Research journal).

The presence of the researcher can affect the way in which those being observed act, Shaffir and
Stebbins (1991, p 13) state that the participants may respond differently from what can be observed
each day, by doing everything by the book! This was demonstrated in the second extract.

Monday morning gynae lists are always sad for me. But for the grace of God, I could be in
this same situation than these poor women. Lucky for me Margaret made me have
something done early. I feel for them so much. Why dont others? These ladies must be so
afraid, why cant the girls make that extra effort? Today things were a bit different. They
are used to me wandering about, but the word is out, I am observing practice. So today the
ladies received the attention that they should get each and every time. Its not that they
mean to appear uncaring, they would be appalled if I brought it up with them, they always
say treat them (patients) like family members. Today the caring behaviours were very
much to the fore; patients were given every attention possible. Sad, very sad (Research
journal).

misrepresentation, - attention of unfamiliar acts, participant representation of the truth, and

prejudices of the researcher.

During the conduct of this study there were three main threats to the clear perception of the
everyday working lives of the nurses. These were the attraction of unfamiliar acts, summed up by
Kellehear (1993, p. 128) who suggests that the usual attracts, the familiar taken for granted. At
the beginning of the fieldwork, the technology in the environment coupled with the complexity of
surgical procedures were absorbing because it provided an opportunity to pause and look at what
57

was really going on. In this situation unfamiliarity with the environment was not an issue or
problematic.

Writing the field notes in the operating rooms distracted the nursing staff and altered their activities.
These field notes and observations served to highlight the importance of all the taken-for-granted
and familiar behaviours that indicated when they were somewhat unusual and not at all usual
practices of the group. Ultimately the decisions about what aspects of the culture being studied, that
should be concentrated on and what to disregard as unimportant, were strengthened through this
process.

Boredom and tiredness together with the frequent delayed recording of field notes also play a role in
the potential to misperceive behaviours of the nurses. In the section Research Methods a structure
for writing and expanding field notes was described. The length of time spent observing in the
environment was varied due to workload commitments, however the ability to fully concentrate
during the observation periods and the appropriateness of what was being observed were the main
criteria for the length of an observation session.

The participants interpretation of the truth and the way that may have influenced the manner in
which they represented the truth were a threat to them. They wanted recognition for what they did
and their contribution to patient care. A desire to please, ulterior motives or holding back on what
they wished to say, or feeling constrained in what they say, could be some of the ways in which
participants view the study.

The prejudices of the researcher are also a threat to the study. Gadamer describes prejudice as a
judgement that is rendered before all the elements that determine a situation have been finally
examined (Gadamer 1975, p. 270). Although during the fieldwork the researcher continues to
influence what is acknowledged and accepted in ethnographic research (Schatzman & Strauss
58

1973), it is the researcher that brings theoretically based beliefs and ideas to the setting being
studied, that assist in shaping the study (Glaser & Strauss 1967). Malinowski (1922) says the
theoretically derived ideas the researcher has about a culture before entering the operating room
environment, had to be acknowledged, these he calls foreshadowed problems. The values, beliefs
and behaviours that could influence the study were clarified and accounted for very early in the
study (Lipson 1991). By engaging in the hermeneutic circle, including fusing the horizons, dialogue
and prejudice, and conducting the research using ethnographic strategies, such as using a combined
research journal, only served to strengthen the rigour of the research process and minimised the
threat of the data being influenced by personal values and beliefs.

constraints access to the setting, the presentation of self and the attention to the evidence and
saturation of data.

The final criterion for ensuring rigour of the research is the way in which the constraints arising
from the research were addressed. One of the major constraints that required attention and needed to
be overcome was the novice status of the researcher, new to ethnographic research. The steps in the
research process, in particular that required when conducting fieldwork, the ability to judge
situations accurately and to respond appropriately and make sound research judgement were
continuous throughout the research. The areas in which important decisions and judgements had to
be made were in areas of maintaining access for observations, the presentation of self as researcher,
and concluding the fieldwork. These three aspects will be dealt with separately.

The process of gaining and maintaining access was relatively simple and poised few problems as
the researcher held a senior position in the environment. The formal process discussed in Research
Methods, will not be repeated. The real problem was in time management and the demands of
every-day workload commitments. Hammersley and Atkinson (1995) when discussing fieldwork in
59

general terms, make note of the changeable nature of access and the need to constantly negotiate to
maintain it. The research journal was an excellent tool for writing down and working out poor
decision-making and wrong judgements, and a forum in which to argue conundrums that appeared
during observations.

The problems of not touching anything green and standing in places that were deemed
inappropriate by those in the study setting, did not present concerns as the researcher was extremely
familiar with the environment and its rules.

This was demonstrated in the following extract:

Things did not go well from the start. The patients clinical condition had
apparently deteriorated since last seen by the surgeon the previous day. As
surgery commenced the original diagnosis had failed to reveal the full extent of
the problem. Many of the abdominal organs were stuck together and the colon
perforated with faecal fluid oozing into the abdominal cavity. Suddenly all hell
broke loose, the patient collapsed, the anaesthetist ordering blood be delivered,
drugs be made available and the crash cart brought in on standby. Surgery
suddenly stopped, all the surgical team standing still hoping that the patient would
pull through. It could be seen in their eyes. Ive been there so many times myself
I can feel the same feelings as them at this time. It was hard to just stand there. If
things got worse then what would I do? (Research Journal).

To strike a balance between the two roles of an observer and participant in these types of scenarios
it is more than simply reiteration of the purpose of the observation, but clearly defining the roleplayed by the researcher at that time. The role of the researcher is central, with two other roles
contributing to gaining access; these are the roles of friend and manager. These two roles were
confusing at times, but did not compromise the interpretation of the data collection, but contributed
to gaining access.

Presentation of self as the researcher is closely related to the problem of going native, a phrase that
could be considered as describing the researchers uncritical adoption of the cultural values and

60

beliefs (Shaffir & Stebbins 1991, p. 14). The reflective journal was used in identifying the risk with
going native and encourages the process of critical self-questioning and reflection.

In reviewing the data the process of deciding which leads to follow and those that were best
ignored was of concern and challenging, because initially it was somewhat overwhelming. As the
fieldwork progressed cultural patterns began to emerge. These ultimately indicated whether or not
specific lines of enquiry could be recognised, if not, then the data was again reviewed and further
observations conducted. It was these processes that brought about the decision to include or exclude
information or ideas.

Ultimately the collection of data, the analysis and the ethnography must be brought to a conclusion.
Ethnographic research demands flexibility and responsiveness to the findings that emerge (Burgess
1982).

Shaffir and Stebbins (1991, p. 18) believe that the researcher is not an unknowing adventurer going
into a new or foreign country, but has some ideas of what lies ahead. This knowledge is an
important part of the hermeneutic enquiry, and assists the researcher in demonstrating to the
culture that they (the researcher) are not without some knowledge or are naive (Walsh 1996).
Whilst every effort was made to avoid pre-judging the nature of the problem and its situation
(Shaffir & Stebbins 1991, p. 18), it was difficult for the researcher due to the extensive knowledge
of the study environment and the staff employed.

61

The Participants
This overview of the participants is presented as a means of contextualising the participants as
individuals and as part of a culture.

Eight nurses volunteered to participate in this study, all of whom were employed in the Operating
Room Services where the research took place, however not all the nurses who volunteered were
observed due to time constraints, - this being one of the limitations of the research. Eight formal
interviews were conducted taking at least one hour to complete. The questions presented to the
interviewees were designed to encourage personal experiences, their beliefs and to describe clinical
practice. Some of those interviewed relayed stories of patient interactions. This allowed a full
account of the participants representation of their culture, skill and knowledge of pressure ulcer
prevention in the specialty.

1. Amelia is Australian born, in her mid thirties, and has been qualified as a registered nurse for
approximately 16 years. On completion of her education she commenced a nursing career in a
rural hospital. After one year in the ward areas she entered the specialty of operating room
nursing as a career pathway. Her experience in the study setting has been extensive and she is
currently allocated to the emergency operating rooms. Her role is that of a scrub / scout nurse.

2. Alice is in her twenties and was born in Australia. She left high school and commenced
employment in a Nursing Home, where she continued to work throughout her undergraduate
nursing program at University. Following registration for two years she worked in the ward
areas in a rural hospital. During this time she was exposed to care of the elderly patient,
paediatrics, psychiatric patients and aspects of general surgery. She has been a registered nurse
for approximately 12 years. Her role is that of a scrub / scout nurse.

3. Jennifer is in her mid forties and was born in Australia. She commenced her nursing career as an
Enrolled Nurse, later enrolling in the registered nurse programme. Jennifer transferred to a
metropolitan hospital where she gained further experience in medical and surgical patient care

62

areas. Later she entered the operating rooms and commenced a new career path. In total she has
been a registered nurse for approximately sixteen years. Her role is senior scrub / scout nurse.

4. Joanne is in her mid fifties and was born in the United Kingdom. She entered nursing initially as
an Auxiliary Nurse working in a private hospital where patients requiring palliative care were
nursed. In that environment the issue of pressure ulcer prevention was taken seriously and areas
other than those commonly focused on, ears and shoulders, were given constant attention. Some
time after arriving in Australia, Joanne worked as an Enrolled Nurse, later entering the tertiary
setting to complete registered nurse education. She has been registered for approximately
thirteen years. Her role is that of a scrub / scout nurse.

5. Phillip is Australian born, approximately thirty seven years of age and completed his registered
nurse education in the university environment. He originally planned to complete a Bachelor of
Arts Degree in Archaeology, but worked in a nursing home to supplement his income, provided
the impetus for a change of career path. However, archaeology remains a hobby for him, Phillip
has been a registered nurse for twelve years and currently works in the recovery ward.

6. Joseph is a senior nurse in charge of a large recovery ward having been a registered nurse for
approximately twenty six years. He is in his forties. Prior to entering a nursing career he
managed a fruit block, supervising sixty eight workers at what could be considered a young age
for the responsibility.

7. Annie is Australian born, and a senior recovery room nurse. She entered nurse training
immediately upon completing her high school education. Annie has been a registered nurse for
approximately twenty five years. Recovery room nursing has been the focus of Annies working
life for a considerable number of years, and because of this she has observed or been involved in
the nursing care of a wide variety of post-operative complications following surgery.

8. Max is Australian and country born. He became a Psychiatric Nurse and some years later
completed his general registration. Max is in his mid fifties and has significant nursing
experience. Max is self directing and confident to intervene when he believes patient care could
be compromised. He is competent in both caring for patients in the recovery ward and in
assisting the anaesthetists.
63

Analysis
Once the fieldwork was completed, the data was collated to develop the text for analysis. The text
in this study consists of descriptions that were derived from the interview transcripts and the
observations / fieldwork. The reflective section of the research journal supported the text.

The transcripts and field notes were reviewed and reformatted to allow line numbering of the
individual transcripts. This numbering is a very simple way to keep an account of the position of the
data elements. Each interview is line numbered as a separate entity with pseudonyms used to
identify the interview excerpts.

The methods used to analyse the data reflect both ethnographic and hermeneutic processes.
Thompson (1990, p. 243) states that in the hermeneutic circle tradition, understanding is described
as a process of moving dialectically between a background of shared meaning and a more focussed,
finite experience within it! This is supported by Gadamer (1975, p. 291), who believes that the
enquirer enters into the metaphorical hermeneutic circle in order to understand the whole in
terms of the detail and the detail of the whole. Entering and acting within the circle. This analysis
began once the first note taking of the fieldwork had been completed. Ethnographic analysis was
continuous and resulted in the fact that the progress of the study was unpredictable as most of the
information could only be analysed during the final stages of the study.

The approach used to analyse the data was based on the work of Spradley (1988). For Spradley
ethnographic research should involve the observation and subsequent analysis of social situations
in order to discover cultural scenes, the culture that exists as a framework composed of
definitions of situations.

64

Before a scientifically, supportable interpretation of any data can be produced, there is a need to
isolate specific patterns (domains) or relationships among the patterns in the data related to the
research questions (LeCompte & Schensul 1999).

Definitions vary in groups, and in order to see the differences, Spradley (1988) advises that an
identification of these parts of cultural meaning put to organising them into patterns should be
conducted. This is what Spradley (1988, p. 89) refers to as cultural domain analysis and is the result
of grouping unique things together (cultural domains). These always include three basic elements, a
cover term the main grouping, in this instance the perioperative nurses, included terms being the
names of the categories that make up the main group and the semantic relationship is the link
between the two.

Other domains include folk domains and analytical domains. Domain analysis revolves solely
around the use of language. An example of this is the language that is actually used by the
participants in the study.

An analytical domain arises from the situations that the researcher observed where there is no
explicit meaning verbalised by the participants, the terms used to describe this selected by the
researcher.

Each domain analysis was followed by a search for themes and patterns of meaning. Spradley
(1980, p. 141) describes a cultural theme as a principle recurrent in a number of domains, tactic or
explicit, and serving as a relationship among subsystems of cultural meaning.

These themes or patterns in a section of the text data, soon begin to emerge, because they seem to
appear frequently or are unusual to other patterns or themes. Sometime however they have been
65

rarely documented but are influential, at other times, despite the expectations of the researcher, they
do not appear at all (LeCompte & Schensul 1999). The following takes place, the first step, this is
when the researcher is required to focus on constructing tentative propositions, the second step
involves establishing how typical and widespread the phenomenon is, and finally the third step is
when the propositions are tested against the negative cases.

Initially the notes taken during the interviews of each participant were studied in detail to isolate
concepts and terms which could be matched as included terms to each of the cover terms such as
caring or nursing routines. As an example, the question What sort of equipment do you use that
appears to be the most effective and efficient items for pressure ulcer prevention in the operating
room? might form the basis of an included term in a domain concerning patient care. These
included terms were then grouped into cultural domains relating to the cover terms. Some included
terms occurred in more than one domain, and can be seen to be relevant to both cover terms. The
size of each domain gave an indication of how predominantly specific cover terms featured as part
of individual analysis, for example, one participant might have generated a domain for the cover
term which include two included terms. Other participants may possess a domain for the same cover
term, but include any number of included terms.

Two nurses may have identical numbers of included terms for the same cover terms, these may be
however, completely different in nature. The domain analysis of all the participants is provided in
the form of a narrative that is derived form the initial compiling of the domains. Cover terms are
those considered to be important components of nursing care, that could facilitate pressure ulcer
prevention in the operating rooms, and in the context of this study, could be considered to be an
indication of the prominence and frequency of that particular aspect of pressure ulcer prevention in
that particular nurses practice.

66

Analysis revealed how aspects of an individuals practice related to the selected cover terms. Folk
domains arising from actual participant interviews will now be presented.

The Interviews
Cultural domain analysis of the participant interviews revolved around searching the transcripts of
the interviews for any broad concepts they contained and concepts referred to by the participants.
These concepts were required to describe common definitions of situations for all of them to a
larger or smaller degree. The most significant of these were used as a basis for cover terms. These
cover terms were collated and then used to form anchors which were then used to collate folk
included terms, statements or terms actually used and understood by the participants, ultimately
large folk domains were cultivated in this manner for each participant. These domains will be
described in narrative, using dialogue from the interviews where appropriate.

Data obtained from interviewing the participants are categorised into folk domains, the cover terms
identified for domains from the expressed culture of the participants, and extrapolated to the
expressed culture of the participants, which sought to identify culturally relevant included terms to
complete these domains.

A closer examination of the data gathered from the interviews resulted in the development of three
distinct groups, these were refined to three folk concepts, and used as the basic template to form a
common set of cover terms, these were considered to be applicable to all participants.
The first one, partly dictated by the researcher, was what pressure prevention means to me. It was
included because of the diverse understanding of pressure ulcer prevention as a concept.

The second one and commonly expressed by the participants was a team effort. This formed a
folk cover term because it was frequently referred to in the transcripts and related to the battles

67

experienced by the participants as they attempted to or involved other health care professions in
pressure prevention strategies for patients.

Finally, all participants expressed some degree of difficulty when attempting to implement
preventative strategies. These problems usually revolved around changing views or time constraints
imposed by some members of the medical staff. This takes the form of a disregard for nurses need
to attend to patient positioning in a way they believe will provide the best protection, and the
urgency of the surgeon to complete the surgery.

It is important to note that only the first folk cover term was presented by the researcher, the other
two were proposed by the participants and were their personal beliefs of how the skills and
knowledge of pressure ulcer prevention is demonstrated in the perioperative environment.

Results of Folk Domain Analysis of interview with Amelia

1. What pressure ulcer prevention means to me
Amelia discussed a number of different aspects of what pressure ulcer prevention equipment
and prevention strategies meant to her. She outlined related folk domains containing seven
included terms. She reiterated throughout the interview how she believed that although
pressure ulcer prevention was reasonably good in many ways it could be better! Amelia
was uncertain whether some items were still acceptable today or not sheepskins were
given as an example. She stated that;
Usually a lot depends on the preference of the surgeon. Lithotomy poles for
example. Allens are better, but the surgeon prefers others, so action is bound by
this padding is used and we try to work around the surgeon (Amelia 1: 13-16).

These sort of differences can cause tension in the room, the access for the surgeon to the
surgical field, and what the nurses believe to be better for patient care.

68

Amelia was uncertain if some staff deliberately chose to implement pressure ulcer prevention
strategies or not. Amelia continued by describing how she believed that staff sometimes did not
push their pressure ulcer prevention strategies when they knew that doctors often disagreed
with the approaches to patient care. In her view, if a medical officer did not agree with the
nurses views that patients required to be protected from injury in a specific way, then often the
outcome would be that preventative strategies were not implemented. This was to avoid
confrontation between the two groups of professions. Sometimes, however it may have been
due to their inexperience, and ability to enforce good practice. However some, she thought,
really did not fully understand about pressure ulcer development. (Amelia 4: 18 20).

2. A team effort
The importance of caring appeared continuously through Amelias interview. She explained
how long procedures presented challenges to operating room nurses in their efforts to care for
patients and protect them from harm. Amelia believed that;
Many nurses do not even consider the younger patient. We seem to be locked
into thinking its an age thing. If an older patient then we tend to think like that
(Amelia 4: 26 28).
She concluded by stating that pressure ulcer prevention was a reasonable thing to aim for
during the patients surgical experience (Amelia 1: 20).

3. Medical demands
Amelia articulated her thoughts on the importance of assessing the patients physical condition
prior to surgery. Assessment pre-operatively would allow staff to plan for care and the
availability of specialised items of equipment. She considered a review of the patients medical
history should be taken into account when planning care. For Amelia the length of surgical time
had a definite impact on skin integrity. The composition of the patients skin was one of the
most essential aspects of care for consideration, as it can become damaged before or after the
procedure, especially in the elderly patient, whose skin is often thin and easily torn during
69

movement. She pointed out that if the medical officer did not share the nurses view that a
patient should be treated in a particular way which promoted pressure ulcer prevention
strategies there could be difficulties, conflicting ideas or an outright refusal to wait whilst these
preventative strategies were implemented. Happily she believed that this was not generally the
case.

Pre-operative assessment was highlighted as a beginning aspect of patient care. No interaction

between ward nurse and operating room nurse was observed during the observational fieldwork.
Field notes taken during the fieldwork were studied to isolate concepts and terms that could be
matched as included terms to each of the cover terms. Analysis revealed how nursing practice
related to selected cover terms.

Results of Folk Domain Analysis of interview with Alice

1. What pressure ulcer prevention means to me
Alice spoke at length about her ideas regarding pressure ulcer prevention strategies. She
provided information from which a folk domain was constructed, consisting of seven included
terms (Table 4). She repeated some of Amelias concerns about support of other professionals
and implementing preventative strategies. She did however describe her past experiences in
caring for the elderly in a nursing home setting. These experiences proved to be an excellent
foundation on which she had built her patient care.

Alice recognised the importance of the condition of the mattresses and other support positioning
aids used during surgery. Many appeared to be the best available but she was unsure if there was
a new design on the market. She also was uncertain about the commitment of her colleagues in
pressure ulcer prevention.

70

2. A team effort
For Alice her focus on caring was from a personal basis of treating patients what if this were
me, how Id like to be? She believed that many of her nursing colleagues were fairly conscious
and aware of pressure ulcer prevention and its importance in the operating room environment.

Alice gave examples of how she thought nursing care could be incorporated into practice. She
continued to explain this could be implemented.
I still think movement is possible during surgery. Lets consider the patient
who is having surgery on their hand. The procedure may take as long as 10-12
hours. Not once is there any change to the patients position throughout all that
time. Why dont we move the ones we can, such as this patient. Could we move
and lift them from the table. Their legs are flat for a long time, could we lift
them from the table for a little while without causing grief to the procedure?
(Alice 18 23).

3. Medical demands
Alice brought her focus to examples of caring for the elderly patient. Her assessment of patients
pre-operatively highlighted contributing factors predisposing to pressure ulcer development and
the ease of skin trauma. She extended her answer by including the issue of skin preparation
pooling beneath the body. is this Betadine a skin irritant (Alice 3: 6). The frail, elderly
patient, thin and bony compounded by the length of surgery, all required consideration and
assessment in order to plan for the management of the patient.

Whilst assessment was described as being important in order to implement the care and
protection of the patient, this behaviour was not observed in the pre-operative waiting
environment. No communication occurred between the ward nurse and operating room nursing
71

staff about the skin condition of the patient. This observation included some of the participants,
but a large number of non participating nursing staff.

Results of Folk Domain Analysis of interview with Jennifer

1. What pressure ulcer prevention means to me
Jennifer appeared to be knowledgeable about pressure ulcer prevention strategies and her
responsibility for patients in her care. She described in detail the manner in which she
implemented different methods in an attempt to find the best way to protect patients. She often
used what was available at the time but knew that it was probably not the best. Jennifer trialed
positions herself as a means of confirming how the bodys natural position could as far as
possible be maintained during surgery. She articulated a number of different facets of pressure
ulcer prevention in some detail that were used to complete a related folk domain containing
seven included terms.

She was concerned that perhaps many of her colleagues were not as committed as she was to
pressure ulcer prevention. She based this statement on her observations when allocated to other
clinics managed by other nurses. Jennifer stated it is difficult to be complimentary when I
work with other senior staff, Im often disappointed (Jennifer 5: 17 18). She believed that
many surgeons did not consider pressure ulcer prevention a priority, and for this reason,
prevented nurses from implementing preventative strategies. She herself had often done battle
with surgeons in regard to this. They demonstrated frustration about the time. However she had
not been deterred and had persisted and now her practices were accepted.

Jennifer said she often worked around the surgeons in order to implement pressure ulcer
prevention and protect the patient.

She was excited on learning about an air flotation

mattress that could possibly be suitable for the operating room.

72

 market research should be done, we should start from scratch again. There
are many assumptions and practices that appear to work, but many staff do not
use the process or give respect to the issue it deserves (Jennifer 6: 23 24).

In saying this, she was the only participant to acknowledge that resources were needed in order
to implement preventative strategies properly. Jennifer raised the question would there be
money set aside to purchase equipment if a good product were found? (Jennifer 5: 43 44).
From her experiences, Jennifer believed that you should use everything for everyone, some
equipment available better than others, age is irrelevant (Jennifer 6: 43 44).

She elaborated that there was a poor handover of information from ward staff about the patient.
She herself ensured that she provided a comprehensive handover of patient details post surgery
including the condition of the skin.

2. A team effort
Jennifer elaborated that in order to provide nursing care in the operating room meant that one
could find themselves in conflict with medical staff who found the time needed to protect the
patient frustrating. Their focus was to proceed with the surgery. Because this could cause
some conflict in the surgical team, many nursing staff would choose to avoid it. Interestingly,
Jennifer believed strongly that pressure ulcer prevention was;
simply part of basic nursing care, then young and humble 16 years, I
would still be very mindful of patient care. A baseline, consider training, basic
care, slots off into specially thing, should not be considered as anything
special! (Jennifer 5: 12 16).

73

Jennifer acknowledged the existence of a hierarchy of power in the operating room, and was
passionate when explaining how this limited her ability to provide patient care. However she did
believe that if patients could be moved during surgery, at the consent of the surgeon, then
tension could be temporarily relieved from their back. Lifting the legs from the table for short
periods would surely help and ease the tension from behind the patients knees. Jennifer
concluded by explaining how she used everything available to protect the patient, Spenco, Gelpad, bootees. Some she believed were much better than others. She discussed how she even
uncurled the patients fingers and laid them in a natural position, pre-planning for care was
always worthwhile. Often it was a simple action such as releasing the ties of the patients gown
that could reduce pressure from the ties or knots!

3.

Medical demands
Jennifer spoke at length about the reasons why an assessment of surgical patients prior to
surgery was necessary. She used the example of the elderly patient or crumbly patient. These
patients required the greatest consideration as they represented the highest risk category. Many
presented with underlying conditions and once they were known it allowed care to be planned
accordingly, taking their special needs into consideration. Again the problem of poor
information from ward staff was highlighted. Visiting the patient pre-operatively is important to
Jennifer, who often visits in her own time. The introduction of patients admitted to hospital on
the day of their surgery has reduced this opportunity. She commented on how she often felt
stressed when dealing with her typical working day due to many of the issues raised in the
interview.

74

Results of Folk Domain Analysis of interview with Phillip

1. What pressure ulcer prevention means to me
Phillip exhibited a good understanding of pressure ulcer prevention. Similar to some other
participants, he associated pressure ulcer prevention with caring and one of education of staff.
He stressed the need for good communication, i.e. handover of patient details post surgery, in
order to fulfil the continuum of care. He believed that the mattresses on the beds in the hospital
were poor, and could possibly contribute to skin damage. Research was the only way to
discover what was the best equipment.
Phillip was of the opinion that staff development education programmes could greatly assist in
addressing some of the poor practices. This may assist him and his colleagues in the recovery
ward assessment.

2.

A team effort
Phillip believed that it was essential to identify with the patient. In order to do this, you have
to communicate with the patient, ask them about heels, elbows and back. He continued;
of course there are the non verbal cues, facial expressions, this can tell you a
lot about how comfortable they are. I think we could do a lot more, some
staff check wounds for bleeding and nothing but nothing else! (Phillip 8: 822).

He considered from what he observed, practices in regard to pressure ulcer prevention were
generally poor, and that things got missed, in particular orthopaedic patients, routine checks of
potential pressure points not done.

For Phillip being an advocate meant pride in ones practice;, and an attitude of;
what if this were me, would I want the nurses to ask me about these things?
communicate with the patient. Pick up on their questions! (Phillip 8: 1314).

75

Phillip stated that he firmly believed that excuses for not doing these things was possible, and
therefore there was not a focus on holistic patient care. Education and an increased staff
awareness was what was required. Patients were rolled but did staff take the time to really
look at the potential pressure points? Phillip believed that often the answer was no.
Experiences in a nursing home setting with elderly patients, specifically residents who
remained in bed, had provided the foundation for Phillip on which many of his practices were
based. In that environment there had been a pro-active approach to the problem. He firmly
believed that there was a very different mentality in those hospitals, pressure ulcer prevention
was considered and practices as part of holistic care in the nursing home!

3.

Medical demands
As with other participants Phillip drew attention to the issue of rushing to get the work done
(Phillip 8: 18). The time to interact with the patient was now reduced considerably with many
arriving on the day of their planned surgery. However it was still possible to conduct some
assessment of the patient. Their age, usually gave an indication of ability to, or restrictions on
movement, weight could be gauged. If bony then substantial inability to protect themselves
against pressure was obvious.

Phillip elaborated an aspect of nurse-patient communication that no other participant

mentioned. He described the non-verbal ones given by patients, that of grimacing. These
facial expressions may not always arise from post-operative pain, but from feeling
uncomfortable due to pressure on parts of the body. He referred on more than one occasion to
his previous working experience in a nursing home (Phillip 8: 8).

76

Results of Folk Domain Analysis of interview with Joanne

1. What pressure ulcer prevention means to me
Joanne spoke of a number of instances related to this cover term. She explained that, while she
found some of her colleagues knowledgable about pressure ulcer prevention, many would state
they were but did not demonstrate their knowledge in their practice. Joanne had sought further
information about the topic from the clinical educator, and found the information it contained
particularly valuable.

The equipment available for use in the operating room to prevent pressure damage was limited,
and some of that available was not a lover of (here she was referring to the gel-pads).
Usually she used what was available at the time. Joanne spoke about the patient who is
physically handicapped. She expanded this and explained about a friend who was disabled and
how she was able to use the information and experiences of this friendship as a basis for many
of her nursing practices;
some people do not look. Im paranoid about positioning, shoulders for
instance, damage can be done that is not always pressure ulcers. Would you like
this to be your mother or family members? (Joanne 7: 17 20).

2. A team effort
Joanne raised a point that none of the other nurses had, that the surgeon may inadvertently put
pressure on the patients body due to the surgical manoeuvres required. When operating room
nurses commence training for the role they are told about the dangers of leaning on, or placing
instruments on the patient. Skin damage can result from any of these actions. Nurses need to
watch for this she said.

77

Education for all staff would remind them of their responsibility as a nurse in pressure ulcer
development and prevention strategies.
would audits be one way of bringing the problem to the attention of staff,
how many ulcers follow surgery, how many are already developed when the
patient arrives in the operating room environment? (Joanne 7: 24 26).

These were the questions raised by Joanne as the interview was concluded, and the statement
that constant reinforcement was needed as a reminder of the nurses responsibility to their patient
care.

3.

Medical demands
This aspect of nursing care was essential for Joanne. Without a good assessment of the patient
prior to surgery how can you plan for care? The frail, elderly emaciated, young or old all
required an assessment;
first because its a big beefy follow obese patient, first because theyre big,
more weight on pressure ulcers (Joanne 7: 15 16).

Joanne spoke again about those patients who were unable to inform the operating room nurse of
any physical problems. With the poor handover of information from the ward nurse being
unfortunately common place, an assessment of the patient is essential in order to prepare and
manage pressure ulcer prevention;
how long has the patient been on the ward or ICU before coming to theatre.
They may already have a sore and we dont know! (Joanne 7: 29 30)

Again Joanne stated some people just do not look!

78

Results of Folk Domain Analysis of interview with Joseph

1.

What pressure ulcer prevention means to me

Joseph demonstrated his vast knowledge of pressure ulcer prevention by articulating a number
of instances related to the cover terms. He gave explanations of his experiences overseas and a
particular item of equipment that he had seen used, and found to be particularly useful in
pressure reduction. This was a turning bed that cost approximately $600 Australian dollars per
day, but this equipment was said to have paid for itself in a very short time by reducing hospital
length of stay due to pressure ulcers. This bed was managed by a computerised mechanism,
and used primarily for long term care patients. Joseph wondered if special mattresses were
available for surgical patients, and even if expensive, a decrease in pressure could also be cost
effective.

As a senior recovery ward nurse he explained that some patients arrive from the ward areas with
their own personal pressure ulcer prevention items and these should not be discarded. He had
noted over time that patients with pressure ulcers seen in the recovery ward appeared to come
from long term care facilities and were admitted for surgery to repair the damage.

There was no specific equipment in the recovery area for pressure ulcer prevention but he firmly
believed that;
blankets are often used between the bottom bed sheet and the mattress,
covering. This appears to reduce the incidence of skin damage, but does this
make a difference? (Joseph 9: 1 2).

Joseph reflected on a 95 year old bed bound patient, who had been nursed at home by family
members for some considerable time. This patient was nursed in the foetal position. Two
incidences of skin damage in eight years was recorded. On being admitted to a major city
79

hospital, routine pressure ulcer care was given, current at the time, - hourly turning. Skin
damage soon became evident. What went wrong? Joseph analysed this information and
reflected that the notion of a blanket and sheet and good innerspring mattress was the reason for
the good outcome. Hospital bed mattresses may be the problem!

For Joseph there have been some improvements in the past few years, however this does not
appear to be supported by the literature.

2. A team effort
Hit and miss were the words used to describe preventative strategies in the recovery ward.
Joseph believed that the junior staff appeared to focus on post operative observations and little
else.
the more senior the staff, the more able they are to attend to more than one
thing at a time. Each nurse had their own particular practices they implemented,
not specific, its down to the individual what they do! (Joseph 9: 15 17).

Joseph made the same comments about airway management as Annie. Both these participants
saw this issue of prevention and a priority in terms of clinical care, but was not standard
practice in the ward. They believed that
a good handover would greatly assist, if not mentioned that there is skin
damage, then it can be missed, can result in an incident. Care has to be taken to
ensure that anything that cause damage is removed, creased wet sheets.

Joseph wondered about the introduction of a scoring system as patients move

through hospital processes. For short stay patients probably;

80

not a problem but as this ward now open 24 hours we may require a review
of our current practices. Data would be useful to see if anything has made a
difference. Should there be a central co-ordination from a recovery ward point of
view? (Joseph 12: 26 50).

3.

Medical demands
a quick assessment is possible when you receive the patient. At a glance and
by touch, you can see that the skin is papery and easily torn! Of course there are
the pre-existing conditions, - the health of the patient (Joseph 9: 10 12).

Joseph voiced his concerns about the development of skin damage for those patients who for
reasons of emergency admission were nutritionally compromised because of long waiting times
for surgery. Although classified as an emergency, other patients take priority over them.
Positioning for surgery can have an impact on post-operative care, as an example those patients
who have undergone spinal surgery, are often unable to move their legs, this can be
problematic. Good nursing skills are essential to pick up the problems before too much damage
happens. The type of bed and mattress, - we need evidence about these things, the
composition of the mattress!

Pressure ulcer prevention is practiced in the recovery ward but not to the extent that it is in the
operating rooms, nor is it given any form of a priority status. The priority in the recovery ward
is airway management (Joseph 8: 9).

81

Results of Folk Domain Analysis of interview with Annie

1.

What pressure ulcer prevention means to me

Annie and Joseph considered pressure ulcer prevention in a manner unlike other participants.
This was because of their working environment the recovery ward. Here patients are received
immediately following completion of surgery and for Annie the focus is first on airway
management and second on blood pressure wound, or urine charting.

She was unsure of all measures taken by the surgical team, the amount of or type of pressure
ulcer prevention equipment either used or available in the operating rooms. There was no
equipment readily available in the recovery ward, except for pillows and the occasionally used
saline bag, or gloves filled with air. The air and Spenco mattresses she was aware of as they
were on beds in the area. Annie believed that they played a role in pressure ulcer prevention.

Her knowledge of the current practices for pressure ulcer prevention management was;
fairly reasonable and effective, there is low incidence I think, but we could
do things better perhaps. There must be newer mattresses on the market that are
better for ulcer prevention! (Annie 16: 13 16).

Overall however Annies answers and comments to questions about pressure ulcer prevention
strategies were limited. As she explained, the focus on patient care was different in the
recovery area, it was simply that this was not the immediate priority.

2. A team effort
Annie was concerned about the lack of patient information provided by operating or anaesthetic
nursing staff following surgery. For her it was important to know if the patient had been
admitted to the environment with existing damage, areas of redness or bruising. The elderly
82

patient in particular, required special attention to their delicate skin. Patients who undergo
Pelvic Reconstruction present a problem, because even if we wanted to move them, we cant,
not even from side to side.

Annie then spoke of the importance of the other things. She discussed nursing care which
incorporated ideals such as dignity, respect, comfort, compassion and good interpersonal skills.
Observation of Annie at work had shown that she was seen on occasions to deviate from post
operative orders or compromise practice in order to move a patient and relieve their discomfort.

3.

Medical demands
The assessment of the patient from Annies perspective was one of firstly checking for post
anaesthetic respiratory problems. This was her focus on the patient arriving in the Recovery
Ward. It was often not until some time later that other assessments were made. This is
supported by observations conducted in the Recovery Ward during the course of the data
collection for the project.

Annie as a senior recovery room nurse, is respected by the medical staff and when she called
for them to assess patients they were observed to accept her suggestions for treatment with little
question. This was the case when she wanted to change some of the positioning of the
orthopaedic patients, in particular those having pelvic surgery.
you discuss a patient with them, and your concerns, and they say thats good,
well do that. I mean, you can see the patients IV (intravenous therapy) and the
condition of the patient and ask that they review the orders (Annie 16: 6 11).

83

Results of Folk Domain Analysis of Max

1.

What pressure ulcer prevention means to me

Max had a substantial domain built up around this cover term. Like Jennifer, he appear to
equate pressure ulcer prevention with knowledge. From Maxs point of view, there did not
appear to be any equipment better or worse at this. For him it depends on how it is used,
good equipment can become bad equipment if used wrongly. The focus on getting things
done was also commented on in a manner similar to Joanne and Jennifer. He was strong in his
objections to patients being pushed through and the in and out mentality.

Max spoke at some length about when he taught new staff and explained the role they played in
patient care. Max believed that pressure ulcer prevention management in the environment was
sort of average. For him it appeared that many staff did not have sufficient knowledge to do
the job well. He focused on doing the job well, not taking short-cuts, and using best practice
philosophy. He did believe that the whole surgical team needed to be involved in this aspect of
patient care.

2. A team effort
Max was emphatic about his conceptualisation of pressure ulcer prevention. He spoke in a
manner of someone who had arrived at the conclusions through years of experience. An
analysis folk domain of the transcript showed that Max held many pressure ulcer prevention
values without always labelling them as such. Through the process of interview, he gradually
laid out a perception of a nurses role which was deeply empathetic individual patient focused
and humanistic.

84

He spoke about the commitment of nursing staff and time required to care for patients.
However he did believe that often staff could not consider the short time needed to complete
some tasks, sometimes simply a few minutes were all that was required in order to make a
difference.

Max gave a detailed explanation of how he implemented pressure ulcer prevention in his role
of anaesthetic nurse. He believed that as the Anaesthetists ask for time to complete certain
induction procedures, then nurses should also request time to complete nursing tasks. As the
patient advocate a strong stance on this is needed by nurses. In his experience;
the surgeons generally do not become too bothered about delays if
positioning is being done well. Most medical staff are happy to wait. In fact
sometimes the surgeons make comments about the position and make known
their concerns. The Anaesthetists are very good about this, they expect things to
happen to protect the patient (Max 12: 27 32).

Max continued and elaborated on the dangers of simply acting as a technician.

you have to be more than a technician, nursing things often get lost. Once
the tube is down, staff revert to ignoring nursing. You must incorporate nursing.
Special cases need nurses to be on hard anticipating and implementing nursing
care as well as assisting induction (Max 15: 37 43).

He believes that the Anaesthetist could easily anaesthetise the patient without any assistance,
but what about the nursing care?

Max continued by stating that there were times when the medical staff demonstrated stand
over tactics when staff were implementing pressure ulcer prevention strategies, this was not
good, and from his perspective rare, but he did know of some staff who had experienced
85

difficulties. Due to experience he found it easy to present his case to the medical staff, but
many of the younger and lesser-experienced nurses would possibly allow themselves to be
directed by medical staff.

Max stated that it should always be considered that planned surgery can change and likewise
the position of the patient. It was important to be aware of what would be the required outcome,
and to be prepared, but asking for time to fix.

He concluded with the remark that often anticipated long procedures receive consideration, but
the short ones did not, and the situation can change. Often little time was needed to cause
damage.

3.

Medical demands
Max discussed some aspects of assessment not often raised by others interviewed. He believed
that to see the patient prior to surgery was of extreme importance. He outlined what this
entailed, and the advantages of this practice.
It allowed him to;
look at the patients arms and legs, hold their hand and this way I get a
feeling of the patients skin texture, this is an indication of how easily it may tear
or be damaged (Max 12: 4 7).

An awareness of the physical and mental condition of the patient could be taken in at a
glance. Once positioned, if the patient did not look comfortable, then one could alter and
reassess. If not right, damage may result. For Max the main thing was to stop the rush and slow
down!

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Information was tabulated and used to compile an index of behaviours observed in the practice of
the study participants that was entitled, Analytical Domains. This appears in Table 6.

Patterns and Themes

A number of patterns were seen when reading and reflecting on the field notes taken during
observations of the participants, (Table 6)

Table 6 Patterns & Themes

Domain

Number of included terms in each domain

Amelia

Alice

Jennifer

Joanne

Phillip

Joseph

Annie

Max

Caring

11

12

Involving other health

Communication

Disempowerment

Knowledge

10

Nursing routines

Assessment of the

10

12

10

11

Cover Term

care professionals

patient

Before beginning to explore any patterns and themes that emerge from the presentation of the
results of folk domain analyses, the process of formulating the cover terms should be established.

The search for a common meaning concerning pressure ulcer prevention in the operating rooms,
revealed a cohesive set of understandings of the problem. All the participants interviewed described
in detail, the ways in which pressure ulcer prevention contributed to patient safety and well-being.
The knowledge of how pressure ulcer prevention could be implemented produced many suggestions
and reasons why this important caring practice is not consistently demonstrated. Some participants
believed their colleagues have a lack of understanding that ulcers may develop from a visit to the
87

environment. Importantly most believed that funding could provide for the purchase of superior
equipment.

All nurses described the importance of a holistic, individualised approach to pressure ulcer
prevention, however it was stated on a number of occasions that operating room nurses had
experienced difficulties sometimes when attempting to implement preventative strategies. Often it
was to do with the extra time it took before surgery could commence.

Caring was the domain with most included terms for all the participants, a majority of these terms
arose from observation of perioperative nurses fulfilling some aspect of physiological need for the
patient. However much of this was due to the requirements for surgery.

Once the patient entered the operating room there were some included terms associated with the
actions taken by the nurses that were of a clinical or physical necessity. This was not so in the
waiting area where nurses were rarely observed as approaching patients other than to confirm
personal details and check their consent for the surgical procedure. This suggests that nurses focus
is on moving the patient as fast as possible, and that at this stage of the patients perioperative
experience, their psychological needs were not central due to the demands of the surgical staff who
demanded quick turnaround time.

Analytical Domain Analysis of the Observation

Initially, the field notes taken during the observations were studied in some detail to isolate terms
and concepts that could possibly be matched as included terms to each of the cover terms. This may
be explained by the example of the nurses did not approach the patient and might form the
basis of an included term in a domain concerning communication. These included terms were
grouped into cultural domains relating to the cover terms. Some of the included terms appeared in
88

more than one domain professional can be relevant to both the cover terms, communication and
standards of practice!

In this manner, analysis revealed how some aspects of individual nursing practice related to selected
cover terms, each important components of pressure ulcer prevention in the perioperative setting.
This information was used to index pressure ulcer prevention behaviours observed in nursing
practice. An example of the included terms in domain is presented in Table 7.

From the analytical domain analysis of the observations of the participants, a number of themes can
be discerned. The analysis revealed that, of the components of pressure ulcer development, the
skills and knowledge, of the perioperative nurses role in pressure ulcer prevention strategies
continues to revolve around nursing routines in carrying out the demands of the surgeon in
preparing the patient for surgery. Other aspects of nursing care were sometimes carried out, but
generally omitted, and the constraints of time hindering the process.

Some nurses were seen to make efforts to communicate with patients, other than to confirm details,
and attempting to make light-hearted conversations with the patient in order to help them become
less anxious.

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Table 7

Included terms in each domain

Caring
Comfort
Dignity
Touch
Unrushed Friendly
Considerate
Professional
Listening
Knowledge
Education
Research
Review of practice
Experience
Pre-operative visits
Involving Other Health Professionals
Best practice
Collaboration
Positioning requirements
Team work
Communication
a)
handover
information clear
expectations
team discussions
high workload
busy workload
failure to care
Assessment
Touch
Smell
Listening
Observation
Review of medical and
nursing records
Nursing Routines
Myths, rituals
Policies
Standards of practice
List session times
Lack of evidence
Shift status and finishes

are ways to

enhance nursing care

are ways to

enhance nursing knowledge

are ways to

reduce pressure ulcer

development

enhance communication
are ways to

b)

inhibit communication

are ways to

are examples of

enhance the assessment of

the patient

nursing routines

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The cover terms as presented in Table 7 will be discussed and expanded under the heading of
discussion.

Overall the picture was disappointing as the caring aspect of nursing appeared to be missing until
just prior to the transfer to the operating room, when there was a change in attitude, and the nurses
became attentive. Generally there appeared to be a focus on getting the work done.

Discussion
There have been some improvements with the introduction of the day of admission process. The
operating room nurses have begun to collect the first patients for the day from the adjacent
admission facilities. It is pleasing to observe nurses talking to patients during this process, but the
lack of a formalised assessment, with a view to implementing preventative strategies remains
uncertain at this time.

In conducting ethnographic research, the culture of a particular group of people is investigated and
observed. In a culture where there has been minimum research conducted, the thoughts of Gadamer
on observations are worth serious consideration, in that only when the universality found in
experience has been attained, can we look for reason and hence begin scientific enquiry (Gadamer
1995, p. 359). This study is an account of the culture of one perioperative environment in relation to
pressure ulcer prevention, knowledge and practice.

There is a unique culture in the operating room environment, and a relationship that perhaps exists
in no other environment in the hospital. This relationship profoundly affects the way in which these
nurses experience their daily working lives. The work of this culture is largely invisible, and often
overlooked by those working outside the environment, and the relatives of patients who have
received care from these nurses.
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Perioperative nurses are charged with the safety and well-being of their patients throughout their
surgical experience, and are also responsible for the management of surgical sessions in which they
are allocated. For this reason the operating room nurse is frequently perceived of as merely a
technician, task oriented, handmaiden to the surgeon. The nurses challenge these perceptions, and
believe they are experienced clinicians providing valuable caring behaviours for patients in their
care. The value of the perioperative nurse has been overshadowed by the somewhat stereotypes that
have been ascribed then. Perioperative nurses have a unique body of knowledge, mostly unwritten.
This should be rectified. Gadamer (1975, p. 279), says authority has nothing to do with blind
obedience to commands. Indeed authority has to do not with obedience but with knowledge. It is a
culture where from time to time a nurse stands firm against the demands of the surgeon, she/he
becoming a hero in the eyes of their colleagues, be it only for a brief period of time.

Caring
This domain was the one that caused the researcher the most concern, because from this domain
many of the problems of pressure ulcer development could possibly be resolved. An example of the
perceived lack of caring behaviour of nurses is presented.

The patient is transferred to the table, there were a number of positioning aids available, I notice the
patient is rather obese and fits the width of the table. The mattress is the usual one, nothing
special. The anaesthetic nurse stands by the patient, touching her and talking to her. The instrument
and scout nurse are discussing the procedure, the instrument nurse stating she feels apprehensive, as
shes not been involved in one of these procedures for some time, so perhaps they should make a
start. Usually the set-up does not commence until the patient is asleep. Today is different, they
start earlier I suspect because of the uncertainty and knowing that the surgeon can be somewhat
demanding and impatient. The anaesthetist asks the anaesthetic nurse for something, she moved to
the top of the table. They both have their backs to the patient. In a split second of that happening,
92

the scout nurse moves to the computer and begins to enter details, she now also has her back to the
patient and due to the way that the set-up is done, the instrument nurse has her back to the patient.
The patient is alone in a room full of people! I am the only one watching her. I see her leg
beginning to fall from the table, the scout nurse at that time turns, notices and jumps into action.
She glances at me I say nothing. I was about to break my cover. For a period of time it was
almost as if the patient was invisible (Research Journal).

It would be incorrect to say that caring is totally absent from the research setting. During some
periods of observation it was noted that nurses would frequently ask the patient if they were
warm enough, and provide them with either a blanket, pre-heated from the warming cupboard or
utilise the forced air warming equipment that included a special blanket designed for that purpose.
The expression on the faces of the patients always a delight as they snuggled into the warmth of
the blanket. Some nurses appear to have developed the skills to discern when patients are very
anxious and moved from what is considered normal before surgery. This ability to recognise very
subtle changes in behaviour have been in the literature (Glaze 1999a).

Knowledge
During the interviews nurses were asked to comment on their practice in terms of methods used to
prevent pressure ulcer development in the operating room. Participants appeared to have no
difficulty in the identification of equipment most suitable for prevention of skin damage. Some
could readily state specific items they believed to be better than others. All wondered about whether
there could be better items available today, but unknown to them. Those nurses employed in the
roles of instrument / scrub nurse and anaesthetic nursing all agreed that the Spenco mattress was the
best available although there is only one in the service area. Recovery Ward nursing staff did not
demonstrate any knowledge of this equipment.

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All spoke of assessing the physical condition of the patient so that pressure ulcer prevention
management could be implemented. However observations conducted during the study did not
reveal any evidence of this behaviour. At no time during the observations were questions asked of
ward staff, or of the patient themselves, about skin damage.

Of concern was the issue that what was stated was not always practiced and this is supported by the
literature (Bietz et al 1999, Bostrom & Kenneth 1992, Halfens & Eggnik 1993, Panagiotopoulou &
Kerr 2000). This raises the question about the knowledge of those nurses who were not participants
of the study. Those participants volunteering obviously had an interest in the subject, the question
then arises, what would be the answers of those who were not involved?

As the number of nurses interviewed was limited it is difficult to state that all staff are aware of the
aetiology of pressure ulcers and the associated risk factors that contribute. However from the
observations it is perceived that there may well be deficits in the most up-to-date information
available on this topic. One example of this was during an observation period, additional linen was
used on an overlay, the literature revealing that this practice has no benefit and may well be a
contributing factor in pressure ulcer development.

Two authors, who share the belief that health professionals, other than nurses, need to be involved
in pressure ulcer prevention, are Theaker (2002) and Pope (1999). Both these authors are of the
opinion that a multidisciplinary approach is the way in which the problem of pressure ulcer
prevention can be resolved. Theaker (2002, p. 163) makes the point that it is increasingly
apparent that the complex nature of pressure sore development means that it is unrealistic to expect
a single discipline to manage the problem effectively!

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Pope (1999, p. 310) stresses that education of the multidisciplinary team is vital. She believes that
education should be focused on the aetiology of pressure sores, appropriate use of risk
assessment tools and preventative techniques based on research . If this were to be introduced it
would lead to a greater awareness of the potential problems. Importantly the knowledge gained
would ultimately result in enhanced patient care and clinical effectiveness. Whilst the
statements made by these authors were in reference to Intensive Care Units and seriously ill
patients, there is no reason to believe that they could be applicable and worthy of consideration in
the perioperative environment.

The deficits are evident in the significant variability of the attention given to pressure ulcer
prevention among staff in the research setting. The ACORN Standards for Perioperative Nursing
are used extensively in the setting when developing and reviewing policy associated with patient
care in this specialist area. Positioning the patient for surgery S.15 (2004) (Appendix 9) clearly
states that all patients shall be assessed. As many of the nurses employed in the area are not
members of ACORN, perhaps they remain unaware of this standard, or the manual itself. It is a sad
reflection on nursing that so many do not belong to ACORN or indeed any other professional
organisation. It is disappointing that they do not understand the importance of belonging to a
professional organisation, not only for their chosen area of nursing but for the nursing profession as
a whole.

Involving other health care professionals

It is not surprising to find, that the role of the nurse working in the operating room services revolves
around ensuring the needs of individual surgeons and patients are met. Observations demonstrated
that this aspect of patient care, preparation for the procedure, gathering equipment and
instrumentation, was almost always attended to with great enthusiasm. Whereas physical care and
infection prevention on the whole was regulated in service policies and standards of care (Appendix
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9), other facets of patient care were not well attended to, such as aspects of pressure ulcer
prevention. Generally it was disappointing to observe the lack of nurse-patient interactions and
nurses not actively seeking information about skin damage. There are a number of issues that
require attention on completion of this study, a nursing assessment of patients prior to surgical
intervention and documentation of patient skin integrity.

The implications of medical dominance played a role in the manner in which nurses rushed to
meet timeframes demanded by surgeons. Riley and Manias (2002, p. 316 324) considers the
relationship between medicine, nursing, hospitals and power and conclude that a major source of
frustration for nurses is the difference in status and associated power between themselves and the
surgeons. In an environment that is completely oriented towards surgical and technical intervention,
nurses engage in the emotional labour that keeps the surgeon happy!

There are times when the surgical team does become involved in discussing the patient and all the
issues surrounding their care, suggesting that the services of a speciality nurse would need to be
arranged perhaps a breast nurse for prosthesis fitting following mastectomy. This is very different to
the usual when most of the time the operation is not the main topic of the conversation. Surgeons on
the whole pay little attention to the positioning and protection of patients, except in circumstances
where the patient is required to be placed into a specific position required for access for surgery.
This issue raises the question about the skill and knowledge of this group of staff also.

Medical staff play a pivotal role, one that is of critical importance in the surgical environment.
Surgeons do however hold the power to raise or lower the tension and stress in the room. There is
an imbalance in the power and authority, an example being the demand for quick turnaround times
and not allowing nurses to initiate pressure ulcer prevention strategies. The nurses prepare the
environment and equipment suitable for the procedure. To complete this task they refer to surgeons
preference cards and other idiosyncrasies. Good preparation usually ensures a harmonious
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atmosphere. This preparation may have taken some considerable time and effort on the part of the
nurse to organise. The nurse is left in control of all of these preparations. However once the
surgeon enters the room, the situation changes as the surgeon assumes the position of control (Bull
2002, p. 246).

Nurses frequently view surgeons very favourably, that can perhaps best be described as a form of
hero worship. For these surgeons the nurses will go to great length to ensure that he is happy and
all his particular needs are met. This revolves around the performance of the surgeon, and the
comparison to other surgeons performing similar procedures. Nurses constantly discuss the ways in
which the surgeons overcome difficult situations (Bull 2002, p. 247).

Unfortunately, the status and power between nursing and surgeons can become a source of anxiety
and unhappiness. Bull (2002, p. 247) makes frequent references to the manner in which nurses and
surgeons interact with each other in the operating room. Often the nurses will have been exposed to,
or been involved in surgical procedures, a great deal more frequently than the doctor performing the
surgery. These nurses can, if allowed, provide valuable advice on specific aspects of the procedure
or surgical manoeuvres. Many of the medical staff do not receive this advice graciously, and in
some situations openly ignore or rebuff the comments made by the nurse. This may be perceived as
an imbalance in the power and authority. Others welcome the advice and openly seek the input of
the nurse in complicated procedures. There are often no complaints made by the nurses and
therefore it could be concluded that they are conferring to the good nurse and not complaining
about behaviour that in other situations would not be tolerated. It is often discussed that medical
staff would more readily support technicians, who are usually male in gender, and are under control
of the medical staff, thus increasing the power base and control over the environment. This situation
appears to be condoned by the hospital in the way that things are done!

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It could be said that perioperative nurses circulate by the threads of power that are exercised in
order to contain or reduce costs that are associated with surgical procedures (Bull 2002, p. 247).
Reduction in costs will in all probability, reduce stock or inventory levels and result in a potential
that patient care may be compromised due to a lack of, or limited availability of equipment. In
situations described perioperative nurses are subject to power that is exercised by management, all
in their quest for cost control and the purchase of further equipment to assist with pressure
prevention. Perioperative nurses are caught between the power exercised by surgeons, management
and ultimately the hospital (Riley & Manias 2001).

Communication
Good communication and interpersonal skills are essential in the perioperative environment. It is
essential because throughout all the stages of the patients surgical experience, information about
the patient is passed from one group of nurses to another, before anaesthesia, during surgery and
following on into the handover details in the post anaesthesia recovery unit. Effective handover will
ensure the success of the surgical experience and beyond.

Information about the physical condition of the patient allows the appropriate preparations to be
completed such as positioning aids and support surfaces can be made available that will assist
prevent pressure, and the instrumentation and consumables suitable for the surgical procedure,
postoperative drains and dressings available. Collectively this information assists the nurses to
manage the environment.

Again a collaborative multidisciplinary approach to reducing this problem would appear to be the
one proposed by a number of authors (Theaker 2002 and Pope 1999). Information from perassessment clinics and wards in advance of surgery would assist in planning, however the patient
should be assessed on entering the environment.
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Assessment
Patients arriving in the operating room setting are greeted by the receiving nurse and details
checked. Apart from the personal details, there did not appear to be any attempts to perform a
specific assessment of the patients skin or at least enquire as to the existence of pressure ulcers.
When the nurse collected patients for transfer to the operating room, again only basic information
such as personal details and consent were confirmed, and no skin assessment undertaken.

Whilst all the participants interviewed stated they firmly believed that patients required assessment,
and could list the many and varied problems that could be detected and perhaps avoided if this were
to be routinely performed, only two of the group were ever observed as initiating this important
aspect of patient care. Neither nursing nor medical staff appeared to make even a superficial
assessment and no documentation was made.

There are believed to be many reasons for this lack of assessment, all of which will require action at
a later date:

knowledge, not only about the aetiology of ulcers, but the availability of suitable
equipment

the increase numbers of patients admitted to the hospital on the day of their surgical
procedure. Patients attending via this route are assessed for suitability for anaesthesia
and the procedure in a special clinic but sadly, not addressed for pressure ulcer risk.
Later, in order to provide the patient with some control over their visit, they generally
walk to the reception area and are escorted to the allocated room, limiting time for the
nurse to perform any assessments, perhaps believing that they are fit and healthy if they
have walked and therefore believed to be not at risk.

The need to complete all the surgery planned for the session. Turnaround times
continue to be reviewed and comparisons made against other health care organisations.
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Nurses bear the brunt of the criticisms, and are very mindful of the need for shortened
times. In the midst of all this action perhaps the patient is becoming lost?

A lack of focus on this specialist area as being one of risk for every patient, has perhaps
resulted in nurses also not considering it in a conscious way except when positioning the
patient and protecting them from touching the metal of the table or attachments when
electrosurgical equipment is used.

One other explanation is presented by Theaker (2002) who puts the problem very succinctly.
It is easy to see why support surfaces are both relied on and heavily utilised
the major premise is that they reduce pressure. The minor premise is that pressure
causes damage and it follows therefore that support surfaces reduce damage.
(p. 167)

Perhaps this is the way that perioperative nurses think. The issue of the effectiveness of the support
surface not considered.

Theaker (2002, p. 166) makes an important statement which supports the lack of research into
pressure prevention equipment. She goes on to say that:
modern pharmaceutical studies undergo a formidable amount of testing which
includes post marketing surveillance to monitor adverse effects. It is, of course,
arguable that when it comes to pressure-relieving devices there is no need to be so
stringent, but manufacturers increasingly describe and market products as having
therapeutic properties. If this is so then they must be examined with the same
depth and rigour associated with the pharmaceutical industry. Not to do so is to
compound the modern doctrine of evidence-based practice.

Nursing Routines
Routines can be often confused with rituals. The difference between the two is in the understanding
of what is associated in the actions. A routine may be repetitive, but the purpose has long been
forgotten and there is no reason for it to continue, as they no longer serve a justifiable purpose
(Philpin 2002, Benton & Avery 1993). Katz (1981) argues that rituals are often overlooked in the
perioperative environment because in fact they are routines. Helman (1994) and Wolf (1988) argue
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that rituals have a significant and symbolic meaning for people within a specific culture. There
could be many other examples of routines or rituals in the operating room; performing the count
procedure and wearing of surgical masks, two of the most commonly observed.

Routines that exist in the perioperative environment sometimes border on the unreal and
according to Katz (1981), is part of the co-ordination required to maintain a calm environment,
with all members of the team playing specific roles in their efforts to bring about cohesion in their
high-pressure and challenging working day.

Perceived barriers to implementing best practice

Some of the participants referred to the problems sometimes encountered by them when attempting
to implement pressure ulcer prevention. Three of the operating room nurses referred to situations in
which they were pressured by surgeons about the time they were spending on pressure prevention
strategies. Of interest however was the comment made by one participant who totally disagreed
about the lack of medical support. This nurse believed that there were very few exceptions and
generally, medical staff were very supportive of any nurse attempting to protect patients, and had
observed them assisting as well as, providing suggestions about the use of some positioning aids.

The number of years qualified did not appear to influence the level of knowledge about pressure
ulcer development, but did appear to influence the degree of assertiveness they demonstrated when
seeking to initiate nursing care. It is believed that commitment to ensure the patient was provided
with the most appropriate care was the issue, not knowledge or skill. There was generally
agreement about the most useful methods but uncertainty about methods that are not useful at all. In
service education was suggested by many as one way in which to gain a greater level of knowledge
about the most efficient and effective positioning and support equipment and the various disease
processes that may contribute to the development of skin damage.
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Meeting the purpose of the research

The study sought to contribute to the ways of preventing pressure ulcers in the operating rooms. In
order to do this an interpretive ethnographic account of the knowledge of pressure ulcer prevention
was constructed. Nurses principally informed the content and structure of the ethnographic account
of their patient care. The body of the literature that related to the research was used to establish the
background and need for the study. This complimented the actions and words of nurses. Within the
ethnographic account, the voices and actions of the nurses were made clear allowing the nursing
voice to be clearly heard throughout the process and account of the study.

Addressing the research question

The aim of the study was to guide the way in which the research question was addressed, and the
manner in which the questions were formulated. The research uncovered a nursing contribution that
suggested that nurses could play a significant role in the care of patients in the operating room and
importantly, in the prevention of pressure ulcers. Knowledge and skills about pressure reducing
equipment, risk assessment tools and practices based on evidence, not on personal beliefs or myths,
contribute to nursing care in the operating room environment. There are other more basic ways of
demonstrating care to patients, these aspects are often overlooked in one way or another.

In the perioperative environment the opportunities for care are somewhat restricted. There is so
little time to develop any real interpersonal relationships with patients and the limited understanding
of the nature of care by others has alienated perioperative nurses from the mainstream accounts of
nursing in the profession. All this contributing to the specialty as one that is technically driven and
task-orientated (Magee 1991, Sandelowski 2000). It is often suggested that these nurses fail to
understand and demonstrate their roles appropriately and importantly, convince many critics of the
need for them in the environment.

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Riley & Manias (2002) argue that an analysis of operating room nurses could perhaps shed a
different light on the specialty. That would require these nurses to highlight the skills, practices and
knowledge that occurs as part of the everyday working life of those nurses, that could distinguish it
from other specialty areas of nursing.

Burchiel (1995) believes that perioperative nurses practice very similar to a cook following a recipe,
only in this scenario it is the parts of a surgical procedure that is planned, if not planned in advance
and nurses acquired the skills and knowledge then there is a possibility that the cake will not rise, or
at worse discarded. A recipe that fails for the surgical patient will in all probability have
catastrophic results. If perioperative nurses do more than simply bake a cake then they need to
demonstrate the uniqueness of their caring for the surgical patient.

Focusing on caring requires the nurse to be acutely aware of the international components of
practices. In a setting where technical skills are valued, it is so easy to loose sight of patient needs in
seeking to meet deadlines.

Advocacy, for the perioperative nurse clearly fits into the definition of caring for these nurses.
Actions such as keeping the patient warm, covered, speaking and touching, are all good signs.
However there are many opportunities these nurses should consider that would go some way to
demonstrate the uniqueness of the role. Hankela and Kiikkala (1996) believe some aspects of caring
are common sense and easily implemented.

speaking and actively listening to the needs and concerns of patients

addressing them by name, never referring to the patient as a surgical procedure

touch them when they are awake and touch them gently when anaesthetised

provide a warm friendly, relaxed atmosphere on reception

inform the patient about what is happening, and talk to them frequently, guiding
them through all the stages of the experience

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plan for the care to ensure the equipment will not harm the patient, and involve them
in decisions

review and amend the care if required

always consider the patient as a family member.

Patients have little to say about their perioperative care. The short time before anaesthesia
commences, when patients are awake, can be crucial to the whole process of the perceptions of
nursing care (Leino-Kilpi & Vuorenheimo 1993).

Unfortunately little research has been conducted in this specialty setting. The few that have, have
focused on the nurses role in the patients psychological and physiological changes that are
generally caused by the stress and anxiety of the impending surgery, premedication and fears of the
outcome of the surgery. From results it appears that good nursing care in this environment is
defined as the control of patients, their physiological changes and the prevention of post-operative
complications (Hankela & Kiikkala 1996).

The constant cry from nurses today is there is no time. This must be reconsidered and accepted,
the caring aspects of patient care given the priority the patient should expect. Burchiel (1995, p. 257
258) believes it is time for nurses to listen to what the patients perceptions of caring are. She asks
the question what would an outcome statement of perioperative caring look like? If there are
no critical pathways, then they need to be developed, how would they be expressed in terms of
perioperative caring? She goes on to state that if perioperative nursing includes caring, where is
the evidence of a theoretical base. For her these are the challenges for the specialty that are essential
for demonstrating the necessity of the nurse in providing patient care (Burchiel 1995, p. 257 258).

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Effectiveness of the research strategies

The research strategies employed to conduct this research combined rigorous ethnographic methods
with a hermeneutic philosophical basis. They provided a pragmatic, workable set of research tools
and facilitated the engagement of key hermeneutic concepts that included the fusion of hermeneutic
circle, dialogue, prejudice and the horizons.

Data collection and analysis methods in the study included:

observations of the nurses at work and field notes

interviews and the production of verbatim transcripts

maintenance of a research journal incorporating a reflective journal, fieldwork

journal and research log

a staged process of the analysis

The observations in the field provided descriptions of clinical practice. The journal provided a
forum in which the prejudices and bias could be documented and later considered. It also provided a
log of activities, and a tool to assist with the enquiry. Data was categorised so that it could be sorted
into a manageable process, while still retaining data as a whole set. The hermeneutic circle provided
the forum for the intuitive and intellectual exploration of the data.

Ethical dimensions of the research

Writing an ethnography demands that a great deal of care is required in order to clearly represent
the information. In this study this means that the knowledge and skill of the operating room nurses
is being represented truthfully, being careful not to choose what is written and what is not, what
will be divulged and what will not.

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Protecting the rights of patients throughout the observations was imperative, as they were not the
focus of the study. Confidentiality and anonymity was maintained by deleting any information that
could lead to their identity. Wilson (1989) states that participants may feel abandoned and used.
This did not become a problem as the researcher is in constant contact with these participants due to
the nature of their work.

Relevance of the research

Nurses in the operating room have been portrayed as technicians, who lack autonomy and seek
refuge in the myths and rituals frequently found in their practice (Kneedler & Dodge 1991, Bull
2002). Their work is often perceived as one of being a handmaiden to the surgeon, and diminished
to the status of a technician due to the influx of equipment used in surgery today. They need to
change these perceptions to one of legitimate providers of care to surgical patients.

This study has produced an account of perioperative nursing staff that reflects their skills and
knowledge in the prevention of pressure ulcer development. By observing the nurses, and listening
to their answers regarding pressure ulcer prevention it has contributed to the development of text
upon which nurses can reflect about their practice. It also offers a possible platform for the
introduction of an education programme about this important topic.

Limitations
There are some limitations in writing ethnography as it can not hope to address the entity of a
culture. This study applies to one operating room complex, and in other organisations there may be
differences, so this ethnography can not be generalised.

Ethnography is unable to address the total concepts of a culture and this ethnographic study is no
different. The study is significant to the operating room nurses as they seek to protect their patients
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from injury. This study was conducted in a major metropolitan hospital, but may have information
useful to other operating room settings.

This study has provided a brief insight into nursing practices associated with pressure ulcer
prevention in the operating room. Further work is required so that this information can assist nurses
to respond appropriately to the changes of practice required for prevention. The study findings
suggest nurses need to refine their practice and change their management of patient positioning to
ensure quality patient care. It is important also for these nurses to gain the knowledge necessary to
implement evidence-based practice in order to provide optimum care in the specialised
environment. These nurses contribute to patient care and safety and maintain the efficient and
effective running of the surgical team. Unless these nurses are able to provide clear and concise
accounts of their contribution to patient care their role remains questionable. This research provides
one interpretation of the contribution that nurses make in the operating room in the prevention of
pressure ulcer prevention, however further research should include other members of the team.

The major findings of this study are that operating room nurses do not routinely practice ulcer
prevention, as part of everyday practices. Participating nurses were generally shown to have a poor
conceptual understanding of pressure ulcer prevention, which is most likely the result of having
adopted a medical mindset, in order to function within the health care system. This concept is
supported by Bull (2002) as she observed perioperative nurses interactions and behaviours in this
setting. The strongest area of agreement was that high pressure over a long period of time
immobility, shear and friction due to transfers, were the most important contributors to the
development of pressure ulcers.

The focus of the nurses activities was on patients and the provision of instrumentation and
equipment for the surgeon in order for him / her to complete surgical intervention. The operating
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room is an environment where often the nurses role is controlled by medical dominance. This can
be observed when at times there is disagreement about the time taken by the nurse to safely position
the patient for surgery. Surgeons have traditionally led the activities in the operating room, nurses
being firstly employed as housekeepers then later as assistant to the surgeon (McGarvey, Chambers
& Boore 2000).

This study revealed that there is considerable scope for improving perioperative nurses knowledge
of pressure ulcer prevention. A pressure ulcer prevention policy needs to be developed, put into
practice and audited by knowledgeable nurses. Maintaining skin integrity must become a priority
and can only be accomplished through a co-ordinated effort, and only with a co-ordinated effort can
any real change occur in this critical patient outcome. Unless perioperative nurses are
knowledgeable about their contemporary practices, and able to provide clear and concise accounts
of them, they remain vulnerable to outside influences.

Drawing upon shared common meanings about the everyday aspects of operating room nursing, has
created the foundation for this study, and will also provide the catalyst for future enquiry into
patient care provided in the specialty.

These include but are not limited to:

documentation which identifies patients at risk,

development of a policy and protocol for patients attending the operating room for a
surgical procedure,

education, crucial for the maintenance of a preventative program,

review of operating table mattress selection process, and replacing with the most up
to date over a planned budget capability,

periodic auditing of mattresses,

evaluation of any ongoing process for monitoring, assessing and intervention.

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Nurses, who have chosen to care for patients in the operating room environment, belong to a unique
culture, and it is this that affects the way in which these nurses experience their daily work. Their
work is largely invisible and routine, generally not well acknowledged by others, and also by
themselves. They do however, believe that their work and the role they play in the specialist
environment, is essential and important for patient care. Unless these nurses are knowledgeable
about their contemporary practices and can provide a clean account of them, their practice will be
vulnerable to outside influence, and their future uncertain. Operating room nurses must state and
demonstrate their contribution to patient care in this specialised environment, and confront the
challenges of the customary images of these nurses as subservient technologists.

Evaluation of the Research Process

One of the critical aspects to ethnography is winning the confidence of the culture to allow
observation and conversation to take place. The study sought to contribute to the nurses knowledge
and skills in relation to pressure ulcer prevention in the perioperative environment. In order to
demonstrate that the purpose of the study has been achieved, the aim of the study will be addressed.

The study sought to capture the complex every day working lives of the nurses who work in the
specialised environment.

The body of the literature that related to the research topics was used to establish the background
and need for the study and to compliment the actions and conversations of the nurses. Voices and
actions were made clear within the ethnographic account through the utilisation of collected field
notes and extracts of the interviews. Observations in the field and the taking of notes provided
concrete descriptions of daily activities and nursing care associated with pressure ulcer prevention
practices.

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Summary of the Research Portfolio

The portfolio comprises two pieces of work, both pertaining to the prevention of pressure ulcer
development in the perioperative environment. The role of the nurse is integral to the success of the
patients surgical experience, but the success depends greatly on the level of skill and knowledge of
the nurse in the prevention of pressure ulcer development.

Operating room nurses are no different from their colleagues who work in other areas providing
nursing care, they have a responsibility to ensure that patients receive individualised optimal care
(Burls & Milne 1996). All nurses involved in providing patient care need to be accountable for the
effectiveness of that care (Popay & Williams 1998). In the current healthcare environment where
there is a continual focus on economic constraints and demand for services, the focus of healthcare
has shifted to outcomes rather than input and from traditional rituals to care that is based on
decisions made on sound evidence (Burls & Milne 1996). This evidence can be attained through the
conduct of a systematic review (Sackett, Rosenberg, Muir Gray, Hayes & Richardson 1996). The
research in this portfolio aimed to identify the effective pressure ulcer prevention practices and
determine the nurses level of skill and knowledge in the prevention of pressure ulcers in the
perioperative environment.

The first piece of research in this portfolio is a critical review of the literature pertaining to studies
that investigated the most effective composition of materials used to manufacture operating room
table mattresses that significantly reduce the incidence of pressure ulcer development in patients
undergoing a surgical procedure. The critical review process used a methodological, predetermined
plan, to appraise, synthesise and summarise the findings of the primary research on an area of
interest or topic (Evans & Pearson 2001). It proved to be difficult to conduct a systematic review
due to a lack of rigorous research in this area. For this reason a critical review was conducted.
Although it is not possible to make clear recommendations that either of the two mattresses
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identified in the review is more effective than the other, it is possible to recommend that an audit be
conducted of their condition, and they are replaced on a regular basis. This critical review did
highlight the lack of quality research in this area, and the need for further research into this topic
that should include the effectiveness of other available mattresses.

The second piece of research in this portfolio was directed to the perceived skill and knowledge of
nurses in the prevention of pressure ulcers in the perioperative environment. The aim of this study
was to examine to what degree pressure ulcer prevention was incorporated into the clinical practice
of nurses working in the perioperative environment. This was accomplished through the use of
accepted techniques of ethnography, beginning with the observations of nurses followed by
interviews with eight nurses from all the specialties of Anaesthetic, Recovery Ward and the
Operating rooms. The participant interviews were used to further elucidate the data. The data was
then analysed using a method based on that used by Spradley (1980), which is one of a cultural
domain analysis.

The major finding of this study is that pressure ulcer prevention is practiced by perioperative nurses,
but is not consistent or well planned. An analysis of the participant interviews backed by the
conclusions drawn from observations of other nurses in the clinical setting, reveal that often the
greatest constraints to pressure ulcer prevention is a lack of the most effective equipment, a
perceived lack of skills and knowledge of the nurse, and a hierarchy of power. The nurses who
participated in the interview process demonstrated their concern for the problem by the simple act
of a wish to be involved. These nurses displayed uniformity in knowledge about the problem and
the inhibitory influences that can periodically arise when attempting to initiate pressure prevention
strategies. However what was spoken about did not generally match observed behaviour of these
and other nurses towards patients. This lack of caring and criticism of the perioperative nurse, are

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perhaps clearly demonstrated when nurses in the research setting wait for the first patients of the
day to be received into the surgical environment.

Patients arrive for surgery from the wards and other areas, to find there will be some delay to the
commencement of their surgery because the surgeon or anaesthetist has been delayed for one reason
or another. The patient is approached by the nurse allocated to the reception area who proceeds to
check the documentation and confirm patient details and consent. The ward nurse remains until this
is completed, then returns to the ward area. Nursing staff allocated to assist the surgeon, anaesthetist
congregate in the reception area are waiting for them to arrive. They talk amongst themselves,
rarely approach the patients, communicate with them or demonstrate any concern for their anxiety.
The nurses remain isolated from their patients, even those who they will shortly escort to the
operating room. No assessments of the patients skin or enquiries about pre-existing pressure ulcers
is confirmed.

Recommendations
This study has provided an insight into perioperative nursing practice in the prevention of pressure
ulcers. Unless these nurses are knowledgeable and skilled, and can provide an account of their
contribution to patient care, their practice may be questioned and they will remain vulnerable to
outside influences. More importantly they need to demonstrate their own worth to be able to
confront the challenge and participate in the future of the specialty. Nurses in this specialised
environment contribute extensive technical skills and knowledge that is embedded in an ethos of
care.

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There have been some important factors that have emerged from the findings in this study:

an assessment of the patient pre-operatively in order to plan appropriate care and identify
patients at risk.

ongoing education for nurses in order to remain abreast of best practice. In service
programmes are important to address perceived knowledge deficits, and increase or maintain
competency

the development of a pressure ulcer prevention policy. This should reflect the commitment
of the environment to preventative management for all patients.

evaluation of the prevention programme and the policies. This is essential to determine the
effectiveness of an implemented policy and protocols. The evaluation should be part of an
ongoing process of monitoring, assessing and intervention.

The conclusion to be drawn from this research is that further investigations need to be conducted
into the effectiveness of other operating room table mattresses in use today and several areas where
education and changes to nursing practice need to urgently be discussed.

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Where to from here?

Perioperative nurses care for patients throughout all phases of their surgical experience, some
nurses are employed as an anaesthetic nurse, as an instrument / circulating nurse, or recovery room
nurse; in designated emergency operating rooms or rooms allocated for elective surgery. All
environments require the nurse to assimilate large amounts of information rapidly and
instantaneously, and then react with skill and precision, and many of their decisions are dependent
upon the patients condition, and the nurses skill and knowledge.

Caring for the surgical patient requires a commitment to remain abreast of new advances and
protocols that result in quality outcomes for patients. Perioperative nurses collaborate with other
health care professionals to ensure these outcomes. This same collaboration with all members of the
team, is required when considering any form of pressure reducing strategies within this
environment.

For too many years these expensive and painful complications have been largely ignored, and the
entire problem managed by nursing staff. Theaker (2002, p. 163) states that evidence of their
existence can be traced back to the days of Pharoahs when Egyptologists from the British Museum
examined the embalmed body of a Priestess of Amen and discovered pressure sores on both
buttocks and shoulders. If the prevention of these ulcers is to be considered seriously, it is both
necessary and mandatory that all staff support, and be involved in, any prevention programme. A
prevention programme must incorporate risk assessment and current perioperative treatments for
pressure ulcers. However, without knowledge nurses may be unaware of appropriate interventions,
be able to identify risks, or assessment findings indicative of pressure ulcers.

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The implementation of pressure ulcer prevention strategies should be part of everyday patient care.
OCallaghan (2001), believes
the future directive of nursing practice dictates that nurses can ill afford
to ignore the economical, ethical, humanitarian and legal implications which
command adherence to the principles of evidence based nursing.

Pressure ulcer prevention is not well demonstrated in the study setting. Whilst it would be incorrect
to state that it was not incorporated into patient safety and positioning, the researcher believes that
because of a lack of formalised commitment to pressure prevention, any implementation of
prevention strategies is varied and dependent upon individual nurses beliefs or ideas. Routines and
rituals to some degree still rule over research activities (OCallaghan 2001). The situation could be
greatly improved if standardised systems for assessing patients at risk of developing pressure ulcers
were used.

Other important factors that have emerged from the findings of this study is that there are degrees of
commitment, and knowledge of, pressure ulcer prevention. In order to re-dress this, it is planned to
use the results of the study in order to ensure that maintaining skin integrity becomes a priority in
the service. This will be proposed at a major staff meeting. Other strategies are to:

meet with the study participants who stated an interest in being involved in any
further developments associated with the topic.

collaborate with this group, develop a risk assessment tool to be used as part of the
checking system when patients enter the reception area. This information would
remain with the patient throughout their surgical experience.

develop standards for patient positioning, adapted from the ACORN Standards for
Perioperative Nurses (2004).

ensure that the service is included in the snap-shot of pressure ulcers conducted in
the hospital.

continue to communicate with manufacturers of mattresses on their products and

obtain the research that their product is focussed on.

115

Develop a reporting system so that the ward reports earlier skin trouble in surgical
patients. This will allow a review of the patient management and equipment used,
providing an evaluation of practice and the equipment.

The perioperative nurses knowledge of risk factors, causes, and prevention of skin breakdown both
within and outside of the perioperative environment is critical in predicting potential problems.
Accurate pre-operative and post-operative skin assessments are essential for documenting
incidence. Early detention of skin changes by these nurses may enhance early treatment and
preventative measures to reduce further complications from surgical procedures.

The relationship that perioperative nurses have with patients is principally concerned with ensuring
the safety of patients through the stages of the perioperative experience. The constant struggle
between managing the technological equipment and the activities required to ensure the physical
and psychological support is the one that brings most of the criticism about the real need for their
existence. Those nurses have minimum time with their patients before they are anaesthetised, but it
was observed that within the study setting, those patients entering the environment because of the
need for a specialist surgeon, or severe trauma situations, were treated differently. Concern for their
well-being was generally well demonstrated. Criticisms such as these about a lack of knowledge
and skill in the prevention of pressure ulcers in the perioperative environment do little to reduce the
destructive comments about the specialty. The challenge for those nurses now is to confront the
criticisms and deficits in knowledge, review practice, and seize the opportunity to demonstrate that
they do play a major role in providing nursing care to the surgical patient.

116

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129

Appendix 1 - Tool 1
THE BRADEN SCALE FOR PREDICTING PRESSURE SORE RISK
Patients Name_______________________
SENSORY PERCEPTION

Ability to respond meaning

fully to pressure-related
discomfort
MOISTURE
Degree to which skin is exposed
to moisture
ACTIVITY

Evaluators Name _______________________________

1.
Completely Limited
Unresponsive (does not moan, flinch,
or grasp) to pain stimuli, due to
diminished level of consciousness or
sedation.
OR
Limited ability to feel pain over most
of body.
1.
Constantly Moist
Skin is kept moist almost constantly
by perspiration, urine, etc.
Dampness is detected every time
patient is moved or turned.
1.
Bedfast
Confined to bed.

Degree of physical activity.

MOBILITY
Ability to change and control
body position.
NUTRITION

1.
Completely Immobile
Does not make even slight changes
in body or extremity position without
assistance.

Date of Assessment _______________

2.
Very Limited
Responds only to painful stimuli.
Cannot communicate discomfort
except by moaning or restlessness
OR
Has a sensory impairment which
limits the ability to feel pain or
discomfort over of body.
2.
Very Moist
Skin is often, but not always moist.
Linen must be changed at least once
a shift.

3.
Slightly Limited
Responds to verbal commands, but
cannot always communicate
discomfort or the need to be turned.
OR
Has some sensory impairment which
limits ability to feel pain or
discomfort in 1 or 2 extremities.
3.
Occasionally Moist
Skin is occasionally moist, requiring
an extra linen change approximately
once a day.

4.
No Impairment
Responds to verbal commands. Has
no sensory deficit which would limit
ability to feel or voice pain or
discomfort.

2.
Chairfast
Ability to walk severely limited or
non-existent. Cannot bear own
weight and/or must be assisted into
chair or wheelchair.
2.
Very Limited
Makes occasional slight changes in
body or extremity position but
unable to make frequent or
significant changes independently
2.
Probably Inadequate
Rarely eats a complete meal and
generally eats only about of any
food offered. Protein intake includes
only 3 servings of meat or dairy
products per day. Occasionally will
take a dietary supplement.
OR
Receives less than optimum amount
of liquid diet or tube feeding.

3.
Walks Occasionally
Walks occasionally during day, but
for very short distances, with or
without assistance. Spends majority
of each shift in bed or chair.
3.
Slightly Limited
Makes frequent though slight
changes in body or extremity
position independently.

4.
Walks Frequently
Walks outside room at least twice a
day and inside room for at least once
every two hours during waking
hours.
4.
No Limitation
Makes major and frequent changes in
position without assistance.

3.
Adequate
Eats over half of most meals. Eats a
total of 4 servings of protein (meat,
dairy products per day. Occasionally
will refuse a meal, but will usually
take a supplement when offered.
OR
Is on a tube feeding or TPN regimen
which probably meets most of
nutritional needs.

4.
Excellent
Eats most of every meal. Never
refuses a meal. Usually eats a total of
4 or more servings of meat and dairy
products. Occasionally eats between
meals. Does not require
supplementation.

1.
Very Poor
Never eats a complete meal. Rarely
Usual food intake pattern.
eats more than _ of any food offered.
Eats 2 servings or less of protein
(meat or dairy products) per day.
Takes fluids poorly. Does not take a
liquid dietary supplement.
OR
Is NPO and/or maintained on clear
liquids or IVs for more than 45
days.
FRICTION & SHEAR
1.
Problem
2.
Potential Problem
Requires moderate to maximum
Moves feebly or requires minimum
assistance in moving. Complete
assistance. During a move skin
lifting without sliding against sheets
probably slides to some extent
is impossible. Frequently slides
against sheets, chair, restraints or
down in bed or chair requiring
other devices. Maintains relatively
frequent repositioning with
good position in chair or bed most of
maximum assistance. Spasticity,
the time but occasionally slides
contractures or agitation leads to
down.
almost constant friction.
Copyright Barbara Braden and Nancy Bergstrom, 1988 (reproduced with permission, April 2000)

4.
Rarely Moist
Skin is usually dry, linen only
requires
changing
at
routine
intervals.

3.
No Apparent Problem
Moves in bed and in chair
independently and has sufficient
muscle strength to lift up completely
during move. Maintains good
position in bed or chair.

Total Score

130

Tool 2
The Norton Risk Assessment Scale
Physical Condition

Mental Condition

Activity

Mobility

Incontinence

Good

Alert

Ambulant

Full

Not

Fair

Apathetic

Walks with help

Slightly limited

Occasionally

Poor

Confused

Chair-bound

Very limited

Usually of urine

Bad

Stuporose

Bed-bound

Immobile

Doubly

Patient at risk with score of 16 or less

Norton Risk Assessment Guidelines

Physical condition encompasses current medical condition and physical health (consider nutritional
status, tissue integrity, muscle bulk and condition of skin)
Good
= stable medical condition, appears health, well nourished
Fair
= generally stable medical condition, appears fairly healthy
Poor

= unstable medical condition, appears healthy

Very bad
= critical medical condition, appears acutely ill
Mental condition encompasses level of consciousness and orientation
Alert
= orientated x 3, aware of surroundings
Apathetic

= orientated x 2-3, dull affect, passive

Confused

= orientated x 1-2, conversation inappropriate at times

Stuporose

=generally unresponsive, lethargic

Activity degree to which is ambulatory

Ambulant
Walks with help
Chair-bound
Bed-bound

= able to walk independently, includes can/walker

= unable to walk without human assistance
= walks only to chair, limited to chair by condition and/or physicians orders
= confined to bed due to condition and/or physicians orders.

Mobility degree to which subject controls and moves extremities.

Full
Slightly

= moves and controls all extremities at will, independent in moving

= able to control and move extremities, but some degree of limitation,
needs assistance to change position.
Very limited
= unable to change position without help, offers minimal assistance
with moving, paralysis, contractures
Immobile
= no ability to move, unable to change position
Incontinence degree to which subject has control of bowel / bladder
Not
= total control of bowel and bladder (exceptions: with diagnostic
test), has Foley catheter and no bowel incontinence.
Occasionally
= has had 1 to 2 episodes of urine/faeces incontinence in 24 hours
(not related to laxatives/enemas), has condom catheter, has Foley
catheter but has continent stools
Usually urine
= has had 3 to 6 episodes of urinary incontinence or diarrhoea stools
in past 24 hours
Doubly
= never able to control bowel and bladder function, has 7 to 10
episodes in 24 hours

131

Tool 3
The Waterlow Risk Assessment Score
0
1
2
3

Build / weight for height

Average
Above Average
Obese
Below Average

Continence
0 Complete / catheter
1 Occasional incont.
2 Cath/incont. Faeces
3 Doubly incontinent

Skin Type and visual risk areas

0 Healthy
1 Tissue Paper
1 Dry
1 Oedematous
1 Clammy
2 Discoloured
3 Broken
Mobility
0 Fully
1 Restfulness/fidgety
2 Apathetic
3 Restricted
4 Traction
5 Chairbound

Sex and Age

1 Male
2 Female
1 14 49
2 50 64
3 65 74
4 75 80
5 >81
Appetite
0 Average
1 Poor
2 NG Tube or Fluids only
3 NBN / Anorexia

Special Risks:
Tissue Malnutrition:
8 Terminal cachexia
5 Cardiac Failure
5 Peripheral vascular disease
2 Anaemia
1 Smoking
Neurological Deficit
Diabetes
M.S.
C.V.A.
Motor / Sensory paraplegia

Major Surgery / Trauma

4-6

Orthopaedic
Below waist spinal
OR > 2 hours

Medication
Steroids
Cytotoxics
Score: >10 At Risk; >15 High Risk; >20 Very High Risk

High dose Anti-inflammatories

132

Appendix 2

OPERATING ROOM SERVICES

An invitation to all perioperative nurses

Would you like to be part of a research project that is investigating the

knowledge and skills of operating room nurses in regard to pressure
ulcer prevention in the perioperative environment?

Interested staff should contact:

Judith Berry
Ext: 25548 or
Email:

jberry@mail.rah.sa.gov.au

133

Appendix 3
Information sheet accompanying the consent form

A study exploring the Operating Room Nurses knowledge and skills of Pressure Ulcer Prevention

Investigator: Judith Berry, RN, BN, MngSc.

I am a Doctor of Nursing student undertaking research at the University of Adelaide. The purpose of
this study is to uncover aspects of nursing knowledge about pressure ulcer prevention in the in the
operating room. The significance of this study is that despite an abundance of information and
publications about the development and prevention of pressure ulcers, spanning many years, little has
changed, and these ulcers continue to be a problem for many patients. The study will be conducted in
a metropolitan hospital in South Australia and will include both observation of the nurses at work in
the operating room and interviews with nurses who consent to be interviewed.
Observations will be conducted over a four-month period and will occur on early, late or night shifts. I
will always ask your permission before I observe you and you may withdraw that permission at any
time.
Information will also be gathered through interviews and will be tape recorded. I will conduct the
interviews at a time and a place suitable to you. This could be in the work setting, at your home or
mine for example. The initial interview will last approximately 1 hour, the second interview (if
needed) will last approximately 30 minutes. During the interviews you will be invited to discuss
operating room nursing from your practice perspective. Tapes will then be transcribed and your name
and any identifying information will be delated at this time. Following this I will send you a copy of
the transcript for your interest and validation. At all times the principle of confidentiality will be
observed.
You are free to stop the interview and/or withdraw from the study at any time even though you
have given consent to participate.
If you have questions regarding this research study please contact:
Judith Berry
Residential Wing
Royal Adelaide Hospital
I can also be contacted at work on 08 8222 5548 or email me at jberry@mail.rah.sa.gov.au
If you have any concerns regarding this research study please contact me as above or my supervisor:
Dr Helen McCutcheon, RN, PhD
Department of Clinical Nursing
University of Adelaide
Adelaide SA 5000
Phone: 08 8303 3637

134

Appendix 4
ROYAL ADELAIDE HOSPITAL

RESEARCH ETHICS COMMITTEE

CONTACTS FOR INFORMATION ON PROJECT AND INDEPENDENT COMPLAINTS

PROCEDURE

The Human Research Ethics Committee is obliged to monitor approved research projects. In
conjunction with other forms of monitoring it is necessary to provide an independent and confidential
reporting mechanism to assure quality assurance of the institutional ethics committee system. This is
done by providing research subjects with an additional avenue for raising concerns regarding the
conduct of any research in which they are involved.
The following study has been reviewed and approved by the Royal Adelaide Hospital Research Ethics
Committee:
An exploration of the ways in which operating room nurses care for their patients:
An interpretative focused ethnography based in Gadamerian Hermeneutics.
(now entitled: A study exploring the Operating Room Nurses knowledge and skills of Pressure
Ulcer Prevention)

1.

If you have any questions or problems associated with the practical aspects of your
participation in the project, or which to raise a concern or complaint about the project, then you
should consult the project co-ordinator.
Name: Dr Helen McCutcheon, RN, PhD
Department of Clinical Nursing
University of Adelaide
Adelaide SA 5000
Phone: 08 8303 3637

2.

If you wish to discuss with an independent person matters related to:

Making a complaint, or
Raising concerns on the conduct of the project, or
The University policy on research involving human subjects, or
Your rights as a participant
Contact the Research Ethics Committees Secretary on telephone: 8303 4014.

135

Appendix 5
Consent form
THE ROYAL ADELAIDE HOSPITAL
STANDARD CONSENT FORM
See also Information Sheet attached
1.

I,
(please print name)
consent to take part in the research project entitled:
A study exploring the use of pressure prevention equipment in the operating room.

2.

I acknowledge that I have read the Information Sheet entitled:

A study exploring the use of pressure prevention equipment in the operating room.

3.

I have had the project, so far as it affects me, fully explained to my satisfaction by the research
worker. My consent is given freely.

4.

Although I understand that the purpose of this research project is to improve the quality of
nursing care, it has also been explained that my involvement may not be of any benefit to me.

5.

I have been informed, that while information gained during the study may be published. I will
not be identified and my personal results will not be divulged.

6.

I understand that I am free to withdraw from the project at any time and that this will not affect
medical advice in the management of my health, now or in the future.

7.

I am aware that I should retain a copy of this Consent Form, when completed, and the relevant
Information Sheet.

Name ..

Signature / date

WITNESS
I have described to ... (name of subject)
The nature of the procedures to be carried out. In my opinion she/he understood the explanation.

Name ..

Signature / date

STATUS IN PROJECT: investigator

136

Appendix 6
INTERVIEW QUESTIONNAIRE

What sort of equipment do you use that appears to be the most effective and efficient items for
pressure ulcer prevention in the operating room?

How do you consider the needs of your patients in regard to pressure ulcer prevention?

What sorts of things make you think about implementing pressure ulcer strategies for your patients?

Tell me what you think about our practices in terms of pressure ulcers.

Are there any ways we could do things better?

137

Appendix 7
PATIENT DATA SHEET

PATIENT NAME:

Age

Sex

UR:

Obese / fat / normal / thin / physically weak

Date

The nurse;1.

Checked the OR table for proper functioning. clean, brakes on, clamps for attachments
available.
yes
no

2.

Assembled required positioning aids pillows, pads, head ring, Mayfield Headrest, stirrups.

3.

Padding
Foam clean, at least two inches thick
Water-filled glove

y Gel filled clean, not repaired

y Other

Mattress
Foam, gel-filled, spenco, other
Clean

y With overlay gel-filled, egg crate foam, other

y Undamaged
y Repaired

4.

5.

Skin integrity assessment conducted prior to surgical invention

yes

no

6.

Operating room nurse inspected patients heels, elbows, sacrum

Reviewed case notes
y Asked ward nurse / patient about condition
of skin

7.

Patient admitted to the operating room with existing skin damage existing pressure ulcer,
grade 1 2 3 4, discolouration, breakdown, bruising, redness yes
no

8.

Tissue padding applied to bony prominences / pressure sites, heels, elbows, sacrum, scapula,
head, other yes
no

9.

Documented the patients skin condition pre and post operatively, and other relevant
information for recovery room and ward staff.
yes

no

COMMENTS:

138

Appendix 8
DEMOGRAPHICS OF STAFF INTERVIEWED

Gender

Age

20 24
25 29
30 34
35 39
40 49
50 59
55+

Basic Training
Hospital
University

Degree

RN

Number of years qualified

15
5 10
10 15
15 20
20 25
25 30
30+

139

Appendix 9

ACORN CRITERIA FOR POSITIONING OF PATIENTS

POSITIONING THE PATIENT FOR SURGERY

ACORN believes that safe positioning for and during surgery, and in the immediate post-operative
period, minimises the risk of and prevents unnecessary surgical complications.
The patients surgical outcome is influenced by the use of a position which provides the surgeon with
optimal access to the surgical site while allowing the anaesthetist to access intravenous lines and
monitoring devices, yet does not compromise the patients respiratory function or normal body
alignment.

STANDARD 1
An assessment of the patient shall be made before the patient is transferred to the operating
table.

Criteria
The perioperative nurse, in consultation with the surgeon, anaesthetist and other multidisclipinary team
members shall:
1.1. assess pre-existing condition, disease processes and physical limitations;
1.2. evaluate skin condition and integrity
1.3. monitor the pressure area rating score (if applicable); and
1.4. consider patient and surgical factors, including:
1.4.1 age
1.4.2 height
1.4.3 weight
1.4.4 nutritional status
1.4.5 procedure type
1.4.6 position requested.

140

STANDARD 2
All personnel involved in positioning the patient shall have knowledge of the position required,
the equipment needed, the anatomical implications of the position and the physical limitations of
the patient.

Criteria
The multidisciplinary team shall have full knowledge of the types and uses of positions for surgery.
These include the following and their modifications:
2.1.
supine
2.1.1. Trendelenburg
2.1.2. Reverse Trendelenburg;
2.2.
Lithotomy
2.3.
Prone
2.3.1. Jackknife or Kraske
2.3.2. Knee-chest
2.3.3. Seated prone (as used in spinal disc surgery);
2.4.
Lateral
2.4.1. Flexed lateral
2.5.
Sitting
2.5.1. Semi-sitting

STANDARD 3
The position to be used shall be communicated to all relevant team members.

Criteria
The perioperative nurse shall:
3.1
ascertain the position required from the surgeon
3.2
confirm the position required with the anaesthetist, and
3.3
advise other relevant team members of the required position.

STANDARD 4
Equipment required to achieve the necessary position shall be available in the operating room
prior to the commencement of patient positioning.

Criteria
The perioperative nurse shall:
4.1
consult with the surgeon and other team members as to the equipment needed;
4.2
check the equipment for cleanliness and function prior to use;
4.3
check that positioning equipment is the correct size for the patient, or is adjusted accordingly,
and
4.4
ensure that suitable pressure relieving devices and equipment are used.

141

STANDARD 5
During positioning and the operative procedure, the patient shall be monitored for body
alignment and skin integrity.

Criteria
The perioperative nurse and the mutlidisciplinary team shall;
5.1
ensure that the patient is moved in a safe and careful manner;
5.2
ensure that there are adequate personnel to perform a safe transfer;
5.3
check the patients position prior to commencement of surgery to ensure that no body systems
are compromised, and
5.4
recheck the patient if any repositioning of either the patient or the operating table takes place
during the procedure.

STANDARD 6
During all phases of the positioning process, patient and staff safety shall be considered.

Criteria
The perioperative nurse shall:
6.1
identify safety considerations for each patient position;
6.2
prevent dislodgment of items such as catheters, drains and tubes during positioning;
6.3
minimise the exposure of the patient during positioning to avoid heat loss and preserve dignity,
and
6.4
give due consideration for personal safety and the safety of team members during positioning
of the patient by:
6.4.1 using correct lifting techniques;
6.4.2 ensuring sufficient personnel are available, and
6.4.3 using the correct equipment.

STANDARD 7
The patient shall be appropriately positioned for the post-anaesthesia period at the completion of
surgery.

Criteria
The perioperative nurse shall:
7.1
ensure adequate personnel and equipment are available for the safe transfer of the patient onto
the bed or trolley.
7.2
safely return appendages to normal position, and
7.3
check the patients skin integrity and documents any alterations.

142

STANDARD 8
All aspects of patient positioning shall be documented in the patients perioperative record.

Criteria
The perioperative nurse shall:
8.1
document the position(s) used;
8.2
include a written description of the patients skin integrity before and after the procedure;
8.3
record the location of any equipment applied to the patient, and
8.4
notate the use and type of pressure management devices or equipment, if used.

REFERENCES:
Gruendemann, B.J. & Fernsebner, B. 1995, Comprehensive Perioperative Nursing, vol. 1, Jones & Bartlett, Boston
REFERNCE: A17

Authorised by the ACORN Board

Current Issue: May 2002

143

Appendix 9
ACORN CRITERIA FOR MAINTAINING A STERILE FIELD
ASEPTIC TECHNIQUE
Aseptic technique is the practice utilised by perioperative personnel to minimise the patients risk of
exposure to exogenous microorganisms while the bodys natural defences are breached during surgery
or other procedures.
Aseptic technique is used for activities within and around the sterile field. The sterile field includes the
area immediately surrounding the draped patient, the sterile surgical personnel, sterile draped
instrument tables and equipment.
Activities to prepare, create and maintain a sterile field include the wearing of proper theatre attire,
correct hand washing methods, gowning and gloving methods, correct selection and use of surgical
drapes and sterilisation of surgical instruments. Other activities within the operating room which
impact upon the maintenance of asepsis include adequate traffic control and environmental cleaning.
ACORN believes that all personnel (nursing and non-nursing) participating in a surgical procedure are
responsible for maintaining asepsis within the sterile field, as the patients surgical outcome is
influenced by their knowledge and application.
This standard should be used in conjunction with the ACORN Standards for:
Counting of Accountable Items Used During Surgery
Disposal of Surgically Removed Human Tissue and Explanted Items
Environmental Management in Perioperative Settings
Perioperative Suite Attire
Reprocessing of Reusable Items: Cleaning, Packing, Sterilisation and Storage of Sterile
Supplies
Surgical Scrubbing, Gowning and Gloving.
STANDARD 1
Personnel with a sterile field shall wear sterile gown and gloves
Rationale
To minimise the risk of patient exposure to exogenous microorganisms when the bodys natural
defences are breached during surgery.
Criteria
The perioperative nurse and other scrubbed personnel shall:
1.1
have a thorough understanding of the requirements for the creation and maintenance of
a sterile field;
1.2
complete an approved method of surgical handwash;
1.3
wear sterile gown and gloves;
1.4
immediately change sterile gloves whose integrity has been compromised, and
1.5
immediately change sterile gowns which become contaminated.
144

STANDARD 2
Items used within a sterile field shall be sterile.

Criteria
The perioperative nurse and other members of the surgical team shall:
2.1
treat articles with suspect integrity or sterilisation indication as non-sterile;
2.2
consider the surgical gown sterile only in the areas from mid-chest to waist level in the front,
and from elbows to the glove cuffs;
2.3
be aware that the draped sterile field incorporates only the horizontal surfaces of the patient or
instrument tables;
2.4
consider that areas of drapes or surgical supplies which fall below this horizontal line to be non
sterile, and
2.5
consider sterile items placed onto a dirty surface (eg floor or sink etc) to be unsterile.
Note:

Cleaning, packaging, sterilisation, handling and storage of sterile articles shall be in

accordance with the appropriate ACORN and Australian Standard AS4187:1998.

STANDARD 3
All items introduced onto a sterile field shall be opened, dispensed and transferred by methods
that maintain sterility and integrity.

Note:

In the event of an emergency procedure, and the instrument nurse is unable to take

items by hand, some items may be flipped into a sterile bowl, placed specifically for this purpose.

Criteria
3.1
The circulating nurse shall:
3.1.1 inspect all sterile items prior to opening, to verify the integrity of the packaging
and that a sterilisation process has been completed;
3.1.2 consider the edges of sterile packaging to be non-sterile once the package is open;
3.1.3 place and open rigid containers with heavy items on a separate surface;
3.1.4 open the wrapper fold furthest away first, the sides next and the nearest last, when
an item is wrapped in a linen or other wrapper, and
3.1.5 secure all open wrapper edges to avoid contamination when sterile items are
presented to the sterile field.
3.2

The instrument nurse shall:

3.2.1 receive items using a method that maintains sterility;
3.2.2 ensure sterile items are not left unattended once opened, and
3.2.3 ensure instrument tables are set up immediately prior to the surgical procedure.
145

STANDARD 4
Sterile drapes shall be used to create and maintain a sterile field.

Rationale:
Drapes are barriers that minimise the passage of microorganisms between non-sterile and sterile fields.

Note:

All textiles for use as surgical drapes shall comply with the appropriate Australian

Standards AS3789.2 and AS3789.6.

Criteria
The perioperative nurse shall:
4.1
establish an effective aseptic barrier by the proper positioning of sterile drapes, and:
4.1.1 ensure sterile drapes be placed on the patient, furniture and equipment to be included
in the sterile field,
4.1.2 ensure that sterile draping is only performed by scrubbed personnel,
4.1.3 form a cuff of the sterile drape over the gloved hands to reduce the risk of potential
contamination;
4.2

ensure that surgical drapes are handled appropriately to minimise potential contamination of
the surgical site, and:
4.2.1 ensure drapes are folded to enable ease of application,
4.2.2 minimise movement and handling of the sterile drapes,
4.2.3 carry the drapes folded to the operative site, holding them high enough to avoid
contamination, draping from the incision site to the periphery,
4.2.4 ensure that once drapes are positioned, they are secured to prevent movement;

4.3
4.4

prevent contamination and strike-through from fluids, as drapes are sterile only when dry, and
discard drapes into a suitable receptable positioned close to the sterile field utilising standard
precaution policies.

STANDARD 5
The sterile field, once established, shall be constantly monitored.

Criteria
The perioperative nurse shall:
5.1
ensure that sterile fields are prepared as close as possible to the time of use;
5.2
secure surgical equipment to the sterile field with non-perforating devices;
5.3
ensure that equipment introduced to or over the sterile field shall be covered appropriately with
sterile drapes, and
5.4
ensure that sheaths/sleeves for instruments and equipment, are not used as a substitute for
cleaning and disinfecting procedures as per AS4187:12.5.
146

STANDARD 6
Movement of personnel and equipment within or around the sterile field shall be minimal and
deliberate in order to maintain the integrity of the sterile field.

Criteria
6.1
Scrubbed personnel shall:
6.1.1 touch only sterile draped surfaces,
6.1.2 move draped tables by placing hands on the horizontal surfaces only,
6.1.3 face the sterile field at all times; if movement is to occur within the sterile field,
scrubbed personnel shall pass back to back or front to front, and
6.1.4 avoid altering the level of the sterile field and be seated only when the operative
procedure is to be performed at that level.
6.2

Unscrubbed personnel shall:

6.2.1 avoid leaning over the sterile field,
6.2.2 maintain appropriate distance from the sterile field at all times (approximately
30cms),
6.2.3 refrain from moving between two sterile fields, and
6.2.4 move sterile draped equipment by holding vertical uprights below the level of the
drape.

STANDARD 7
All movement within the operating room shall be kept to a minimum.

Rationale:
Excessive movement causes increased air movement and microbial shedding is a potential source of
microorganisms that can contaminate the surgical field.
Criteria
The perioperative nurse shall:
7.1
monitor activity in the operating room;
7.2
ensure that all doors to the operating room remain closed except for the movement of staff,
equipment and the patient, and
7.3
limit the number of personnel in the room to only those required to safely undertake the
procedure.

147

STANDARD 8
The flow of clean and sterile supplies and equipment shall be separated from contaminated
supplies, equipment and waste.

Rationale:
The use of appropriate procedures for the transportation of items to the operating rooms will preserve
the qualities of the sterile and clean environment.
Criteria
The perioperative nurse shall:
8.1
ensure that the flow of supplies moves from the clean area, through the operating room to the
external corridor;
8.2
ensure that soiled supplies, instruments and equipment are not moved back into the clean area;
8.3
place soiled supplies, instruments and equipment within covered containers or vehicles for
movement to the designated decontamination area, and
8.4
ensure that the decontamination area, soiled linen and rubbish areas are separated from
personnel and patient traffic areas.

________________________________________________________________________________________________
REFERNCE: A2
Authorised by the ACORN Board
Current Issue: May 2002

REFERENCES:
Association of Operating Room Nurses 2001, Recommended practices for maintaining a sterile field, AORN Journal,
Vol 73, No. 2,pp 477-482.
Associate of Operating Room Nurses 2000, Recommended practices for traffic patterns in the perioperative practice
setting, AORN Journal, Vol 71, No.2,pp 394-396.
Fairchild, S. Perioperative Nursing: Principles and Practice, 1993 Jones & Bartlett, Boston.
Hind, M & Wicker, P. 2000 Principles of Perioperative Practice. Churchill Livingstone.
Meeker, M.H. & Rothrock, J.C. 1999, Alexanders Care of the Patient in Surgery, 11th edn, Mosby, St. Louis.
Infection Control Today, 07/2000: Asepsis and Septic Practices in the Operating Room,
http://www.infectioncontroltoday.com/articles/071best.html

148