Operating room nurses' experiences of skin preparation in connection with orthopaedic surgery: A focus group study

Background: Preoperative skin preparation is performed differently by different operating room nurses. Aim: To deepen the understanding of skin preparation within an orthopaedic surgical setting from the operating room nurse perspective and to explore their experiences. Methods: A qualitative exploratory design was used. Four focus group interviews were conducted during 2016 – 2017, at four hospitals in Sweden, using procedures developed by Krueger and Casey. A total of 19 operating room nurses were recruited through purposive sampling. Results: Statements were categorized into four categories of experiences: (1) Knowing, which related to learning and sources of knowledge; (2) Doing, which related to skin preparation and activities based on tradition and evidence; (3) The Team, which related to the assignment of responsibility and collaboration with patients and other professions; and (4) The Setting, which related to factors around the patient and included feelings of time pressure and access to supplies. Conclusions: Theory and practice differ, and some skin preparation used are based on tradition rather than on evidence or recommendations. Elements both within the team in the operating room and within the organization influence the result. Operating room nurses' duty to perform safe skin preparation must be respected in the team.

• The procedures used deviate from manufacturers' recommendations and available guidelines.
• Several skin preparation methods are based on traditional routines that lack scientific support.

What this paper adds?
• Skin preparation is mostly taught and learned in a traditional manner, and a knowledge/practice gap exists.
• The organization, the team, the patient and the availability of supplies influence the performance and results of skin preparation.
• A rising demand for keeping up with productivity made operating room nurses concerned for patient safety.

The implications of this paper:
• To provide safe care, skin preparation needs to be based on evidence.
• To ensure patient safety, management and head nurses must address the insufficiency of resources, the most prominent of which is insufficient time for the assessment and performance of careful skin preparation to prevent surgical site infections.

| INTRODUCTION
Surgical site infections (SSIs) are the most frequent hospital-acquired infections in developing countries and the second most frequent in Europe and the United States (World Health Organization [WHO], 2018.SSIs cause excessive health care costs: in the United States alone, SSIs contribute to patients spending more than 400 000 extra days per year in hospital, at a cost of an additional $10 billion per year (WHO, 2018).SSIs are a major, yet often preventable, threat to patient safety and cause patient suffering, morbidity and mortality (Badia et al., 2017;Brown, Tanner & Padley, 2014;Zimlichman et al., 2013).SSIs associated with orthopaedic surgery may cause physical limitations, additional surgery and a decrease in healthrelated quality of life (Andersson, Bergh, Karlsson, & Nilsson, 2010;Darouiche, 2004).
The prevention of SSIs is complex and requires targeted efforts before, during and after surgery (Berríos-Torres et al., 2017).The pathogens that most frequently cause SSIs in surgery derive from the endogenous microbiotic skin flora of the patient or the health care staff (Li, Guo, Ou, Dong & Zhou, 2013;Uçkay, Hoffmeyer, Lew & Pittet, 2013).Skin preparation is performed to decrease the bacterial colonization at the surgical site, even though the scientific evidence that it decreases SSIs is not fully proven (WHO, 2018).
A previous survey among orthopaedic surgery departments concluded that skin preparation interventions differ greatly.Evidencebased practice (EBP) was not always followed, and the procedures used deviate from manufacturers' recommendations and guidelines (Markström & Bjerså, 2015).Nursing practices within skin preparation intervention may be based on traditions that do not have scientific support (Rassool, 2005).The discipline of patient safety has coordinated efforts to prevent errors and adverse effects for patients caused by the provision of health care itself (WHO, 2017).Within this project, we have approached patient safety in the operating room (OR) setting from the perspectives presented in The Competencies for Nurses publication from the Quality and Safety Education for Nurses (2018).However, OR nurses' experiences of skin preparation to prevent SSIs have not been extensively studied.Consequently, skin preparation performed by OR nurses should be further explored to identify ineffective or unsafe health care practices.

| Aim
The aim of this study was to deepen the understanding of skin preparation within an orthopaedic surgical setting from OR nurses' perspective and to explore their experiences.

| Design
A qualitative exploratory semistructured interview study design, according to Krueger and Casey (2015) following the consolidated criteria for reporting qualitative research (COREQ) guidelines, was used.

| Sample
The inclusion criteria were practicing, registered OR nurses, working within an orthopaedic surgical setting.Heads of departments performing orthopaedic surgery at nine Swedish hospitals were contacted: three university hospitals, two regional hospitals and four minor hospitals.Four of the heads of these OR departments (two regional and two minor hospitals) agreed to participate.Study information was distributed with the help of a nurse with a management position at each department.We used a purposive sampling strategy based on the size of the hospital and on the gender, education level, length of professional experience and age of the personnel to obtain a broad range of experience.All OR nurses at each hospital received a letter that described the study aim and procedures and a request whether the OR nurse agreed to participate.

| Data collection
Interviews with four focus groups were conducted between January 2016 and February 2017.A semistructured interview guide was developed and tested in one pilot focus group.This interview was included as focus group interview number one because only minor changes were made to the interview guide after this interview (Table 1).It also generated rich data in line with the aim of the study.
Further three focus group interviews were conducted.The interviews were free flowing, guided by the interview guide.A picture of an OR nurse performing skin disinfection was placed on the table in front of the informants during the interviews as stimulus material (Figure 1; Wibeck, Dahlgren & Öberg, 2007).Finally, a short summary was given at the end of each interview, and the OR nurses were given the opportunity to confirm the summary (Krueger & Casey, 2015).
Interviews with focus groups were performed in a neutral conference room, in close connection with the informants' workplace and working hours.The first author served as moderator for all interviews, and the third and the last coauthors served as assistant moderators in two interviews each.The assistant moderator supported the moderator, took notes, observed the interaction, posed probing questions and assessed the moderator's interviewing technique.Both the moderator and assistant moderators had experience of working in the perioperative environment.The observations of the assistant moderator were discussed in a debriefing immediately after each interview, and a short report was written.The interviews were recorded, lasted between 61 and 77 min and transcribed verbatim by the first author.

| Ethical considerations
The Research Ethics Board at the relevant university approved this study.All informants who participated received written and oral information about the study aim and settings and were informed that participation was voluntary and confidential, with the option to withdraw at any time.Further, the informants were informed that it would not be possible to identify them in any reports.Informed consent was obtained before starting each interview.

| Data analysis
The research group systematically analysed the transcripts, according to Krueger and Casey (2015).Data were collected until it was judged that no new information was obtained.The transcribed interview texts, supplemented by the field notes on group interactions, formed the data on which the inductive analysis was performed.The statements were coded with descriptive names using NVIVO version 11 (QSR International).The coded statements were subsequently compared with other codes and grouped into subcategories and finally categories.Table 2 presents examples of the analysis process.
The main categories that emerged were represented in all focus groups.
The entire study was performed in a systematic manner using standard procedures developed by Krueger and Casey (2015) in order to ensure its trustworthiness.Three coauthors had earlier experience from qualitative research.The validity of the interview was assured by testing the questions in a pilot interview.Additionally, the researchers who acted as moderator and assistant moderators had nursing experience and had insight into the OR setting, which was known by the informants.All were aware of the risk of personal judgement in research in own's field of practice, and this risk was critically and continuously discussed (Lincoln & Guba, 1986).The informants were asked to verify the summary at the end of the interview in order to ensure credibility.Further, the credibility was secured by the first author being involved during all steps of the study.All authors carefully read the entire transcripts to identify statements related to the aim, which further ensured credibility (Krueger & Casey, 2015).Verbatim quotations were used to ensure validity and verify the categorization.This study is not intended to generalize, but because it was carefully designed, conducted and analysed, we believe that the results can be transferred to similar contexts (Lincoln & Guba, 1986).

| RESULTS
A total of 19 OR nurses participated in the study, with ages from 29 to 63 years (M = 49, SD = 11).The mean length of service was 21 years (SD = 13).Table 3 presents information about the 19 study participants.
Four categories emerged from the analysis: (1) Knowing, (2) Doing, (3) The Team and (4) The Setting (Figure 2).The first category • What is the first thing that comes to your mind when I say skin preparation?
Transition question: • Would you please tell us how you plan for skin preparation interventions?
Key questions: • Would you please tell us about how you usually perform skin preparation?
• Would you please tell us why you practise the skin preparation you are practising today?
• What is your impression of the products you are using?
• Would you please share your thoughts regarding your work environment and the possibility to work with skin preparation based up on existing guidelines?
Probing questions: • Would you explain it further?Can you give us an example?How do you think about that?
Summary questions: (First, the moderator gives a short oral summary) • How well does the summary captured what was said here today?
• Is there something you would like to discuss further or add to the discussion?
concerns knowledge of skin preparation and includes the subcategories Learning in education and Sources of knowledge.Abbreviation: OR, operating room.

| Knowing
Skin preparation was experienced as consisting of fundamental procedures for which the OR nurses had received knowledge and skills mainly from their courses and clinical practice.When new knowledge was obtained, it was primarily from colleagues and from local or a national clinical guideline.

| Learning in education
Knowledge was primarily acquired during the nurses' courses, but lit-

| Sources of knowledge
Although both national and local clinical guidelines for skin preparation were available and familiar to most of the OR nurses, they were seldom or never consulted.
I would say that it is inherited (Informant 2, Interview 4) Other sources of knowledge were more experienced colleagues, discussions at professional meetings, students, nurses specialized in hygiene and medical product representative specialists.
The participants had limited access to scientific research and considered that the member's journal of the Swedish Operating Room Nurses Association was an important source of evidence-based knowledge.The informants expressed a desire to receive regular Operating room nurses experience of skin preparation feedback on infection rates to ensure the development of their skills and knowledge.

| Doing
Doing comprised two subcategories: The skin preparation process, in which the informants described the performance of skin preparation interventions, and skin preparation according to evidence and local routines.

| The skin preparation process
First, the condition of the skin was assessed.The patient's medical records were usually reviewed, searching for information that concerned the patient's skin, such as diseases, test results and hypersensitivity or allergy.Informants emphasized the importance of making notes in the medical records regarding skin condition.
… if there is a diabetic, higher infection risks, then maybe you really think one more time if something is going to be affected, or like cortisone, yes as it gives fragile skin (Informant 5, Interview 2) Talking to the patient, when possible, was experienced as beneficial.Visual inspection included the location of the incision and its size.
Fragile skin, dirt, eczema, spots or wounds were considered to increase the risk for SSIs.The surgeon was consulted if skin abnormalities were observed.A sterile medical dressing could be used to cover minor skin abnormalities.
Body hair was experienced as increasing the risk of SSIs and delaying wound healing, and the need for hair removal was always thoroughly assessed.If hair interfered with the procedure of the adaption of drapes or wound dressings, it was removed with single-use clippers.Some informants highlighted the importance of hair removal as close to the time of incision as possible to avoid skin injuries and bacterial colonization.
Local cleaning of the surgical site with chlorhexidine gluconate (CHG) soap (4%) was another intervention described, called by the informants 'prewash' or 'local wash'.Some assumed this to be even more important than the skin disinfection, whereas others considered it to be a complement to the preoperative shower.Some OR nurses perform this cleaning procedure on all their patients for 1 to 3 min, whereas others just use it for certain procedures or in the absence of a preoperative shower.The soap lather was either wiped off with paper or left on the skin to dry.
Conversation Interview 4: The informants described that CHG was used as first-choice antiseptic, although alcohol or sodium chloride was sometimes used for specific procedures and for patients with allergy.To avoid cross contamination of the prepared area, it was necessary to be aware of how the CHG would flow.The informants described that they started at the area of the incision, and one swab at a time was drawn along lateral or medial lines over the area.The skin disinfection proceeded by gradually decreasing the area, from the periphery to the centre.If the surgery included a less clean area, the informants started the preparation process from the cleanest to the least clean area.Coloured CHG was sometimes used for certain surgical procedures to help visualization of the disinfected area.Estimation of the duration of the skin disinfection ranged from 2 to 10 min.
Informants considered it to be important to leave the CHG to dry, but some OR nurses routinely wiped the surface dry at locations where they planned to attach the drapes.CHG could also be wiped off if the nurses felt under stress, in case of emergency surgery, or if they were not able to determine whether the skin was completely dry.The estimated drying time for CHG ranged between 1 and 7 min.
After the incision had been sutured, informants performed postoperative skin disinfection/cleaning with chlorhexidine, alcohol (70%) or sodium chloride.Even though the OR nurses were aware of the risk of bacterial colonization, the primary reason for this disinfection was to improve the attachment of the dressing.

| Skin preparation according to evidence and local routines
Informants found it impossible to work in accordance with evidence all the time and described their profession as challenging and complex.
Skin preparation was experienced as based on scientific evidence in general.However, proven knowledge and clinical traditions were trustworthy sources of information.The informants stated that preoperative skin preparation such as preoperative showering was performed less often than prescribed by guidelines.They justified this by a lack of strong evidence for the efficacy of the procedures.The deviation from guidelines, however, led the informants to express worries about SSIs.OR nurses requested further strong scientific research on the efficacy of prewash, the optimal amount of time between hair removal and incision, postoperative skin disinfection and whether wiping wet CHG off increases the risk of SSIs.

| The Team
Skin preparation performed to prevent SSIs was a central task for the OR nurses and a unique responsibility in the OR team.Collaboration with the patient and the other professions in the team influenced the performance.

| The responsibility of OR nurses
OR nurses experienced skin preparation to be one of the most important assignments they have.The OR nurses were the only profession with aseptic responsibility in the OR team.In particular, skin preparation in connection with orthopaedic surgery must be strictly carried out.
Usually, the OR nurses were able to perform careful skin preparation, although most of them had experienced limited respect from the team for their assignments.Deviations from hygiene regulations by the team were common.
More experienced informants could be more determined concerning control over their responsibility and could empower less experienced colleagues to be more resolute.
When you have worked with this for a while, you have the possibility to put your foot down; this is my decision!It is harder for younger colleagues quite new I believe and stressed as they are not keeping up … but you have to support them so that they get their time … (Informant 2, Interview 3)

| Collaboration around skin preparation
OR nurses must collaborate with the patient and the OR team.The OR team generally consisted of circulating nurse assistants, anaesthesiologists, anaesthetic nurses and surgeons.Communication with the presurgical unit and the ward was also important.
The final outcome of the skin disinfection depended on the actions taken before surgery.These, in turn, depended on the preoperative information and availability of assistance for the preoperative shower specified in the guidelines.Other professions could make decisions about the amount of skin preparation before surgery.
Yes, it was the anaesthetist who decided this.We use the same (skin preparation) for all [patients] (Informant 2)

| The Setting
The setting around the patient influenced the informants' work with skin preparation, as did also feelings of time pressure.Availability of supplies and the use of public procurement for these had an impact on the range of products available and the way in which the OR nurses worked.

| Time
Due to productivity requirements, the informants were required to work in parallel with other surgical preparation.They felt that the time available for the assessment and performance of skin preparation was insufficient.The focus on enhanced productivity aroused concerns for patient safety.
If they want to carry on, well, "OK feel free", but then it may be the case that we have to wake up the patient

| Supplies
The products used for skin preparation were experienced as safe and efficient.Assistive devices, such as patient lifts, were required to ensure adequate skin preparation for most orthopaedic surgery procedures.
Purchase of products was subject to the provisions of a public procurement process.Customized procedure packs with procedurespecific surgical supplies influenced the selection of products for a particular procedure.

| DISCUSSION
This study provides new information about aspects of the performance of skin preparation.The outcome of interventions performed to prevent SSIs was influenced by surrounding factors.OR nurses found it challenging when faced with clinical routines they were unable to generalize and relate to the theory-related knowledge acquired during their education.In order to change the current local learning pattern towards one that is more EBP, it will be necessary to solve this mismatch between theory and practice.This will be possible if students learn to use research as a basis for clinical decision making (Goodfellow, 2004).
Routine skin preparation is performed using practices that do not comply with guidelines or evidence.The clinical practices used are so rooted in tradition that they are resistant to change.These practices persist even though using EBP can improve the quality of care and cut costs (Hanrahan et al., 2015).This is incongruous-practice continues to follow tradition despite evidence that such practices are not optimal.From our perspective, we find it inconceivable that OR nurses knowingly continue to use clinical practices that may harm patients.
Factors that promote the acceptance of EBP are the provision of adequate support, resources and education.Organizations must develop educational programmes to promote EBP and must employ strategies to overcome barriers to implementation (Malik, McKenna & Plummer, 2016).
The informants in our study routinely wiped off CHG, despite current recommendations that it should air-dry completely.This confirms the result of a previous Swedish study in which 34% of OR nurses wiped CHG off the skin prior to draping (Wistrand, Falk-Brynhildsen & Nilsson, 2018).This activity might influence bacterial colonization, but this risk has not been investigated.In contrast to the present study, that of Wistrand et al. (2018) found an overall high compliance with national guidelines among OR nurses.
The OR team consists of personnel with different professions and personalities, which makes it necessary that OR nurses have good cooperation and communication skills (Gillespie, Chaboyer, Wallis, Chang & Werder, 2009).Coe and Gould (2008) showed that different professions in the OR setting may lack understanding and may work towards different goals in the care of the patient.Our findings agree with those of a previous study in which only 23% of OR nurses believed they received the respect that a person of their profession deserves (Prati & Pietrantoni, 2014).Tensions in team communication in the OR are often related to time, safety, efforts to maintain an aseptic environment and work roles (Lingard, Garwood & Poenaru, 2004).It is important for teamwork that the members of the team share the same goal.A previous Swedish study has shown that communication failures in the OR setting may be explained by differences in activity orientation between professions and the provision of insufficient support from social and organizational structures (Rydenfält, Johansson, Larsson, Åkerman & Odenrick, 2012).OR nurses are the only members of the OR team with responsibility that the procedure is aseptic, and deficient knowledge among other team members may explain why the OR nurses' work receives inadequate respect.We suggest clear directives for each profession and that information initiatives are carried out to provide insight into the responsibilities of other team members.
Earlier findings have shown that 'the pressure to work more quickly' is the most stressful factor in the OR (Vowels, Topp & Berger, 2012).The informants interviewed in the present study experienced stress and time pressure that led to worries for patient safety.
It has previously been reported that a focus on productivity influences both ethics and workplace safety in care environments, with higher rates of accidents (Browne, 2009;Clarke & Cooper, 2004).OR administrators should act to eliminate stressful factors such as physical and mental strains in the work environment (Kaye, Fox, & Urman, 2012).
The responsibility and knowledge of the OR nurses regarding infection prevention and preoperative skin preparation are essential for preventing SSIs, and no other profession in the OR team shares these responsibilities or skills.To ensure patient safety, OR nurses need time for careful assessment prior to anaesthesia, as well as time for the careful performance of skin preparation and evaluation of performance.

| Limitations
One aspect that must be considered is whether the selection of participants was biased.It was difficult to recruit five to eight participants for each focus group.However, smaller groups with three to five participants may be more suitable when the discussion is to concern specialized experiences.Such groups enable a deeper insight into the studied area to be obtained and ensure the validity of the conclusions (Krueger & Casey, 2015).It is possible that obtaining the assistance of a person in a management position with the recruitment of informants influenced the findings because it was not possible to ensure that the groups contained informants with a wide range of experiences.A second aspect that must be considered is the willingness of informants to express their opinions.The participants in a focus group may not express their own definitive individual views.The assistant moderators observed and supported the moderator and encouraged the informants to be clear, which increases the reliability of the results.

| CONCLUSION
Even if the OR nurses have unique knowledge and responsibility for skin preparation in the OR team, elements both within the team in the OR and within the organization influence the result.Using traditionbased nursing practice in preference to EBP may jeopardize patient safety and increase the risk of SSIs.
Hence, it is important that the OR nurse learn, both during education and when new in profession, how to use research as a basis for clinical decision making, with a consensus in perspective between academy and clinics.Further, the support from elder colleagues is essential.Proper safe skin preparation requires time to assess the patient, perform skin preparation and evaluate.
Head nurses and OR administrators should organize teamwork in order to support OR nurses for proper and safe skin preparation.OR nurses must be respected by the team for their responsibility to perform standardized evidence-based skin preparation.
Future studies on the different types of skin preparation are needed to give OR nurses the ability to perform the safe, evidence-based skin preparation on patients undergoing all types of high-risk surgery.

•
Please tell us your name and where you work and what do you most enjoy with your work?Introductory question: tle attention was paid to theory.It was not until clinical training that skin preparation was fully introduced, and the knowledge gained was mostly by learning from colleagues: 'See one, do one'.… some teaching and then you have been taught by a bunch of different tutors and then you have been imitating.In the beginning, you are an apprentice … (Informant 2, Interview 1) Skin preparation theory and practice studied in their education programme differed from the routines practised in the OR.
Maybe it's time to highlight what the studies are telling us.Too many things are done a certain way just because that's how it's always been, and no one is questioning it (Informant 2, Interview 2) Thus, most of the OR nurses had knowledge of CHG functions, and they were aware of the need to wait for CHG to dry completely.Nevertheless, they did not follow existing evidence, and informants at all the participating clinics routinely wiped wet CHG off by a sterile towel.
given the time I need to be able to carry out my work, in the best possible way, then … that risk arises.(Informant 4, Interview 4) Informants had been taught that skin preparation should be performed swiftly.If the anaesthetic preparations and induction had been too time consuming, some OR nurses felt a need to catch up on lost time.Inexperienced informants were more affected by time pressure than the more experienced.…cause when you are completely new, of course it is a slow pace and then it could be stressful that someone is standing and waiting and you know it is you that is late … (Informant 2, Interview 2) Feelings of time pressure could occur in connection with emergency surgery and in cases in which a team member needed to hold a heavy body part during the skin disinfection.Another situation that the nurses experienced as causing time pressure was when team members started to dismantle the OR after suturing and before the OR nurses had covered the wound.