1

Background

Every year, approximately 310 million surgical procedures take place worldwide , resulting in a surgery rate of 1 in 25 individuals. The operating room, sometimes referred to as the hospital’s core, is a vital and costly component of a medical facility. The operating room is well recognized as a highly hazardous setting where surgical procedures are conducted by a collaborative surgical team utilizing specialized equipment and tools. The primary objective of every member of a surgical team, which includes the surgeon, perioperative nurse, and anesthesia, is to deliver efficient treatment and ensure the patient’s safety. Any individual’s failure within this team has a direct impact on the overall success of the surgical procedure.

Surgical complications are a major contributor to patient mortality and disability on globally. Several factors affect the outcomes obtained from surgical procedures, and one of these factors is the Missed nursing care (MNC). Missed care refers to the failure to carry out necessary care tasks for patients, either partially or completely. MNC has adverse effects on patient outcomes, such as hospital-acquired infections, pressure injuries, falls, discharge planning, mortality, patient mobilization, feeding, and psychological and emotional support. ^, Failure to provide necessary care compromises patient safety. Across the world, the prevalence of neglect in nursing care ranges from 10 % to 50 %.

Perioperative nurses play a vital role in coordinating the responsibilities of all members of the surgical team. They conduct thorough surgical safety checks to confirm the correct patient and surgical site before any procedure. Additionally, they administer and verify intravenous medications, maintain the sterility of equipment, and monitor the sterile field throughout the operation. Perioperative nurses also closely observe the patient during both the intraoperative and postoperative periods. These actions are crucial for ensuring patient safety during the perioperative process, which includes the preoperative, intraoperative, and post-anesthetic care phases. Despite their critical role, perioperative nurses often face significant challenges in the operating room environment. These include high levels of stress due to time constraints, the complexity of surgical procedures, and the need for constant vigilance to prevent errors. The requirement to collaborate effectively with multidisciplinary surgical teams, manage emergencies, and adapt to rapidly changing clinical conditions adds to their operational workload. Furthermore, resource limitations, such as insufficient staffing or lack of necessary equipment, exacerbate these challenges. The cumulative effect of these pressures may lead to missed perioperative nursing care, compromising patient safety and overall care quality.

Missed perioperative nursing care (MPNC) refers to occasions where certain components of nursing care that were supposed to be supplied are unintentionally ignored or not carried out as intended. MPNC in the operating room is a critical issue that can lead to severe adverse effects on patients, including infection, delayed wound healing, pain, discomfort, anxiety, depression, loss of trust in the healthcare system, and increased treatment expenses. ^, Furthermore, this problem contributes to job burnout and increases the likelihood of operating room nurses leaving their positions. Since approximately 40 % to 60 % of all adverse events in hospitals occur in the operating room, it can be inferred that instances of missed care are more prevalent during surgical treatments.

Numerous studies have been conducted in Iran regarding MNC; however, these investigations have primarily focused on other nursing units, such as emergency departments and general surgical wards, while the operating room remains largely understudied. Existing research has reported varying levels of MNC, ranging from minimal to alarmingly high, indicating a concerning inconsistency in findings. Given this research gap and the conflicting data MNC, there is a clear need for national and regional studies across various hospital units, particularly in the complex and dynamic environment of the operating room. This study aims to explore the prevalence and characteristics of MPNC from the viewpoints of perioperative nurses in Iran.

2

Methods

2.1

Study design and participants

This cross-sectional study was done on 733 perioperative nurses from August 2023 to January 2024 in 20 teaching hospitals of Iran. The sample size was obtained as 670 based on the findings of Ahansaz et al. with standard deviation of 4.87 and d (margin of error)=0.369, using the formula:

<SPAN role=presentation tabIndex=0 id=MathJax-Element-1-Frame class=MathJax style="POSITION: relative" data-mathml='n≥(Z1−α/2d)2′>𝑛≥(𝑍1−𝛼/2𝑑)2n≥(Z1−α/2d)2
n≥(Z1−α/2d)2

Considering a 10 % attrition rate, the final sample size was adjusted to 744 participants.

Data were collected from university teaching hospitals across the country, with 20 hospitals randomly selected using quota sampling a multistage randomized method aimed at increasing generalizability.

The medical science university teaching hospitals in Iran was categorized into five regions: north, south, east, west, and central. From each region, four hospitals were randomly selected. Iran has a total of 150 teaching hospitals, and from this number, 20 were chosen at random for the study. The sample size for each hospital was then calculated based on the number of perioperative nurses employed in each facility relative to the overall sample size. In these hospitals, subjects were selected using a stratified sampling method based on the number of perioperative nurses, utilizing their identification numbers. then, the link of online questionnaires was sent to them through social media. If a nurse declined to participate, another nurse from the same department was randomly chosen. Out of the 744 eligible nurses, three declined to participate. A total of 741 individuals submitted completed surveys. However, eight surveys were removed due to incomplete responses, resulting in 733 questionnaires available for analysis ( Fig. 1 ).

Flow chart for the selection of participants.

The study’s inclusion criteria required participants to meet the following conditions: 1. A minimum of one year of work experience in the operating room, either as circulating or scrub personnel. 2. An associate’s degree or higher in nursing or a related operating room discipline. 3. The ability and willingness to complete the questionnaire and provide informed consent. Additionally, the exclusion criteria encompass: 1. Failure to fully or partially complete the questionnaire and provide informed consent. 2: experiencing persistent physical or mental disease as reported by the individual.

3

Results

The demographic findings of the study indicated that out of 744 distributed questionnaires, 733 were eligible for inclusion, resulting in a response rate of 98.52 %. The mean age of the participants was 30.58 ± 7.10 years. Among the 733 perioperative nurses, 239 (32.6 %) were male and 494 (67.4 %) were female. The majority of participants were married (56.5 %) and held a bachelor’s degree (79.9 %). The complete demographic characteristics are presented in Table 1 .

The findings regarding MPNC showed that the overall mean were 7.36 ± 6.3‏ (range: 0 to 32), indicating a low level of missed care ( Table 2 ). Additionally, as illustrated in Fig. 2 , among the various domains of MPNC, the communication had the highest mean score of 0.27 (range: 0 to 1), followed closely by the legal requierment with a score of 0.26 (range: 0 to 1). In contrast, the closure routine with 0.15 had the lowest mean score.

Table 2

Mean ± SD and correlation between the dimensions of Missed Perioperative care and demographic characteristics ( n = 733).

								Communication				Legal				Preparation				Safety							closure routine				Total MPNC	p
Gender	Female				0.24±0.2				0.23±0.2				0.20±0.2				0.13±0.2				0.13±0.2			6.37±5.7				P=0.003 t =−5.91
				Male				0.34±0.2				0.31±0.3				0.31±0.2				0.22±0.2							0.22±0.2				9.41±6.8
Marital status	Single				0.26±0.2				0.28±0.2				0.26±0.2				0.12±0.1				0.12±0.2			7.42±5.9				P=0.907 t =0.11
				Married				0.28±0.2				0.24±0.2				0.22±0.2				0.19±0.2							0.17±0.2				7.36±6.5
Educational Level		Associate				0.28±0.2				0.20±0.2				0.21±0.1				0.20±0.1				0.07±0.2			6.80±4.6				P =0.333 F=1.1
				Bachelor				0.28±0.2				0.27±0.2				0.25±0.2				0.15±0.2							0.15±0.2				7.53±6.5
				Master				0.20±0.2				0.18±0.1				0.19±0.1				0.20±0.2							0.25±0.3				6.45±6.7
Work Experience			<5				0.26±0.2				0.31±0.2				0.24±0.2				0.12±0.2				0.12±0.2			7.20±6.9				P < 0.001 F=13.3
				5–10				0.34±0.1				0.22±0.1				0.30±0.2				0.26±0.2							0.31±0.3				9.34±5.8
				>10				0.25±0.2				0.19±0.2				0.18±0.1				0.15±0.1							0.06±0.1				5.93±4.6
Age			<25				0.31±0.3				0.34±0.3				0.23±0.2				0.15±0.2				0.14±0.2			7.91±7.7				P = 0.013 F=4.33
				25–35				0.27±0.2				0.23±0.2				0.26±0.2				0.17±0.2							0.19±0.3				7.59±5.8
				>35				0.24±0.2				0.22±0.2				0.19±0.1				0.16±0.1							0.05±0.1				6.05±5.0

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