2018.a safety simulation program for operating room nurses

Featured Article
A Safety Simulation Program for Operating Room
Nurses
Mi Young Lee, RNa
, Sang Suk Kim, PhD, RNb,*
a
Associate Professor, Seoul National University Hospital, Seoul 03080, Republic of Korea
b
Associate Professor, Red Cross College of Nursing, Chung-Ang University, Seoul 06974, Republic of Korea
KEYWORDS
compliance;
operating room;
safety attitudes;
safety awareness;
simulation training
Abstract
Background: A safety program is required for nurses in operating rooms, where accidents are frequent.
Method: A nonequivalent control group preepost design was used, with convenience sampling. Data
were analyzed using chi-square, Fisher’s exact, and ManneWhitney U tests.
Results: Safety attitudes (p ¼ .012) and compliance with safety management (p ¼ .001) differed
significantly between experimental (27, safety simulation program) and control (22, lecture-type
safety education) groups, but awareness of the importance of safety management did not
(p ¼ .17). Associations were observed between variables (r ¼ 0.455-0.837).
Conclusion: The safety simulation program was effective and useful.
Cite this article:
Lee, M. Y., & Kim, S. S. (2018, May). A safety simulation program for operating room nurses. Clinical
Simulation in Nursing, 18, 6-13. https://doi.org/10.1016/j.ecns.2017.12.005.
Ó 2018 International Nursing Association for Clinical Simulation and Learning. Published by Elsevier
Inc. All rights reserved.
The modern medical community provides medical ser-
vices with cutting-edge medical equipment and highly
professional medical knowledge based on scientific de-
velopments. However, death because of medical error has
the third highest overall mortality rate in America, and an
annual death rate of 134,581 hospitalized patients was
recently reported (Makary & Daniel, 2016). The provision
of unsafe medical services not only affects patients’ lives
by causing physical injury (Berwick & Hackbarth, 2012)
but also leads to emotional stress, depression, and guilt in
medical professionals (Hobgood, Hevia, Tamayo-Sarver,
Weiner, & Riviello, 2005).
Patients undergoing surgery are exposed to high risk, as
operating rooms (ORs) are complex environments that
involve the administration of invasive treatments and
anesthesia; use of the latest equipment and scientific
technology; and communication difficulties resulting from
the establishment of temporary interprofessional teams,
including surgeons, anesthesiologists, OR nurses, and
anesthesia nurses (Steelman, Graling, & Perkhounkova,
2013). OR nurses work in environments in which accidents
are highly likely to occur because of rapid changes to surgi-
cal settings and duties. Accidents may result from segmen-
tation, specialization, heterogeneous interdependent
decision-making agents, computerization of medical re-
cords, surgical instruments, and equipment. In addition, a
sharp increase in the complexity of surgery because of sur-
gical advancement and technological improvement is one of
Clinical Simulation in Nursing (2018) 18, 6-13
www.elsevier.com/locate/ecsn
Funding: This research did not receive any specific grant from funding
agencies in the public, commercial, or not-for-profit sectors.
* Corresponding author: kss0530@cau.ac.kr (S. S. Kim).
1876-1399/$ - see front matter Ó 2018 International Nursing Association for Clinical Simulation and Learning. Published by Elsevier Inc. All rights reserved.
https://doi.org/10.1016/j.ecns.2017.12.005

the causes of accidents (Gibbs, 2012; Plsek & Greenhalgh,
2001; Spruce, 2013; Taylor, 2014). According to previous
studies, 82.2% of OR nurses have experienced incidents
in relation to patients’ safety (Jang, Kim, Seok, Oh, &
Kim, 2014), including medical equipment malfunction,
counting discrepancy, spec-
imen loss, patient injury,
pressure ulcers, retention of
surgical items, and wrong-
site surgery, in the OR
(Gibbs, 2012). Therefore,
OR nurses are required to
ensure organized and sys-
tematic management of pa-
tient safety during surgery.
Accordingly, saf-
ety education programs are
needed as they not only pro-
vide safety-related knowl-
edge but also exert a
positive effect on error pre-
vention and management
(Hwang, 2015).
Previous research on
safety education for OR
nurses has included an e-
learning education program
to prevent nursing errors
(Kim, Kim, & Hwang,
2005). A case-based multi-
media learning program
has been developed to pre-
vent malpractice in ORs
(Park, 2015). However,
these research studies were limited as they did not include
feedback for nurses or did not consider hands-on
experience.
The simulation programs used in recent nursing educa-
tion are considered an effective learning strategy for OR
nurses who work in dangerous environments. The simula-
tion is implemented in a safe environment, in which nursing
care is provided via a team-based approach (Mullen &
Byrd, 2013) and improves communication, teamwork
(Dedy, Bonrath, Ahmed, & Grantcharov, 2016), and knowl-
edge maintenance (Madani et al., 2016). Specifically, sim-
ulations that involved standardized patients (SPs) were
shown to exert positive effects not only on nursing com-
petence but also on their problem-solving ability and
communication competence via direct interaction with the
SP (Oh, Jeon, & Koh, 2015; Robinson-Smith, Bradley, &
Meakim, 2009).
Aim
This study aimed to examine the effectiveness of a safety
simulation program involving a standardized patient
(SSPSP) for OR nurses’ safety compliance by exploring
the simulation as a method for teaching safety. The
effects of the SSPSP (experimental group) were
compared with those of lecture-type safety education
(LSE; control group). The specific aims of the study were
as follows:
1. To examine the difference in awareness of the impor-
tance of safety management (AISM) between the two
groups.
2. To examine the difference in compliance with safety
management (CSM) between the two groups.
3. To examine the difference in safety attitudes between
the two groups.
4. To explore correlations between AISM, CSM, and
safety attitudes.
Theoretical Framework
The development and evaluation of the SSPSP were based
on the analysis, design, development, implementation, and
evaluation model.
The analysis phase involves the process of defining
learning content and includes educational needs analysis,
learner analysis, and environment analysis. In this study, we
analyzed OR nurses’ needs regarding safety education, OR
nurses as study participants, and the OR as an educational
environment.
The design phase involves the actualization of the
instructional method in which assessment tools are
developed, with instruction strategies, tactics, and media
chosen based on the importance of performance goals
and instructional content. In this study, we established
the goals (improve AISM, CSM, and safety attitude),
strategies (presentation, discussion, and simulation), and
content of SSPSP education and determined evaluation
strategies.
The development phase involves the process of creating
instructional material that includes the creation of material
after the development of draft instructions and program
modification based on the results of a pilot test. In this
study, we developed modules 1 to 4, trained the SP,
assessed content validity, evaluated a pilot study examining
the SSPSP, and finalized the SSPSP.
The implementation phase involves the process of
implementing the program and includes application of the
developed instructional program, its continuation within the
curriculum, and the management of its maintenance and
modification. In this study, 27 OR nurses participated in the
SSPSP, attended a debriefing session, and shared their
experiences.
The evaluation phase involves the process whereby the
adequacy of the systematic and cyclical instructional pro-
gram is determined (Ozdilek & Robeck, 2009). In this
study, AISM, CSM, and safety attitudes were evaluated
with respect to the effectiveness of the SSPSP.
Key Points
Safety attitudes and
compliance with safety
management (CSM)
differed significantly
between the two
groups, but awareness
of the importance of
safety management did
not.
Awareness of the
importance of safety
managementwassignifi-
cantly correlated with
CSM and safety attitude,
whereas CSM was
significantly corre-
lated with safety
attitude.
The program was
effective in promoting
operating roomnurses’
CSM and improved
their attitudes toward
safety.
A Safety Simulation Program for Operating Room Nurses 7
pp 6-13 Clinical Simulation in Nursing Volume 18

Method
A nonequivalent control group and preepost design were
used to examine differences in CSM, AISM, and safety
attitudes between the experimental group, which parti-
cipated in the SSPSP, and a control group, which received
LSE.
Sample
Convenience sampling was performed to recruit 51 subjects,
including 28 OR nurses from B hospital in the experimental
group and 23 OR nurses from K hospital in the control
group. The inclusion criteria were as follows: employment in
an OR as a scrub/circulating nurse, less than 15 years of OR
experience, and the ability to understand the purpose of the
study. Two subjects withdrew from the study because of OR
duty or personal reasons (dropout rate, 7.6%). Therefore, the
experimental and control groups ultimately included 27 and
22 subjects, respectively.
Instruments
CSM and AISM
An instrument developed by Jang et al. (2008), which was
based on the safety management guidelines of the Asso-
ciation of periOperative Registered Nurses and Hospital
Nurses Association and adapted by Kim and Kim (2011)
to include awareness of safety management and OR per-
formance levels, was used to measure CSM and AISM.
The scale includes 69 items divided between seven do-
mains: specimen management (eight items), prevention of
transmissible infections (13 items), preoperative patient
identification (11 items), electrosurgical unit (seven items),
medical equipment/device (eight items), injury prevention
(eight items), and counts (14 items). Responses are pro-
vided using a five-point Likert scale ranging from 1 (not
important at all) to 5 (very important) for AISM and
from 1 (never done) to 5 (always done) for CSM; higher
scores indicate higher levels of AISM and CSM, re-
spectively. The Cronbach a for AISM was 0.94 in the study
by Kim and Kim (2011) and 0.98 in the present study. The
Cronbach a for CSM was 0.90 in the study by Kim and
Kim (2011) and 0.91 in the present study.
Safety Attitudes
Safety attitudes were measured using the Safety Attitudes
Questionnaire developed by Sexton et al. (2006) for the OR
at the UT Houston Health Science Center. It was translated
into Korean and then back-translated by a bilingual
doctoral nurse. The scale consists of 30 items divided be-
tween six domains: safety climate (seven items), teamwork
climate (six items), working conditions (four items), stress
recognition (four items), perception of management (four
items), and job satisfaction (five items). Responses are pro-
vided using a five-point Likert scale ranging from 1
(strongly disagree) to 5 (strongly agree); higher scores indi-
cate a positive attitude toward safety awareness. Raykov’s p
coefficient for the scale was .90 in the original research
(Sexton et al., 2006), whereas the Cronbach a was 0.95
in the present study.
Ethical Considerations
The study was approved by the appropriate institutional
review board. The subjects received explanations regarding
the study purpose and procedure and provided written
informed consent before initiation of the study. They were
also advised that they could refuse to participate in the
study or withdraw from participation at any time without
penalty. The subjects completed preintervention and post-
intervention self-administered questionnaires.
Procedure
A preintervention survey, the experimental intervention, and
a postintervention survey were conducted between February
and March 2016 to evaluate the effects of the SSPSP on OR
nursing safety. The preintervention and postintervention
surveys were conducted before and immediately after the
program to examine CSM, safety attitudes, and AISM.
The SSPSP for the experimental group consisted of four
modules (Table 1). In module 3, we developed a scenario
involving an orthopedic patient with fractures to both
legs, and this was reviewed by two simulation experts, an
orthopedic doctor, an OR manager, and two OR nurses
with 15 years of experience and then modified according
to their comments. Each team consisted of one SP, one or-
thopedic surgeon, and one nurse (subject). Ten minutes
were allocated for each simulation in the orthopedic OR.
The SP was a woman aged 30 to 40 years (matching the
age and sex presented in the module) selected from among
the SPs at C university simulation center in Seoul, Korea.
The SP was trained though three stepsdreading and ques-
tions and answers about the scenarios; practice and feed-
back by authors; and final practice with two OR nurses.
The SP did not involve evaluation but rather participation
in debriefing and sharing their feelings with OR nurses.
In module 4, a scenario involving a laparotomy case was
developed to demonstrate sponge and instrument counting.
The teams consisted of one orthopedic surgeon and two
subjects playing the roles of a scrub nurse and circulating
nurse. Ten minutes were allocated for each simulation in
the preoperating area. Debriefing sessions lasting 20 to
30 minutes were led by the investigator, using recorded
videos consistent with the debriefing phases described by
Fanning and Gaba (2007), which include description, anal-
ysis, and application. These were presented after the simu-
lations in modules 3 and 4.

The LSE for the control group was presented using an
OR safety PowerPoint presentation, which comprised a
one-hour lecture with the same contents as the lecture for
the experimental group. It was provided by a research
assistant with a master’s degree and 15 years of OR
experience and included the following: (a) the concept of
OR nursing safety; (b) evaluation of medical institutions
with respect to OR safety management; (c) the safety
reporting system; (d) techniques for the analysis of OR
errors; and (e) patient identification, fall prevention, cou-
nting, infection surgery, and communication. The LSE
group also received the SSPSP program after the study was
completed.
Data Analysis
The data were analyzed via nonparametric statistical anal-
ysis, using SPSS 21.0 (SPSS, Inc., Chicago, IL). Subjects’
general characteristics were analyzed using descriptive
statistics, whereas between-group homogeneity was assessed
using chi-square, Fisher’s exact, and ManneWhitney
U tests. Analysis of preintervention and postintervention dif-
ferences in the dependent variables between the experi-
mental and control groups was performed using a Manne
Whitney U test, whereas the correlations between variables
were analyzed using Spearman’s correlation coefficients.
Results
Subjects’ General Characteristics
The following general characteristics of the subjects in the
two groups were found to be homogeneous: age, sex, marital
status, educational level, shift pattern, and OR work
experience. Overall, work experience was not homogeneous.
The average ages of subjects in the experimental and control
groups were 31.61 (standard deviation [SD] ¼ 5.57) and
32.91 (SD ¼ 4.03) years, respectively (c2
¼ À1.99;
p ¼ .056). The average numbers of operations for which
nurses in the experimental and control groups provided assis-
tance each day were 4.07 (SD ¼ 1.52) and 4.55 (SD ¼ 2.22),
respectively (c2
¼ À0.88; p ¼ .383). In addition, 59.2% of
Table 1 SSPSP for OR Nurses
Module Educational Topic Educational Content Educational Method Time
1 Concept of OR nursing safety Wrong-site surgery and count
discrepancy videos
Current status of safety-related
incidents and the need for safety
management in the OR
Medical error classification
Patient safety reporting system
Safety management items for
certification assessment
Video Lecture 60 minutes
S-BAR communication techniques
2 Hazard perception training Safety-related case-analysis techniques Lecture
Group activities for OR hazard
perception training
Discussions in small groups
Presentation and discussion Presentation 60 minutes
3 Preoperative patient identification
using a standardized patient
Purpose of patient identification
Accurate patient identification process
Checking surgical site marking and error
handling
Simulation practice 4 hours
Effective communication with medical
teams
Debriefing
Supportive communication with the
standardized patient
4 Counting Counting process
When to count
Simulation practice
Handling incorrect counts Debriefing
Item counting methods
Effective communication with medical
teams
4 hours
Recording counts
Note. OR ¼ operating room; S-BAR ¼ situation, background, assessment, and recommendation; SSPSP ¼ safety simulation program involving a standard-
ized patient.

the subjects in the experimental group had less than 5 years
of OR experience, whereas 59.1% of those in the control
group had 10 years and more of work experience.
Awareness of the Importance of Safety
Management
Preintervention and postintervention differences in the
AISM scores in the experimental group were slightly
greater relative to those observed in the control group,
but the difference between the two groups was non-
significant (Table 2).
Safety Management Compliance
The preintervention and postintervention differences in
CSM scores differed significantly between the experimental
and control groups (Table 3). In addition, the experimental
group’s scores for the prevention of transmissible infec-
tions, perioperative patient identification, electrosurgical
unit, medical equipment, and count were significantly
higher relative to those observed in the control group.
Safety Attitude
The preintervention and postintervention differences in
safety attitudes differed significantly between the
experimental and control groups (Table 4). In addition,
safety climate scores differed significantly between the
experimental and control groups.
Correlations Between Variables
Correlation analysis showed significant correlations be-
tween the three variables. CSM was significantly posi-
tively correlated with AISM (r ¼ 0.837; p .01) and
safety attitude (r ¼ 0.455; p .05). In addition, AISM
was significantly positively correlated with safety attitude
(r ¼ 0.561; p .01).
Discussion
The most prominent feature of the SSPSP was the
provision of direct and indirect experiences of safe
nursing, which exerted positive effects on OR nurses.
The program provided fundamental concepts related to
OR-related patient safety; in addition, it offered OR nurses
opportunities to participate in realistic simulation educa-
tion involving an SP, in which they could communicate
with the patient and develop coping skills for similar
safety-related incidents in clinical settings. The program
improved OR nurses’ perception of safety management
and technical compliance, which could affect patient
safety directly.
Table 2 Awareness of the Importance of Safety Management
Experimental Group (n ¼ 27), M (SD) Control Group (n ¼ 22), M (SD) z p
Overall score 0.09 (0.20) 0.02 (0.14) À1.373 .170
Specimen management 0.01 (0.36) 0.04 (0.18) À0.011 .991
Prevention of transmissible infections 0.25 (0.62) 0.02 (0.35) À1.637 .102
Preoperative patient identification 0.12 (0.35) 0.01 (0.10) À2.281 .023
Electrosurgical unit 0.13 (0.28) 0.02 (0.23) À1.729 .084
Medical equipment/device 0.07 (0.26) 0.03 (0.29) À1.207 .227
Injury prevention 0.00 (0.21) 0.01 (0.30) À0.321 .748
Counts 0.05 (0.18) 0.00 (0.03) À1.501 .133
Note. M ¼ mean; SD ¼ standard deviation.
Table 3 Safety Management Compliance
Variable Experimental Group (n ¼ 27), M (SD) Control Group (n ¼ 22), M (SD) z p
Overall score 0.59 (0.24) 0.28 (0.26) À3.963 .001
Specimen management 0.30 (0.51) 0.15 (0.32) À2.601 .163
Prevention of transmissible infections 0.69 (0.43) 0.25 (0.71) À2.991 .009
Perioperative patient identification 0.34 (0.41) 05 (0.21) À2.991 .003
Electrosurgical unit 0.34 (0.40) 0.05 (0.21) À2.678 .003
Medical equipment/device 0.69 (0.69) 0.14 (0.40) À1.773 .007
Injury prevention 0.38 (0.41) 0.12 (1.39) À1.773 .076
Counts 0.18 (0.30) 0.03 (0.07) À2.082 .037

AISM improved in the experimental group, but the
difference in awareness between the two groups was
nonsignificant. This finding may have occurred because
counting, patient identification, and fall prevention were
recognized as part of the traditional role of OR nurses, and
the control group’s awareness might have been improved
by the safety lecture. In addition, the safety lecture has been
shown to improve awareness in previous studies (Choe,
2014; Kim et al., 2005; Mikail, Hearney, Nemesure,
2003). OR nurses’ safety awareness levels were already
high, as their awareness extended to aspects of nursing
that OR nurses recognized. In addition, the hospitals with
which the subjects were affiliated were certified medical
institutions, and the certification assessment strengthened
patient safety evaluation (Korea Institute for Healthcare
Accreditation, 2014). The subjects showed high levels of
awareness about the importance of safety management as
they had undergone safety management training in the
preparation for this certification assessment. Perception of
hospital accreditation has been shown to affect the quality
of medical care and nursing performance (El-Jardali,
Jamal, Dimassi, Ammar, Tchaghchaghian, 2008).
The results of previous studies examining compliance
and awareness of safety management (Jang et al., 2008;
Jeong, 2013) have shown that levels of awareness were
higher relative to those of compliance, which is consistent
with the results of the present study. In addition, there ap-
pears to be a gap between nurses’ awareness and compli-
ance. A previous study examining levels of OR nurses’
awareness of and compliance with guidelines for standard
infection-related precautions (Kang, Kim, Choe, 2004)
has reported that levels of awareness were higher relative
to those of compliance. Supervision and education strat-
egies appear to be necessary for the transference of nurses’
awareness to implementation.
CSM improved significantly in the experimental group,
particularly with respect to postintervention patient identi-
fication and counting. These improvements appeared to be
related to increases in confidence and performance capa-
bility resulting from the experience of safety management
via participation in the SSPSP, which included preoperative
patient identification and counting. Some nurses in the
experimental group stated that they not only found the
simulation experience fresh and challenging but also
remembered the information because it felt as though
they were talking to a real patient during their interaction
with the SP. This finding is similar to those indicating
improved clinical competence in previous studies using
simulation-based education for nurses (Abe, Kawahara,
Yamashina, Tsuboi, 2013; Kim Kang, 2015; Wolf,
2008; Yu, 2001). Moreover, the context was similar to
that in previous research (Stayt, 2012) involving SPs, in
that nurses’ clinical skill competence improved. Based on
previous findings indicating that safety management activ-
ity was the main factor affecting error rates in ORs (Song,
2015), the SSPSP could contribute to increases in safety
management activities because of improvements in com-
pliance, as was observed in the present study.
Attitudes to safety culture include not only technical
factors that prevent accidents via the identification and
improvement of causes of safety-related incidents but also
leadership that emphasizes patient safety, teamwork
through effective communication, policies and procedures,
efficient workforce management, and error reporting (Kim,
Lee, Oh, 2010). The present study examined not only the
technical aspects of nursing safety but also safety attitudes,
via simulations involving an SP; discussions regarding
safety culture, held in small groups; video lectures; and de-
briefing after simulations. The current results are similar to
those of previous studies in which safety awareness
increased with the implementation of the OR Briefings
and Wrong-Site Surgery Program (Makary et al., 2007)
and the Zero Hero safety program (Brilli et al., 2013); how-
ever, direct comparison between these programs and the
SSPSP is difficult because of differences in measurement
instruments and study periods.
The results of the correlation analysis showed significant
correlations between compliance, safety attitudes, and
awareness of safety management. Cooperation between
medical and systematic support teams is required at a
departmental level to promote positive attitudes toward
patient safety and increase awareness of safety culture.
Moreover, sufficient time should be allocated for education
to maintain continuity and disseminate simulation education.
The SSPSP was considered more effective in improving
ORs’ compliance, safety attitudes, and awareness of safety
Table 4 Safety Attitudes
Variable Experimental Group (n ¼ 27), M (SD) Control Group (n ¼ 22), M (SD) z p
Overall score 0.58 (0.61) 0.13 (0.62) À2.76 .006
Safety climate 0.43 (0.59) 0.04 (0.66) À2.51 .012
Teamwork climate 0.23 (1.0) 0.22 (0.85) À4.54 .650
Working conditions 0.18 (0.53) 0.25 (0.57) À1.63 .103
Stress recognition 0.41 (1.19) 0.18 (0.78) À0.97 .332
Perception of management 2.0 (0.96) 0.06 (0.85) À1.35 .176
Job satisfaction 0.08 (1.01) 0.01 (0.87) À0.373 .709

management, relative to the lecture. The main significance
of the present study lies in the promotion of compliance
with and awareness of safety management and impro-
vements in organizational attitudes toward safety, through
the provision of a practical educational experience via
simulation education involving an SP for ORs for the first
time in Korea. Future studies involving OR nurses could
use the method and strategies implemented in the present
study.
In terms of cost effectiveness, the simulation program
requires more time and money to develop the scenario and
train SPs in comparison with PowerPoint presentation
education. Cost can be evaluated based on the following:
how long the nurses are educated using the developed
simulation, the possibility of repeated practice, and the
reorganization of their structures of simulation learning by
clinical organizations (Gaba, 2004). However, once the pro-
gram has been developed, nurses can be provided with sys-
tematic education from a trained team of senior nurses.
Particularly in the OR, where many nurses require training,
nurses’ competence might improve more quickly in a real
environment rather than lecture-focused education; thus,
senior nurses’ burden with respect to teaching new nurses
could be reduced. Furthermore, a decrease in the incidence
of medical errors in the hospital can achieve cost
effectiveness.
The study was subject to limitations concerning the
generalization of results because of the small sample size,
recruitment of the sample from two different hospitals, and
implementation of the same simulation regardless of the
subjects’ OR experience. Future research should develop
scenarios based on the level of OR nurses’ experience and
the clinical ladder, provide a variety of safety simulation
education programs related to surgery duties, and develop
multidisciplinary safety programs with the cooperation of
surgery teams and anesthesia. Another limitation was that
the study did not determine whether the lecture, discussion,
or simulation was the most powerful strategy for use in the
program. Future research should use different strategies and
compare their results.
Conclusion
In this study, an education program, which included
simulation with an SP, was implemented for OR nurses.
The results showed that the SSPSP increased compliance
and improved attitudes toward safety. The significance of
the present study lies in the promotion of awareness of
safety management in a safe environment and the improve-
ment of the quality of perioperative care via the imple-
mentation of simulation education involving an SP in the
OR environment, where the risk to patients’ safety is high.
The results could be used in the development of various
education programs designed to increase OR nurses’
compliance.
Acknowledgments
We extend our appreciation to the OR nurses who
participated in the study and thank the managers of the
hospitals for their help.
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