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The patient, case, individual and environmental factors that impact on the surgical count process: An integrative review

Problem identification The surgical count is an integral component of the perioperative nurse’s role designed to reduce the risk of unintentional retained items (URIs) during surgery. Current literature provides statistical data that URIs continue to occur which has exposed a lack of adherence to the surgical count process as a possible contributing factor. This review was undertaken to identify what is currently known about perioperative nurses’ practices in relation to the surgical count and the perceived barriers and enablers when trying to follow best practice as outlined in ACORN’s Standards for Perioperative Nursing in Australia.


Problem identification
Counting surgical instruments and consumables in health care facilities (HCFs) is an important component of perioperative practice in relation to patient safety. Despite HCFs' duty to comply with best practice standards in relation to surgical counts, sentinel events concerning unintentional retained items (URIs) during surgical procedures continue to occur. Contributing factors include non-adherence to hospital policy, procedure, process and guidelines; poor communication; a fast-paced work environment and the levels of knowledge, skills and competence of practitioners involved.
This integrative literature review describes the surgical count process and its relationship to patient safety and the perioperative nurse's role in ensuring the count process is undertaken in accordance with best practice principles. To date, there is limited research that describes factors that impact on the surgical count. There is an abundance of literature that provides statistical data related to URIs but little in relation to the operational aspects of managing the count process. The review revealed a number of themes that researchers attributed to incorrect counts. These included patient, case, individual and environmental factors. All of the studies examined showed little documentation of best practice in relation to the count. No studies were found that directly addressed perioperative nurses' perceptions of factors related to the patient, case, individual and environment, or their perceptions of nurses' ability to follow best practice and policy. Because undertaking accurate and appropriate count processes is prescribed by professional organisations as an integral component of quality and safety, further research is needed to identify and describe perioperative nurses' perceived barriers and enablers to undertaking best practice.

Literature search
The researchers undertook an integrative mixed method review using Whittemore and Knafl's 1 integrative review framework. This enabled a comprehensive review of the surgical count process, using qualitative and quantitative research. The integrative review identifies the current empirical evidence and gaps in knowledge related to surgical counts which provide an in-depth understanding of the potential problems surrounding the surgical count 1 . The research question that provided the focus for this review was 'what factors contribute to URIs in surgery?'

Inclusion and exclusion criteria
Papers were included if they were full-text, English language, primary research articles, referred to the surgical count from a quantitative or qualitative perspective and were published between January 2000 and February 2018. The time frame was chosen to ensure current relevance to the chosen topic and to provide breadth and depth of relevant literature to be included in the review.
Research papers other than those written in English were excluded as were papers that referred to the key search terms but had no reference to the surgical count process in the article. Quantitative studies that provided data pertaining to retained items were also excluded if they did not detail the reasons these items were retained and relevance to a surgical count process or nursing concerns. Government reports were also excluded as these did not expand on the issue underlying URIs. Papers based on literature reviews, quality improvement projects or with no abstract available were also excluded. Nursing and Allied Health Literature (CINAHL) Plus, Cochrane Library, MEDLINE (Ovid) and Google Scholar. Boolean connectors 'and' and 'or' were used to combine the key words and medical subject headings (MeSH) were used in the execution of the MEDLINE database searches.

Search strategies
The reference lists of sourced journal articles were hand-searched for further relevant articles. Identified articles were screened by the research team in reference to the aims of the review and the inclusion and exclusion criteria.

Data extraction and synthesis
The articles collated for this review included quantitative, qualitative and mixed methods research which were synthesised to provide a clearer picture of the research available relative to the included studies. The content of the results and discussion sections of the included articles was synthesised using inductive thematic analysis. Themes were generated based on patient, case, individual and environmental factors that contribute to URIs. Data extraction from the integrated literature review included the lead author, year, country, study aim, design, sampling and results. Limitations of each of the studies were identified and considered in relation to internal and external validity of study findings and study quality. Data verification was performed independently by two of the researchers who met regularly to consider whether papers met the inclusion criteria.

Quality assessment
To assess the quality of the included papers, the QualSyst appraisal tools developed by Kmet, Lee and Cook 2 were used. QualSyst tools are a hybrid of research assessment tools that provide a framework to critically appraise individual quantitative and qualitative study designs.
Papers that involved a mixed methodology were assessed using the mixed methods appraisal tool (MMAT). The MMAT checklist tool allows assessment of the methodological quality of studies that have diverse designs based on predetermined objective criteria. It provides five domains that a study can be assessed against with a maximum total of 11 criteria 3,4 .

Quality scores
The QualSyst scoring process for the quantitative studies included 14 set criteria and for the qualitative studies, 10 criteria. Both types of studies were scored as either 0 ('no') if the criteria were not included or discussed, 1 ('partial') if some elements of the criteria were included but not fully discussed, or 2 ('yes') if the criteria were fully included or discussed in the literature. Mixed methods papers were assessed against the three domains recommended in the MMAT checklist, including qualitative, quantitative descriptive and mixed methods, with the responses corresponding to 0 ('no'), 0 ('can't tell') and 1 ('yes').

Findings Descriptive characteristics
The literature search identified a total of 215 studies. Of these, 189 were obtained through electronic searching and a further 26 identified through manual searches of reference lists of the included research articles. Following screening, 109 were identified for further review using the preferred reporting items for systematic reviews and metaanalysis (PRISMA) flow chart 5 as shown in Figure 1.
Six exclusion criteria (detailed in Table 1) were applied to exclude a further 52 articles from the final review. In total, 10 articles were included in the final sample, with a date range of 2003 to 2018. Six papers originated from the US, two from Australia and two from the UK. The articles included in the final review related to patient, case, individual and environmental factors that affect the process of undertaking a surgical count.
A summary of the included descriptors from the qualitative, quantitative and mixed methods research articles describing each study is presented in Tables 2, 3 and 4. Nursing concerns referring to the count process but not providing any further information 6 Quality improvement projects 3

Literature reviews 1
Root cause analysis studies 1 Practice reviews 1 Attending surgeon most likely to be named in a lawsuit so is highly likely to be the named instigator for communication breakdown.
Does not represent all contributing factors.

16/28
Notes: BMI = body mass index, RN = registered nurse. • four group interviews with participants from each site.
• researcher diary over two years To explore power relationships in communication interactions between surgeons, nurses and doctors in the OR as they engage in the practice of the surgical count.
Case-related factors: • speed and efficiency in direct conflict with patient safety • dual roles for scrub nurses. Nurses unable to undertake a count due to power exercised by surgeon when having to assist.
• counts not seen as important during an emergency, nurses using professional judgement • surgeons unaware of count process decisions • counts varied at each institution and disparities in interpretation of the guidelines and how they applied to each situation individual factors: • misinterpretation of hospital policy  Case-related factors: • rushing • more than one circulator Individual factors: • 80.4 per cent respondents reported reading count policy • 90 per cent reported that they followed count policy (not conclusive with observations) • 20 per cent were observed to follow policy • staff observed to be multitasking, not fully concentrating on count • perceived lack of delegation, leadership, teaching, coaching • observed poor practices left unchallenged • length of service observed as having no bearing on count process being followed • observed no compliance with tray list use • no change-over counts observed Single hospital site.
Limited sample size.

Quality assessment
Six quantitative papers were scored against the 14 criteria, with a maximum score totalling 100 per cent. The quality score of these papers ranged between 46 per cent and 82 per cent, with an average score of 66 per cent. Three qualitative papers were reviewed against this criterion with a maximum score of 20 points. The quality scores for these papers ranged from 45 per cent to 65 per cent, with an average score of 57 per cent. Two papers were reviewed using the MMAT tool with the total of 'yes' responses divided by the total criterion (11) to provide an overall percentage assessment. The final assessment ranged from 55 per cent to 82 per cent.
All the studies related to the incidence of URI with a reported range of 68 to 1122 incidences and including a mixture of needles, sponges and instrumentation. They identified areas of perioperative practice that may have contributed to URIs during surgery or the surgical count process. The following sections present a narrative synthesis of the findings of this review under the following categories: patientrelated, case-related, individual and environmental factors.

Implications for perioperative nursing practice or research Patient-related factors
Although age, gender and comorbidities may contribute to increased risks during surgery 6 , the only patient-related factor that was identified in four of the papers as contributing to URIs was a high body mass index (BMI). A high BMI may lead to deep surgical incisions that could fill with bodily fluids and make it difficult to keep track of surgical packs and instrumentation 7-10 .

Case-related factors
Case-related factors encompassed emergency, unplanned and planned surgery and length of time to undertake a procedure. Multiple surgical teams, perioperative nurses undertaking dual roles and multiskilling are documented factors that may contribute to URIs. Five studies identified emergency and unplanned surgery as circumstances that contribute to incorrect counts. Emergency procedures, a change in the patient's status and a sudden change in the surgical procedure may leave insufficient time to account for all surgical instruments and consumables at the commencement of the procedure 9, 10, 13, 15, 17 . In contrast, three papers identified planned surgery as a contributing factor, with perioperative personnel deemed more complacent during the count process for elective procedures 7,15,17 .
Complications and length of time to undertake a procedure was identified as a case-related factor in three papers 10,13,15 . One study identified multiple teams in a surgical procedure as potentially contributing to an incorrect count 10 , and another study identified the instrument nurse having to undertake a dual role as a contributing factor 13 .

individual factors
Adherence to hospital or departmental policy was a major contributing factor discussed in five of the review papers [12][13][14][15][16] . This was also identified as complacency around the count process 17 , with documentation errors also identified 15 . Rowlands and Steeves 12 found that teams working together ad hoc were less likely to share relevant case-related information, contributing to an incorrect count.
Individual factors contributing to incorrect counts included the type of leadership in an operating room (OR) and the manner in which tray lists were used 16 . The impact of hierarchy was identified with surgeons sometimes not allowing nurses to undertake the correct count procedure 13 . Two papers identified the need to treat other members of the perioperative team with respect in the perioperative environment as an individual factor 12,15 .
Two studies documented individual factors contributing to incorrect counts as untidy instrument trolleys and the inability to find instrumentation in a timely fashion 9,12 .
Difficulty in handling certain pieces of equipment (for example, ratcheted and non-ratchet needle holders) 15 , and disparate views of team members in relation to count practices can contribute to a URI 14 and led to surgeons not being aware of which count process is being followed or documented 13 .

Environmental factors
Environmental factors influencing the count process included rural and teaching facilities, loud music, excessive talking and nursing skill mix. Non-technical factors encompassed communication breakdowns, adherence to policy, respect for each other, hierarchy structures, multiple perioperative teams and surgical counts being documented as correct (even when the count was later found to be incorrect).
One study identified that teaching and procedures in rural hospitals may affect the outcome of an incorrect count 7 . Loud music and excessive talking along with poor skill mix were identified in another study 12 . Two studies identified that URIs were found in cases that had had a correct count documented. It was unclear why this phenomenon occurred, with the URI only picked up following routine radiography 9,17 .
A breakdown in communications was identified in three papers as a major contributor to incorrect counts 11,15,17 and that the sheer pace of surgery, process pressure and time constraints were also causative factors 10,13,15 .

Discussion
Papers in this review examined patient, case, individual and environmental deviations that account for inconsistencies in the prescribed surgical count standard of practice. These factors have the potential to culminate in a URI. Although the count procedure is considered a clearly defined, straightforward, step-by-step process, the integrative review studies identified instances where perioperative nurses struggle to follow the count process [7][8][9][10][11][12][13][14][15][16][17] .
The review identified individual, nontechnical factors that influence count behaviours from a multidisciplinary team perspective. Teamwork and communication include respect for each other, from surgeons, perioperative nurses and other team members. Limited communication may reduce the ability to process required information and influence the ability to follow policy and procedure. An increase in idle conversation and noise escalation were also identified as behaviours that contributed to an ineffective count process [18][19][20][21][22] .
Time pressures related to the surgical and anaesthetic teams pushing to get patients in and out of the OR quickly evidently had a negative impact on nurses' ability to undertake the count process and complete documentation 12,15,23 . Team fatigue leading to diminished concentration and change of perioperative personnel mid-procedure was identified as a contributing factor to poor documentation and count process 9, 10,24-26 .
A lack of professional respect, idle conversation and noise escalation were identified as behaviours that influenced count practices in many of the papers but the missing link in the literature is why these behaviours can continually affect the way the count process is undertaken.
Undertaking observational research will help to uncover why such behaviours occur in real time and increase understanding of the circumstances that lead to these behaviours. Ineffective communication has been identified as a major causative factor for perioperative nurses failing to follow correct policy and procedure in relation to the surgical count 11,12,17,22,24,28 . The inability to follow accepted count practices is often associated with the hierarchical structure in the OR, such as nurseto-surgeon and male-to-female ratios 11,17,29,30 .
Hierarchical confrontations between experienced and inexperienced nurses contributed to junior nurses having difficulty challenging more senior staff regarding the process of undertaking the surgical count 13,23 . Likewise, perioperative nurses who have worked together for years may have adapted the count process to suit their needs and developed shared understandings based on work history 27,31,32 .
The authors of several studies identified that nurses relied on their own professional judgement when deciding on what to count. This led to disparate interpretations of the guidelines and their relevance to each surgical situation 8,9,12,13,15,31,33 .

Limitations
While this review has strengths, it also has limitations. A robust research process was undertaken, encompassing identifying major key words and MeSH terms. It was identified early in the research process that few studies have examined nurse perceptions of incorrect counts and the patient-related, case-related and environmental factors perceived by perioperative nurses in undertaking a surgical count process.
Only five of the ten papers in this review described nurses' concerns regarding the count process and provided some reflection on causative factors and preventable actions. Studies not available in English were omitted from this review. Such studies may have provided further insights into the phenomenon. Research papers on surgical counts may not represent all works in relation to nurses' perceptions of the count process and therefore may have limited the scope of this review. Finally, appraisal of empirical research is somewhat subjective. However, using previously validated tested tools 2,3 provided rigour in the review process in relation to evaluating and scoring papers based on content and methodology.

Conclusion
Throughout this review it was evident that patient, case, individual and environmental factors may contribute to URIs during surgery and that these factors have some impact on the surgical count process. Quantitative data about how many URIs occur and the causative factors related to this phenomenon is in abundance. However, qualitative research into these contributing factors and the implications for perioperative nurses is limited. The surgical count process is a key component of the perioperative nurse's responsibility towards patient safety, yet this review demonstrates that there is limited research about this subject and the contributing factors that may affect their ability to carry out the prescribed process.
Empirical evidence supports the contention that human error continues to occur in relation to the surgical count. Although the surgical count is sometimes considered onerous and repetitive, counting and documentation are pivotal tasks related to patient safety in surgery. The safety culture of an organisation is the product of individual and group norms, beliefs, attitudes and values. These attributes determine an organisation's commitment to managing critical safety issues. A culture of safety should provide a framework that limits variability in practice and, therefore, has the potential to reduce inconsistency and human error.