Implementation strategies by leaders and health professionals to improve the safety climate in the operating room: a scoping review protocol
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* Rosilene Alves Ferreira
* Soraia Cristina de Abreu Pereira
* Olga Maria Pimenta Lopes Ribeiro
* Andressa Aline Bernardo Bueno
* Felipe Caldonazzo de Almeida Pereira
* Danielle Mendonça Henrique
* Flavia Giron Camerini
* Cintia Silva Fassarella

## Abstract

**Introduction** Strengthening the safety climate in surgical centres is essential for ensuring care and patient safety, which directly impacts the reduction in the occurrence of adverse events and complications. In this sense, used to strengthen the safety climate in the operating room.

**Methods and analysis** A scoping review will be carried out on the basis of the method proposed by the JBI and the Preferred Reporting Items for Systematic reviews and Meta-Analyses extension for Scoping Reviews (PRISMA-ScR) will be applied. The selection of studies, data extraction and synthesis will occur on the basis of the following inclusion criteria: Participants (leaders and health professionals), Concept (strategies for improving the safety climate) and Context (operating room) framework. This scoping review considers studies that address improvement strategies employed to strengthen the safety climate within the operating room. The review encompasses all studies published from 2009 to the present. The results will be presented in a narrative format with tables or diagrams.

**Ethics and dissemination** No ethics committee approval is required for this study as it does not involve human participants. The results of the study will be disseminated through peer-reviewed publications, presentations at scientific congresses and targeted knowledge-sharing sessions with relevant stakeholders.

*   Patient Care Management
*   Implementation Science
*   Quality Improvement
*   Health & safety
*   Nurses
*   SURGERY

### Strengths and limitations of this study

*   A robust design was established for this protocol, incorporating a structured review, which was based on search strategy planning, with experts in the field of safety culture and advice from a librarian.

*   The sources of evidence to be used allow the mapping of studies, including sources of grey literature, expanding the investigation.

*   This review is restricted to published studies and gray literature from 2009 onwards.

## Introduction

The study of patient safety has become a central theme in healthcare, especially in complex sectors such as the surgical environment. In this context, safety culture and safety climate are crucial elements for ensuring the quality and safety of the care provided.1 Studies that promote a safe environment for professionals and patients consider the priority agenda of health research and meet the Patient Safety Research initiative.2

Importantly, although it is used synonymously, safety culture is the set of values, attitudes and behaviours shared by the organisation, whereas safety climate is an integral and measurable part of patient safety culture, being the perception of professionals about the safety culture at a given time and context. It considers the nature of the work environment and its components, as well as the organisation’s values about safety, being measured through the perceptions and attitudes of professionals that reflect the organisation’s behaviour.3

In this sense, it is understood that the safety climate can directly influence safe patient care. On the basis of this understanding and considering that research has been conducted to measure the safety climate on the basis of the perceptions of professionals,4–9 this review uses the concept of the safety climate.

The Safety Attitudes Questionnaire (SAQ) is an instrument for measuring the safety climate based on professionals’ perceptions of patient safety. It has been validated in six cross-sectional studies and has high psychometric properties in the six domains explored: teamwork climate, job satisfaction, perception of unit and hospital management, safety climate, working conditions and perception of stress.3

Considering the specific environment of the operating room, a set of six domains that influence individual and collective attitudes towards patient safety provides a framework for understanding the safety climate in the operating room. The domains mentioned above comprise the perspectives of healthcare practitioners on various critical elements, such as the working environment, stress, safety atmosphere, supervision, communication during surgery and expert performance. By evaluating these domains, it is possible obtain a situational diagnosis of the components that support safe surgical patients. For this purpose, the utilisation of a validated questionnaire, such as the Safety Attitudes Questionnaire/Operating Room (SAQ/OR), is recommended.3 10

Given the diagnosis, it is important to implement measures that reinforce vulnerable domains. Importantly, patient safety is a structured system comprising organised activities that cultivate cultures and behaviours within healthcare.11 When implemented consistently and sustainably, cultural and behavioural practices can effectively reduce the probability and consequences of errors, prevent harm and mitigate the impact of such occurrences.4 Therefore, strengthening the safety climate can have a positive influence on care in healthcare institutions.

The motivation for conducting this study is that research on patient safety aligns with the Sustainable Development Goals, particularly Goal 3—Health and Well-Being. Furthermore, it strives to guarantee optimal health and well-being for all individuals across the lifespan while facilitating access to essential, high-quality health services.12 In addition, it is part of the WHO’s priority health agenda, and its actions are defined through the Global Action Plan for Patient Safety 2021–2030.1

Despite the growing progress in studies involving the diagnosis of the safety climate in the operating room,5–7 little has been invested in method robustness8 9 and in studies to implement improvements13 based on the situational diagnosis carried out to understand and strengthen weakened areas.

Although technological development has enabled effective interventions to improve the quality of healthcare, there is a gap between research and practice in the implementation of improvement strategies.14 15 Studies that survey strategies, barriers, facilitators and other actions that help implement evidence-based improvements to promote patient safety are being recommended, highlighting the relevance of this study.16

A preliminary search of JBI Evidence Synthesis, the Cochrane Database of Systematic Reviews, PROSPERO, the Open Science Framework, Lilacs and PubMed were conducted to ascertain whether there were any reviews or studies in progress or previously conducted that were congruent with the objective of this review. A single study on strategies to reduce stress in the operating room workplace was identified. Although stress is explored as a safety climate domain, this review will delve into all the domains that comprise the safety climate assessment. Consequently, the identification of improvement strategies employed to enhance the safety climate in the operating room is imperative and urgent, with the objective of fostering a safer and more conducive surgical environment.

Hence, this scoping review aims to map the improvement strategies used by health leaders and professionals to strengthen the safety climate in the operating room. As a review question: What strategies do operating room leaders and professionals implement to improve the safety climate?

## Methods and analysis

The proposed scoping review will be conducted in accordance with the JBI methodology for scoping reviews and the Preferred Reporting Items for Systematic reviews and Meta-Analyses extension for Scoping Reviews (PRISMA-ScR) for reporting guidance.17 18

### Inclusion criteria

The eligibility criteria have been detailed according to the PCC (Participants, Concept and Context) framework17 (table 1).

### Participants

The review considers studies whose participants (P) include health professionals (multiprofessional), namely: nursing team (nurses, nursing technicians, surgical instrument and perfusion nurses and anaesthesia nurses) and physicians (anaesthesiologists and surgeons). In addition, the support team includes administrative assistants, X-ray technicians, hygiene and cleaning staff, pharmacists, pharmacy technicians, pathologists and other external professionals such as clinical engineering and maintenance personnel. They are professionals who coordinate or manage the operating room.19

View this table:
[Table 1](http://bmjopen.bmj.com/content/15/4/e094904/T1)

Table 1 
Description of eligibility criteria

#### Concept

For concept (C), this review will consider studies that present improvement strategies, that relate or describe the measures or actions implemented in the operating room to strengthen the safety climate. Studies that include the evaluation of the intervention using a validated instrument for measuring the safety climate that explores the following domains will also be considered:3 10

1.  Safety climate: Identifies professionals’ perceptions of the organisation’s proactive commitment to patient safety.

2.  Management perceptions: Relates to the approval of management and leadership actions regarding safety issues.

3.  Perceptions of stress: Involves recognising that stressors influence patient care.

4.  Working conditions: Relates to perceptions of the quality of the work environment and the availability of material and human resources.

5.  Communication in the surgical environment: Refers to the information shared among the multi-professional team that affects the safety of surgical patients.

6.  Perceptions of professional performance: Involves the professional’s ability to recognise and understand that fatigue and workload impact professional performance and, consequently, the safety of surgical patients.

#### Context

Regarding context (C), studies conducted in hospital operating rooms will be considered, as this is the environment where elective and emergency anaesthetic-surgical, diagnostic and therapeutic procedures are carried out.19

#### Types of sources

Concerning the methodological approach, the review will include quantitative studies, qualitative studies, mixed methods studies, systematic reviews, editorials, field reports, conference reports, evidence implementation studies and grey literature.

### Search strategy

First, an initial limited search was conducted in the Medical Literature Analysis and Retrieval System Online (Medline) databases via PubMed and Latin American and Caribbean Literature in Health Sciences (Lilacs) through the Virtual Health Library (BVS) to determine if there was any material to support this review (see online supplemental file 1).

### Supplementary data

[[bmjopen-2024-094904supp001.pdf]](pending:yes)

The terms contained in the titles and abstracts of the relevant articles obtained and the descriptors used will be used to develop a complete search strategy. We will then conduct a second search using all identified keywords and synonyms in the following data sources: Medline via PubMed, Cumulative Index to Nursing and Allied Health Literature (CINAHL), Scopus, Web of Science, Lilacs via BVS, PsycINFO, Cochrane Library and Embase.

The search for data in the sources of grey literature will be carried out in the following databases: WorldCat, Digital Library of Theses and Dissertations (BDTD), Brazilian Association of Surgical Center Nurses, Material and Sterilization Center and Anesthetic Recovery (SOBECC), Association of Portuguese Operating Room Nurses (AESOP), Association of Perioperative Registered Nurses (AORN), Institute for Healthcare Improvement (IHI), Agency for Healthcare Research and Quality (AHRQ) and the WHO.

In the third stage, the reference lists of the articles included in the review will be evaluated for possible selection of additional articles. Notably, the review will consider studies in any language, starting from 2009, considering the publication of the second global patient safety challenge ‘Safe surgeries save lives’20 stimulating the production of knowledge on the subject.

#### Study/source of evidence selection

The studies identified in the databases will be exported to Rayyan and the duplicates will be removed. A pilot screening test will be conducted independently by both reviewers on an initial total of 25 titles and abstracts. Reviewers will discuss discrepancies and make modifications to eligibility criteria and definitions if necessary. This pilot test will continue until at least 75% agreement is reached among the reviewers.17

The titles and abstracts will be analysed by two independent reviewers to assess the eligibility of the studies in relation to the initially defined inclusion criteria, for reading in full. This step will take place after reviewers have familiarised themselves with the source’s results and have tested the extraction form on three sources to ensure that all relevant results are extracted.17

Full studies that meet or potentially meet the inclusion criteria will be reviewed. The full texts of the selected references will be evaluated according to the inclusion criteria by two independent reviewers. Any disagreements between the reviewers at each stage of the selection process will be resolved by consensus or by the decision of a third reviewer. After reading in full using the Rayyan software, the studies that are considered for the writing of the review results will be exported to the Zotero reference manager.

The reasons for the exclusion of articles will be recorded in Rayyan during the selection process, both at the first level and second level of screening. The selection process and research results will be reported in full in the final scoping review and presented in a PRISMA flowchart.18

### Data extraction

Two independent reviewers will develop a tool to extract data from the studies (see online supplemental file 2).

### Supplementary data

[[bmjopen-2024-094904supp002.pdf]](pending:yes)

### Data analysis and presentation

The analysis for this scoping review will primarily consist of content analysis, focusing on the data extracted from the literature. The extracted data will be presented in the form of tables or diagrams, aligning with the objective and research question of the review. A descriptive summary will accompany the tables or diagrams, providing context and explaining how the data are related to the review’s objectives.

## Ethics statements

### Patient consent for publication

Not applicable.

## Footnotes

*   Contributors All authors contributed to the conception and design of the work; drafting the work or revising it critically for important intellectual content; final approval of the version to be published and agreement to be accountable for all aspects of the work. RAF, FCdAP and CSF the acquisition, analysis and interpretation of data for the work. RAF acted as guarantor.

*   Funding Fundação Carlos Chagas Filho de Amparo à Pesquisa do Estado do Rio de Janeiro - FAPERJ, nº SEI-260003/006194/202

*   Competing interests None declared.

*   Patient and public involvement Patients and/or the public were not involved in the design, or conduct, or reporting, or dissemination plans of this research.

*   Provenance and peer review Not commissioned; externally peer reviewed.

*   Supplemental material This content has been supplied by the author(s). It has not been vetted by BMJ Publishing Group Limited (BMJ) and may not have been peer-reviewed. Any opinions or recommendations discussed are solely those of the author(s) and are not endorsed by BMJ. BMJ disclaims all liability and responsibility arising from any reliance placed on the content. Where the content includes any translated material, BMJ does not warrant the accuracy and reliability of the translations (including but not limited to local regulations, clinical guidelines, terminology, drug names and drug dosages), and is not responsible for any error and/or omissions arising from translation and adaptation or otherwise.

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