A Narrative Review on Intraoperative Adverse Events: Risks, Prevention, and Mitigation.

INTRODUCTION: Adverse events from surgical interventions are common. They can occur at various stages of surgical care, and they carry a heavy burden on the different parties involved. While extensive research and efforts have been made to better understand the etiologies of postoperative complications, more research on intraoperative adverse events (iAEs) remains to be done. METHODS: In this article, we reviewed the literature looking at iAEs to discuss their risk factors, their implications on surgical care, and the current efforts to mitigate and manage them. RESULTS: Risk factors for iAEs are diverse and are dictated by patient-related risk factors, the nature and complexity of the procedures, the surgeon's experience, and the work environment of the operating room. The implications of iAEs vary according to their severity and include increased rates of 30-day postoperative morbidity and mortality, increased length of hospital stay and readmission, increased care cost, and a second victim emotional toll on the operating surgeon. CONCLUSIONS: While transparent reporting of iAEs remains a challenge, many efforts are using new measures not only to report iAEs but also to provide better surveillance, prevention, and mitigation strategies to reduce their overall adverse impact.

Barriers and Motivations for Health Insurance Subscription Among Health-Care Users in Cameroon.

INTRODUCTION: Surgical care is a significant component of the overall health expenditure in low- and middle-income countries. In Cameroon, out-of-pocket payments for surgical service are very high with many patients declining potentially curative surgical procedures. Less than 2% of the population is enrolled in a health insurance scheme leading to a propensity for catastrophic health expenses when accessing care. To assess the perceived barriers and motivations for health insurance subscription among health-care users in Cameroon. METHODS: This was a cross-sectional community-based qualitative study conducted in the Center Region of Cameroon. A total of 37 health-care users (health insurance subscribers and nonsubscribers) were purposively identified. Four focused group discussions and thirteen in-depth interviews were conducted. All anonymized transcripts were analyzed using a thematic analysis approach. RESULTS: The six major themes identified as barriers to health insurance subscription were lack of trust in the existing health insurance schemes, inadequate knowledge on how health insurance works, premiums believed to be too expensive, the complexity of the claims processing system, minimal usage of health-care services and practice of self-medication. Motivational factors included the knowledge of having access to quality health services even without money in the event of an unforeseen illness and having a large family/household size. The importance of mass sensitization on the benefits of health insurance was noted. CONCLUSION: Health insurance is still very underutilized in Cameroon. This results in significant out-of-pocket payment for health services by Cameroonians with catastrophic consequences to households. With most Cameroonians in the informal sector and underemployed, it is imperative to put in place a national strategic plan to overcome existing barriers and increase health insurance coverage especially among the poor. This has the potential to significantly increase access to safe, quality, timely and affordable surgical care.

Use of statewide financial incentives to improve documentation of hernia and mesh characteristics in ventral hernia repair.

BACKGROUND: Documentation of intraoperative details is critical for understanding and advancing hernia care, but is inconsistent in practice. Therefore, to improve data capture on a statewide level, we implemented a financial incentive targeting documentation of hernia defect size and mesh use. METHODS: The Abdominal Hernia Care Pathway (AHCP), a voluntary pay for performance (P4P) initiative, was introduced in 2021 within the statewide Michigan Surgical Quality Collaborative (MSQC). This consisted of an organizational-level financial incentive for achieving 80% performance on eight specific process measures for ventral hernia surgery, including complete documentation of hernia defect size and location, as well as mesh characteristics and fixation technique. Comparisons were made between AHCP and non-AHCP sites in 2021. RESULTS: Of 69 eligible sites, 47 participated in the AHCP in 2021. There were N = 5362 operations (4169 at AHCP sites; 1193 at non-AHCP sites). At AHCP sites, 69.8% of operations had complete hernia documentation, compared to 50.5% at non-AHCP sites (p < 0.0001). At AHCP sites, 91.4% of operations had complete mesh documentation, compared to 86.5% at non-AHCP sites (p < 0.0001). The site-level hernia documentation goal of 80% was reached by 14 of 47 sites (range 14-100%). The mesh documentation goal was reached by 41 of 47 sites (range 4-100%). CONCLUSIONS: Addition of an organizational-level financial incentive produced marked gains in documentation of intra-operative details across a statewide surgical collaborative. The relatively large effect size-19.3% for hernia-is remarkable among P4P initiatives. This result may have been facilitated by surgeons' direct role in documenting hernia size and mesh use. These improvements in data capture will foster understanding of current hernia practices on a large scale and may serve as a model for improvement in collaboratives nationally.

Assessment of surgical, anesthesia, and obstetric workforce in Somalia.

BACKGROUND: One of the core indicators recommended by the Lancet Commission is surgical workforce density, aiming to improve the number of surgery, anesthetists, and obstetric (SAO) providers to 20 per 100,000 population by 2030. We assessed SAO workforce capacity in Somalia and made recommendations for improvement. METHOD: A cross-sectional study was conducted using a structured questionnaire from the WHO Program for Global Surgery and Social Change (PGSSC) Surgical Assessment Tool. All hospitals that offer surgical care services were included. A descriptive analysis was conducted using the statistical software SPSS. RESULTS: Of the 55 surveyed facilities providing surgical care services, 28 (50.9%) were public, mainly in urban areas. We found that there were 474 SAO specialists and non-specialists (SAO providers) and 446 other important personnel (e.g., midwives, radiologists, and pathologists). Out of 474 SAOs, Banadir had 288. Overall, surgery specialties were the most prevalent profession among SAO providers' workforce, accounting for 160 (33.7%) surgery specialists, with 1.2 per 100,000 population. The six states of Somalia have 54 OB/GYN specialists (0.4 per 100,000 population). There were a total of 22 anesthesia specialists, with a ratio of 0.2 anesthesia specialists per 100,000 population. CONCLUSION: We found a serious shortage of the SAO workforce in Somalia, and it is unlikely to meet the 2030 Lancet Commission on Global Surgery targets. There is a need for additional training of SAO providers who can offer effective leadership in surgical care services to combat the extremely avoidable surgical-related morbidities and mortalities.

Responding to the need: An evaluation of the subspecialty units in a pediatric surgical department in a limited resource setting using selected optimal resources for children's surgery strategies.

BACKGROUND: The Global Initiative for Children's Surgery group published the Optimal Resources for Children's Surgery (OReCS) document outlining the essential criteria and strategies for children's surgical care in low-resource settings. Limited data exist on subspecialties in pediatric surgery and their contribution to global surgery efforts. The study aimed to evaluate the development of subspecialty units within Chris Hani Baragwanath Academic Hospital (CHBAH) Department of Pediatric Surgery (DPS) from January 1, 2018 to December 31, 2021 using selected OReCS strategies for the improvement of pediatric surgery. METHODS: A retrospective descriptive research design was followed. The study population consisted of CHBAH PSD records. The following data were collected: number of patients managed in PSD subspecialty unit (the units) clinics and surgeries performed, number of trainees, available structures, processes and outcome data, and research output. RESULTS: Of the 17,249 patients seen in the units' outpatient clinics, 8275 (47.9%) burns, 6443 (37.3%) colorectal, and 2531 (14.6%) urology. The number of surgeries performed were 3205, of which 1306 (40.7%) were burns, 644 (20.1%) colorectal, 483 (15.1%) urology, 341 (10.6%) hepatobiliary, and 431 (12.8%) oncology. Of the 16 selected strategies evaluated across the 5 units, 94% were available, of which 16.4% was partly provided by Surgeons for Little Lives. Outcome data in the form of morbidity and mortality reviews for all the units is available, but there is no data for timeliness of care with waiting lists. There were 77 publications and 41 congress presentations. CONCLUSION: The subspecialty units respond to the global surgical need by meeting most selected OReCS resources in the clinical service provided.

Digitizing operating theater data in resource-limited settings: Understanding surgical care delivery post-implementation at Tanzanian referral hospital.

BACKGROUND: Digitizing surgical data infrastructure is critical for policymakers to make informed decisions. The implementation of the first web-based operating theater (OT) recordings at Muhimbili Orthopedic Institute (MOI) represents significant advancements in data management for Tanzania. This study aims to share post-platform implementation outcomes, challenges, and insights gained offering guidance to settings facing similar data repository challenges. METHODS: In July 2023, after training clinicians, the platform was deployed at MOI operating theaters (OTs) to facilitate prospective data entry following procedures, ensuring timely updates of perioperative outcomes. Semi-structured interviews were conducted with key stakeholders to gather insights into the platform's functionality and efficient data management systems. We presented data from August 2023 to February 2024 along with platform insights. RESULTS: Over 4449 procedures were conducted, comprising 1321 emergencies and 3128 electives, with orthopedics/trauma accounting for the majority (3606). Trauma-related emergencies (921) predominate among interventions. General anesthesia was prevalent; 60.56% in emergencies and 44.51% in electives. Orthopedics/trauma utilized 90.91% of assigned operating days in electives, while neurosurgery utilized 93.39% (p < 0.011). The cancellation rate was 7.5%, primarily due to emergency interferences (32%). Of procedures, 96.76% were discharged, while 2.81% died. Challenges encountered during platform implementation included securing local support, integrating technology, and navigating administrative adjustments. Lessons learned emphasized continuous communication for stakeholder buy-in and training for platform familiarity. CONCLUSION: The web-based OT recordings at MOI succeeded with local support and showed promise for wider scalability. To ensure sustainability, ongoing follow-up, monitoring of platform functionality, local funding establishment, and strengthening global partnerships are recommended.

Advancing pediatric perioperative care in India: A contemporary overview.

BACKGROUND: In the last 30 years, significant advances have been made in pediatric medical care globally. However, there is a persistent urban-rural gap which is more pronounced in low middle-income countries than high-income countries, similar urban-rural gap exists in India. While on one hand, health care is on par or better than healthier nations thriving international medical tourism industry, some rural parts have reduced access to high-quality care. AIM: With this background, we aim to provide an overview of the present and future of healthcare in India. METHODOLOGY: With the cumulative health experience of the authors or more than 100 years, we have provided our experience and expertise about healthcare in India in this narrative educational review. This is supplemented by the government plans and non government plans as appropriate. References are used to justify as applicable. RESULTS: With the high percentage of pediatric population like other low to middle-income countries, India faces challenges in pediatric surgery and anesthesia due to limited resources and paucity of specialized training, especially in rural areas. Data on the access and quality of care is scarce, and the vast rural population and uneven resource distribution add to the challenges along with the shortage of pediatric surgeons in these areas of specialized care . Addressing these challenges requires a multi faceted strategy that targets both immediate and long-term healthcare needs, focusing on improving the facilities and training healthcare professionals. Solutions could include compulsory rural service, district residency programs, increasing postgraduate or residency positions, and safety courses offered by national and international organizations like Safer Anesthesia from Education Pediatrics, Vital Anesthesia Simulation Training, and World Federation of Society of Anesthesiologists pediatric fellowships. CONCLUSION: India has achieved great strides in perioperative health care and safety. It has become the major international medical industry due to high-quality care, access and costs. Crucially, India needs to establish local hubs for pediatric perioperative care training to enhance healthcare delivery for children.

Nurses' experiences of moral distress and how it affects daily work in surgical care-a qualitative study.

AIM: To describe nurses' and specialist nurses' experiences of moral distress and how it affects daily work in surgical care. DESIGN: A qualitative descriptive study design was used. METHODS: A qualitative study with 12 interviews with nurses and specialist nurses working in surgical care. All interviews were conducted during October and November 2022 in two hospitals in southeastern Sweden. Data were analysed using conventional qualitative content analysis. FINDINGS: Three categories and seven subcategories generated from the data analysis. The three categories generated from the analysis were Experiences that lead to moral distress, Perceived consequences of moral distress and Strategies in case of moral distress. The results show that a lack of personnel in combination with people with complex surgical needs is the main source of moral distress. Both high demands on nurses as individuals and the teamwork are factors that generate moral distress and can have severe consequences for the safety of patients, individual nurses and future care. CONCLUSIONS: The results show that moral distress is a problem for today's nurses and specialist nurses in surgical care. Action is necessary to prevent nurses from leaving surgical care. Prioritizing tasks is perceived as challenging for the profession, and moral distress can pose a patient safety risk. IMPACT: Surgical care departments should design support structures for nurses, give nurses an authentic voice to express ethical concerns and allow them to practice surgical nursing in a way that does not violate their core professional values. Healthcare organizations should take this seriously and work strategically to make the nursing profession more attractive. PATIENT OR PUBLIC CONTRIBUTION: There was no patient or public contribution.

Current status and issues regarding surgical education in the region: a questionnaire survey in Oita prefecture in Japan.

BACKGROUND: The shortage and aging of surgeons in regional surgical care has been remarkable, and the importance of surgical education for young surgeons in the region is only increasing. However, there are very few reports about regional surgical education. This study aimed to clarify the current status and issues regarding surgical education in regional surgical care and to examine the ideal way to provide surgical education in the region. METHODS: Two questionnaire surveys were carried out. (1) "Survey on the awareness regarding the education of young surgeons" was conducted by mail in institutions where surgeons worked. (2) "Survey on the current status of surgical education for young surgeons" was conducted via the Internet with surgeons under 40 years old and mentors at the same facility. RESULTS: There were 175 respondents to survey (1), among whom 131 (75%) surgeons were interested in educating young surgeons, and 112 (64%) were actively participating in this educating. Regarding the best evaluation methods for mentors who are educating young surgeons, the most frequent answer was "I don't know (51%)". The number of respondents in survey (2) was 87, including 27 (31%) young surgeons and 60 (69%) mentors. Although there was no difference between young surgeons and mentors in the level of satisfaction with the current status of young surgeons, 37% of young surgeons in urban areas were dissatisfied with their current status, compared to 0% in the regional area (p < 0.05). CONCLUSIONS: Although surgeons did not have confidence in their own education, the level of satisfaction among young surgeons was high even in those providing regional surgical care. Development of an evaluation system for surgical education is necessary for young surgeons to receive more effective surgical education in the region.

Missed nursing care in surgical care- a hazard to patient safety: a quantitative study within the inCHARGE programme.

BACKGROUND: Missed nursing care occurs globally, and the consequences are severe for the patients when fundamental care needs are not fulfilled, nor delivered in a person-centred way. This study aimed to investigate the occurrence and cause of missed nursing care, and the relationship between registered nurses' and nursing assistants' perceptions of missed nursing care, in a surgical care context. METHODS: A quantitative study was performed using the MISSCARE survey, measuring missed nursing care and associated reasons, in three surgical wards with registered nurses and nursing assistants as the participants (n = 118), during May-November in 2022. The MISSCARE survey also covers background data such as job satisfaction and intention to leave. The survey was distributed paper-based and the response rate was 88%. RESULTS: Aspects of nursing care rated to be missed the most were 'attending interdisciplinary care conferences', 'turning patient every 2 h', 'ambulation 3 times per day or as ordered', and 'mouth care'. Differences between registered nurse and nursing assistant ratings were detected for eight out of 24 items, where registered nurses rated more missed nursing care. The uppermost reasons for missed nursing care were 'inadequate number of staff' and 'unexpected rise in patient volume and/or acuity on the unit'. Registered nurses and nursing assistants rated differently regarding six of 17 items. Almost every fourth staff member (24.6%, n = 29) had the intention to leave within a year in the present department. CONCLUSIONS: The occurrence of missed nursing care is frequent in the surgical context, and in combination with a high number of staff members intending to leave their employment, poses a hazard to patient safety. Registered nurses, holding higher educational levels, reported more missed care compared with the nursing assistants. The main reason for missed nursing care was an inadequate number of staff. These findings support a warranted investment in nursing within the organisation. The results can be used to form strategies and interventions, to reduce nurse attrition and optimise competence utilisation, and to achieve safe person-centered fundamental care.

Hazardous Drinking Interventions Delivered During Medical-Surgical Care: Patient and Provider Views.

Addressing hazardous drinking during medical-surgical care improves patients' health. This formative evaluation examined patients' consideration of options to change drinking and engage in treatment. It explored whether interventions such as "DO-MoST" overcome treatment barriers. We interviewed 20 medical-surgical patients with hazardous drinking in a trial of DO-MoST, and 16 providers. Analyses used a directed content approach. Patients were receptive to and comfortable discussing drinking during medical-surgical care. Interventions like DO-MoST (patient-centered, motivational approach to shared decision making) addressed some treatment barriers. Patients and providers viewed such interventions as helpful by building a relationship with a psychologist who facilitated self-awareness of drinking behaviors, and discussing connections between alcohol- and physical health-related problems and potential strategies to address drinking. However, both groups expressed concerns about individual and system-level barriers to long-term change. Interventions like DO-MoST bridge the gap between the patient's medical treatment episode and transition to other health care settings. TRIAL REGISTRATION: The study is registered on ClinicalTrials.gov (ID: NCT03258632).

Effects of accelerated rehabilitation surgical care on the surgical site wound infection and postoperative complications in patients of lung cancer: A meta-analysis.

To comprehensively evaluate the effect of accelerated rehabilitation surgical care on perioperative wound infections and complications in patients undergoing lung cancer surgery. A comprehensive computerised search for randomised controlled trials (RCTs) of accelerated rehabilitative surgical care applied to patients undergoing lung cancer surgery was conducted using the Web of Science, PubMed, Cochrane Library, Embase, Wanfang and China National Knowledge Infrastructure databases from inception to September 2023. The literature was screened and evaluated by two investigators, and data were extracted from the final included literature. Stata software (version 17.0) was used for data analysis. Overall, 21 RCTs involving 2187 patients were included, including 1093 cases in the accelerated rehabilitation surgical care group and 1094 cases in the conventional care group. The analyses revealed that patients with lung cancer surgery who implemented accelerated rehabilitation surgical care were significantly less likely to develop postoperative wound infections (odds ratio [OR] = 0.29, 95% confidence interval [CI]: 0.17-0.49, p < 0.001) and postoperative complications (OR = 0.26, 95% CI: 0.20-0.34, p < 0.001) and shortened the hospital length of stay (standardised mean differences [SMD] = -1.93, 95% CI: -2.32 to -1.53, and p < 0.001) compared with conventional care. The effect of accelerated rehabilitation surgical care intervention in the perioperative period of lung cancer surgery patients is remarkable, as it can effectively reduce the incidence of wound infection and complications, shorten hospitalisation time and promote patient recovery.

When Antimicrobial Treatment and Surgical Prophylaxis Collide: A Stewardship Opportunity.

Background: In 2002, the Centers for Medicare and Medicaid Services (CMS) in collaboration with the Centers for Disease Control and Prevention (CDC) established the Surgical Infection Prevention (SIP) project for the purposes of developing and standardizing quality improvement measures known to reduce the rates of post-operative surgical site infections (SSIs). Four years later the Surgical Care Improvement Project (SCIP), an expansion of SIP, was published in governmental Specifications Manual for National Inpatient Quality Measures and provided several additional initiatives applicable to the perioperative period. Central to both projects are the assurance of the timeliness, selection, and duration of peri-operative surgical prophylactic antibiotics. In support of this objective, various medical associations, such as the American Society of Health-System Pharmacists (ASHP) and the Infectious Diseases Society of America (IDSA), have developed the Clinical Practice Guidelines for Antimicrobial Prophylaxis in Surgery. To ensure compliance with quality measures, hospitals are required to report data to the Physicians Quality Reporting System, which is then reviewed by CMS for reimbursement purposes and to measure hospital performance. To maintain optimal standards of care and satisfy all core measures, it is expected that patients undergoing most categories of surgical procedures receive prophylactic antibiotics. We recognized that patients already being administered antimicrobial therapy as treatment for the condition requiring the surgery not uncommonly also were prescribed unwarranted and redundant pre-operative antibiotics. Our study was meant to quantify such antibiotic redundancy, which only risks the development of antimicrobial resistance and adverse events, to bolster our and other hospitals antimicrobial stewardship programs. Methods: A retrospective analysis of computerized hospital records over a one-month period of time (November 2022) was conducted focusing on hospital admissions that involved surgical operative procedures. Only those patients who had received a pre-operative surgical prophylactic antibiotic were included in the analysis. Results: Of the 92 surgeries that fulfilled the inclusion criteria, 38 (41.3%) were performed on patients who were already receiving therapeutic antibiotics for more than 24 hours targeted to treat the infection for which they were undergoing surgery. These included laparoscopic cholecystectomy (24), appendectomy (12), wound debridement (12), and soft tissue incision and drainage procedures (9), comprising nearly 50% of each type of these operations performed during the study time period. Conclusion: These findings demonstrate a clear opportunity to strengthen both our, and presumably other, hospitals antimicrobial stewardship programs. Together with physician education, granting the pharmacy the ability to cancel unnecessary and redundant surgical prophylactic antibiotics would conceivably be of great benefit.

Hospital Detention for the Inability to Pay: A Qualitative Study of Patient Experiences in Cameroon.

INTRODUCTION: Equitable access to quality surgical care and low-cost healthcare services for all segments of the population remains a big problem in many African health systems. In Cameroon, it is very common to find medically discharged patients who have received surgical treatment and are unable to pay the resulting bills. These patients can be held in detention in hospitals until payments are complete. Even the corpses of patients who die with unpaid medical bills can be withheld until their family members pay off the debt. While this practice has been ongoing for many y, there remains very little scholarship on the issue reported in the literature. The main objective of this study was to uncover the lived experiences of discharged patients residing in hospital detention for being unable to pay their medical bills. METHODS: In-depth interviews, focus group discussions, and observations were conducted with purposefully selected patients living in detention in 2 rural private hospitals in the Fundong Health District in Cameroon. A thematic framework technique was used to analyze the transcribed data. The study was ethically approved by the Cameroon Bioethics Initiative, and informed consent was obtained from all participants. RESULTS: Living in hospital detention after receiving treatment constitutes an economic, social, and psychological burden for patients. Economically, it exacerbated poverty for the patients unable to purchase food, medications, and clothing due to lack of jobs and financial support. Socially, many of these individuals suffered from isolation, loneliness, shame, stigma, risk of contracting other diseases, and precarious sleeping conditions. The psychological burden was comprised of stress, depression, trauma, nightmares, and suicidal thoughts. CONCLUSIONS: The experiences of discharged patients in hospital detention suggest that they live in very deplorable conditions. There is a need for a functional healthcare protection mechanism, such as universal health coverage, to reduce the cost of healthcare services and surgical operations. Alternative payment mechanisms should also be considered.

A cost-effectiveness analysis of surgical care delivery in Eastern Uganda-a societal perspective.

BACKGROUND: The mismatch between the global burden of surgical disease and global health funding for surgical illness exacerbates disparities in surgical care access worldwide. Amidst competing priorities, governments need to rationally allocate scarce resources to address local needs. To build an investment case for surgery, economic data on surgical care delivery is needed. This study focuses on femur fractures. METHODS: This prospective cohort study at Soroti Regional Referral Hospital (SRRH), captured demographic, clinical, and cost data from all surgical inpatients and their caregivers at SRRH from February 2018 through July 2019. We performed descriptive and inferential analyses. We estimated the cost effectiveness of intramedullary nailing relative to traction for femur fractures by using primary data and making extrapolations using regional data. RESULTS: Among the 546 patients, 111 (20.3%) had femur fractures and their median [IQR] length of hospitalization was 27 days [14, 36 days]. The total societal cost and Quality Adjusted Life Year (QALY) gained was USD 61,748.10 and 78.81 for femur traction and USD 23,809 and 85.47 for intramedullary nailing. Intramedullary nailing was dominant over traction of femur fractures with an Incremental Cost Effectiveness Ratio of USD 5,681.75 per QALY gained. CONCLUSION: Femur fractures are the most prevalent and most expensive surgical condition at SRRH. Relative to intramedullary nailing, the use of femur traction at SRRH is not cost effective. There is a need to explore and adopt more cost-effective approaches like internal fixation.

High and low value care recommended and undertaken prior to knee or hip arthroplasty: a survey study.

INTRODUCTION: National and international clinical practice guidelines have stratified the value of osteoarthritis (OA) interventions. Interventions with strong evidence supporting effectiveness and benefit are 'high value care'. Appointment attendance, audits and practitioner surveys are widely used to determine frequency of recommendations and adherence to high value care. Greater patient reported data is needed in this evidence base. OBJECTIVE: To describe the frequency of high and low value care being recommended and undertaken by individuals awaiting OA-related lower limb arthroplasty. To examine sociodemographic or disease-related variables associated with being recommended different levels of care. METHODS: A cross-sectional survey of 339 individuals was conducted in metropolitan and regional hospitals and surgeon consultation rooms across New South Wales (NSW), Australia. Individuals attending pre-arthroplasty clinics/appointments for primary arthroplasty of the hip and/or knee were invited to participate. Respondents were asked what intervention(s) they were recommended by healthcare practitioners, or other sources of information, and what they had undertaken within two years prior to hip or knee arthroplasty. Interventions were classified as core, recommended, and low value care aligned with the Osteoarthritis Research Society International (OARSI) guidelines. We considered core and recommended interventions high value. The proportion of recommended and undertaken interventions were calculated. We used backwards stepwise multivariate multinomial regression to address aim three. RESULTS: Simple analgesics were most frequently recommended (68% [95% CI 62.9 to 73.1]). 24.8% [20.2 to 29.7] of respondents were recommended high value care only. 75.2% [70.2 to 79.7] of respondents were recommended at least one low value intervention. More than 75% of recommended interventions were undertaken. Respondents awaiting hip arthroplasty, living outside a major city and without private health insurance had greater odds of recommended rather than core interventions being advised. CONCLUSION: While high value interventions are being recommended to individuals living with OA, in most cases they are combined with recommendations for low value care. This is concerning given the high rates of uptake for recommended interventions. Based on patient reported data, disease-related and sociodemographic variables influence the level of care recommended.

Work conditions influencing professional development of specialist nurses in surgical care explored using the Job Demand-Resources theory: A qualitative study.

AIM: The aim of the study was to explore the work conditions that influence the opportunities for professional development of specialist nurses in surgical care. DESIGN: A qualitative descriptive design was used. METHODS: With a purposeful sampling procedure, 14 specialist nurses in surgical care were included. Four focus-group interviews were conducted during November to December 2021 and deductively analysed using the Job Demand-Resource theory as a guiding framework. Reporting adheres to COREQ guidelines. FINDINGS: Work conditions that were identified as job demands and that inhibited nurses' opportunities for professional development were mainly found at an organizational and leadership level. Primarily, those conditions included role ambiguity and time constraints caused by uncompensated nursing shortages that restricted the nurses from exercising their role. Such conditions could also discourage other nurses from further education. Job demands were seen as largely compensated for by work conditions identified as job resources and located mainly at an individual level, for example finding the work interesting and multifaceted. Most prominent was the participants' inner motivation to work with surgical patients and to continue to develop themselves and other nurses professionally. CONCLUSIONS: A prerequisite for professional development is that the specialist role is clearly defined in collaboration with representatives from the nursing profession and universities. Hence, hospital organizations need to reflect on how to utilize the competence. Also, it is important that nurse leaders promote the specialist nurses' motivation by supporting them in the exercise of their role. IMPACT: Findings from this study revealed work conditions that need to be acknowledged during hospital organizations' endeavours to maintain and enhance nursing competence. PATIENT OR PUBLIC CONTRIBUTION: Patient or public contribution was not applicable since the study focused on specialist nurses' working conditions.

Measuring person-centred pain management: Development of a questionnaire using the fundamentals of care framework.

AIM: To develop and test a questionnaire using the Fundamentals of Care framework to measure person-centred pain management. DESIGN: Cross-sectional exploratory descriptive design. METHODS: Development in three phases: (a) literature search for questionnaires measuring person-centred pain management, (b) seven-step process developing items using thematic analysis, (c) initial feasibility and validity testing. Theoretical and empirical evidence was used, including the 'Strategic and Clinical Quality Indicators in Postoperative Pain management' questionnaire, the Fundamentals of Care framework and person-centredness principles. Theoretical experts (n = 2) reviewed the questionnaire, further evaluated by providers (n = 5) and patients (n = 5) using a think-aloud process, and by additional questions in the questionnaire answered by n = 100 patients. The questionnaire was tested February to March 2021, at four surgical wards in a university hospital. RESULTS: The evaluation showed initial support for feasibility and validity, and the questionnaire was found to represent and be sensitive to capture the patients' experiences of person-centred pain management and being easy to answer. The 100 patients with acute abdominal pain who answered the questionnaire (aged 18-89 years, 46 women and 54 men), identified missing elements of fundamental care in their pain management, indicating that the questionnaire is sensitive to capture specific areas for improvement. CONCLUSION: This first attempt at transforming the essential components of person-centred pain management into measurable items in a questionnaire was found promising. The questionnaire is suggested to be further tested for psychometric properties and patient benefit to provide clinical guidance in acute surgical care to meet the patient care need of pain management. IMPLICATIONS FOR THE PROFESSION AND/OR PATIENT CARE: The developed questionnaire addresses the need of nurses and nursing leaders to evaluate the delivery of person-centred pain management in acute surgical care, to relieve the patient from pain. PATIENT OR PUBLIC CONTRIBUTION: Patients and providers were involved in testing the questionnaire.

Testing a model for person-centred pain management: A systematic review and synthesis guided by the Fundamentals of Care framework.

AIMS: To test a model for person-centred pain management using qualitative evidence in the literature and refine it based on the results. DESIGN: A qualitative systematic review with thematic synthesis using the Fundamentals of Care framework. METHODS AND DATA SOURCES: A literature search in February 2021 in six scientific databases: CINAHL, PsycInfo, Pubmed, Scopus, Social Science Premium Collection and Web of Science, reported using ENTREQ and PRISMA. Quality assessment was performed for the individual studies. Thematic analysis and the GRADE-CERQual approach were used in the synthesis including the assessment of confidence in the evidence. RESULTS: The model was tested against the evidence in 15 studies appraised with moderate or high quality and found represented in the literature but needed to be expanded. A refined model with a moderate/high confidence level of evidence presents elements to be used in a holistic care process; The nurse is guided to establish a trusting relationship with the patient and enable communication to identify and meet pain management needs using pharmacological and non-pharmacological management. Nurse leaders are guided to support this process by providing the right contextual conditions. CONCLUSIONS: The strengths of the confidence level in the refined model, and that it is represented from the nurse and patient perspectives in nursing research across countries and cultures, support our recommendation for empirical evaluation. IMPLICATIONS FOR THE PROFESSION AND/OR PATIENT CARE: The model links the knowledge of pain management elements from individual studies together into actions to be performed in clinical practice. It also outlines the organizational support needed to make this happen. Nurses and nursing leaders are suggested to test the model to implement person-centred pain management in clinical practice. PATIENT OR PUBLIC CONTRIBUTION: No patient or public contribution. IMPACT: What Problem Did the Study Address? There is a need to transfer available evidence of person-centred pain management into practice to relieve the patient from pain. What Were the Main Findings? Person-centred pain management is of high priority for patients and nurses around the world and can be performed in a holistic care process including patient-nurse trust and communication, supported by contextual conditions to deliver timely pharmacological and non-pharmacological pain management addressing the patient's physical, psychosocial and relational care needs. Where and on Whom will the Research Have an Impact? The model is to be tested and evaluated in clinical practice to guide the providers to relieve the patient from pain. REPORTING METHOD: Relevant EQUATOR guidelines were used to report the study: The Preferred Reporting Items for Systematic Reviews and Meta-Analyses Statement.

Development and validation of the perioperative care and user participation (POUP) questionnaire.

AIM: To validate a Perioperative User Participation questionnaire (POUP) that measures elective adult surgical patient experiences and evaluation of the significance of selected perioperative care items. MATERIALS AND METHODS: A generic perioperative user involvement questionnaire (POUP) was developed in the form of four psychometric scales based on the Fundamentals of Care (FoC) framework. The POUP is designed to capture patients' perceived and subjective importance of selected items of perioperative care. It was developed in Danish and comprehensive Danish-Norwegian translations were conducted. Face and content validation were conducted involving patients and expert nurses. The relevance of items was assessed by 68 patients, and the internal consistency of the scales was calculated. RESULTS: Danish and Norwegian patients assessed the POUP's face validity, and perioperative expert nurses reported no problems in clarity or ambiguity. However, a few reformulations of the questionnaire texts were suggested. None of the questions were reported as irrelevant or difficult to answer nor was any topic reported missing. Patients assessed all items as relevant, and the internal consistency for the three scales was between 0.8 and 0.9, and no differences between countries were found. CONCLUSION: The POUP questionnaire has four scales; the items are valid, but the scales need further statistical validation and refinement. At present, the POUP might provide insight into how elective adult surgical patients value the significance of perioperative care.