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Articles that were not written or officially translated in English were excluded from the review. Articles included were required to be fulltext and peer-reviewed. Primary and secondary research has been used. Search strategies A computerised search of databases was undertaken to find relevant literature to support the research question. Search terms used were ‘perioperative’, ‘nursing’, ‘staffing’, ‘safety’, ‘fatigue’, ‘ratio’ and ‘training’ as well as derivatives and synonyms of these. Boolean operators of ‘AND’, ‘NOT’, and ‘OR’ were used. Examples of search strings used to search for literature include ‘perioperative nursing AND fatigue’, perioperative nursing staffing AND safety’, and ‘training FOR perioperative nurses’. Reference lists of the searched literature were also assessed to find relevant sources such as seminal research and primary studies that were referred to in secondary research. Data extraction and synthesis The references and articles identified for this review comprised primary studies, primarily qualitative, and mixed methods as well as secondary studies. Articles were appraised for relevance and synthesised. Synthesis used inductive thematic analysis and structured reporting. Themes generated related to perioperative nurse staffing in relation to fatigue, rostering practices, nurse training and nurse-to-patient ratios. Data extraction included collecting data on author, publication year, country, study aims, methodology, results, discussion and limitations. (Refer to the supplemental material: Literature matrix for data collection.) Data verification was completed by one reviewer to ensure that articles were relevant and met inclusion criteria. Quality assessment and quality scores Quality assessment of the articles was undertaken using the Standard Quality Assessment Criteria for Evaluating Primary Research Papers (Quantitative & QualSyst) tool10 and the Mixed Methods Appraisal (MMAT) tool11. These tools provide a framework to review research articles and allow for quantitative scoring of primary research articles to ensure their quality and rigor. Table 1 shows the scores given for each paper. Based on the QualSyst tool, a conservative cut-off of 0.75 was chosen for article inclusion, and an MMAT score of less than 15. Using tools such as QualSyst and MMAT allowed the reviewer to analyse and critique research articles using a series of frameworks and criteria. The diversity of these tools allowed a wide variety of articles to be examined, taking into consideration the vast array of different methodologies available. Using these tools has ensured that all articles included in this literature review are rigorous and of good quality. Discussion A multitude of factors exist that effect patient safety and quality of care within perioperative nursing. The perioperative field offers unique hazards and complexities which place patients at risk of suffering an adverse outcome during their admission. In the 2018–2019 report, the Australian Institute of Health and Welfare reported 2.6 health care– associated complications per 100 admissions across Australian public hospital facilities2 . Undeniably there is a direct link between perioperative staffing and safe surgical care of perioperative patients8 . ACORN has provided specific guidelines for perioperative nursing practice since 1977 when the first ACORN standards were developed12; however, ACORN’s contemporary standards allow for a more dynamic staffing process to take place8 . This process allows for assessment of patient acuity, turnaround times, procedure complexity and appropriate staffing to be implemented to provide safe and quality patient care8 . Discrepancies occur when budgetary factors override these staffing standards and jeopardise patient safety8 . The current ACORN Standards views nursing staff as valuable assets in perioperative care, and therefore cost-saving initiatives should not jeopardise safe staffing8 . A review of the available literature uncovered three common staffing themes that effect patient safety and the quality of care, these were; fatigue, nurse-to-patient ratios, and staff training1,3,4,6,8–25. The findings of this review in relation to these three themes will be examined, limitations will be noted and
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