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likely to make errors15 . Traditionally, health care organisations have been slow to adopt anti-fatigue policies16 . The implications of this are increased staff fatigue causing a higher risk of errors that compromise patient safety, and a poor workplace culture16. Conversely, the implementation of anti-fatigue policies causes a significant positive shift in patient safety and quality of care16. This in turn, fosters a culture that creates staff satisfaction and a positive work ethic13 . Additionally, perioperative nurses should be aware of the signs of fatigue, and manage their own fatigue appropriately7,13. Nurse-to-patient ratios The ratio of perioperative nurses to patients has been a topic of debate for some time4,8. This discussion is further complicated by the inclusion of anaesthetic technicians and surgical assistants8 . ACORN acknowledges that nursing staff have an integral role within the perioperative setting in ensuring staff safety8 . Current Australian standards recommend the operating room have a minimum of 3.5 nurses per session or per patient8 . For this review, only registered nurse (RN) staffing was reviewed in terms of patient safety and quality of care. The direct correlation between nurse staffing levels and patient safety is well examined in historic and seminal literature; however, there is a lack of current literature exploring this topic4,8. A series of mixed method surveys and audits completed in the United States of America show the importance of maintaining safe staffing levels within the perioperative setting17. This primary research revealed that as nursing staff levels increased per operating room, patient outcomes also improved17. From the hospital cohort (n=32) included in this study, 90 per cent (n=28) only had one nurse per operating room17. These hospitals saw 9 per cent of patients having a surgical complication and 7 per cent mortality during their inpatient stay17. Hospitals that had more nurses per procedure demonstrated improved outcomes for patients and decreased length of stay17 . Despite this research being from 2005, it is highly relevant and continues to be referenced in contemporary research. An important limitation to recognise is the complexity of influences on patient outcomes; therefore, it is difficult to ascertain the direct correlation between staffing and patient outcomes. Similar results were found in a seminal qualitative study conducted by Saver in 2005 where 1075 surveys were completed by nurse managers and directors across multiple health care sites18. Findings revealed that 67.33 per cent of participants stated that their department maintained staffing levels of two nurses and one technician per patient18. Following on from Saver’s work, another large seminal paper was published in 2008 by Garrett, conducting a crosssectional analysis performed with 10184 nurses and 232 342 patients revealing that each additional nurse per patient in the operating theatre increased safety and improved patient outcomes by 7 per cent16. The unique complexities of the perioperative department do not allow for traditional nurse-to-patient ratio formulas to be applied, instead staffing should be seen as a dynamic process8 . Thus, recommendations to uphold 3.5 nurses per patient per procedure should be strictly followed8 . Training The education and training requirements of perioperative nurses has long been discussed and researched18. This review found numerous articles, both historical and contemporary, relating to perioperative nursing staffing and education17–21. Perioperative nursing is not taught in the core curriculum of all Australian undergraduate nursing courses which presents two possible problems: difficulty recruiting new nurses to the perioperative specialty, and a lack of surgical and perioperative nursing knowledge19–21. Thus on graduation, novice nurses who enter the perioperative environment lack the theoretical knowledge and specialist practical skills to enable them to work in this specialist field22. This in turn may require timely and costly orientation programs to assist novice perioperative nurses to gain rudimentary skills and may cause significant stress to both staff and resources22. Secondly, if undergraduate nurses have not
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