In the present study, after the introduction of the poster-based educational intervention, the performance of the operating room nurses with regard to their application of electrosurgical units improved in several aspects corresponding to the items of the checklist. Nurses must apply equipment in accordance with standard principles [20], and the results of the present study can help with better standardization of electrosurgical units. Accordingly, it is recommended that educational interventions be used more frequently to enhance compliance with the guidelines for application of electrosurgical units.
The statistically significant difference between the pretest and posttest performance of the operating room nurses with regard to items 2, 3, 5, 9, 11, 12, 16, 21, 25, 26, 27, 28, and 30 shows that they were influenced by the educational content of the poster: the nurses' mean score was significantly higher after intervention. With regard to the other items of the checklist, absence of a statistically significant change in the nurses' performance indicates that the educational intervention had not been effective, which can be attributed to various factors, including lack of specialized equipment in operating rooms or non-standardization of operating rooms for application of the latest equipment and facilities.
Items 1-8 on the checklist are instructions which are intended to increase the life of electrosurgical units and reduce the risk of electrocution. In order to increase safety and avoid stray voltage, it is vital that all operating rooms be equipped with earthed electrical outlets for electrosurgical units. Earth wires conduct unwanted electricity to the ground so the patient will not be involved in the current and will not suffer electrocution or burns [16, 21]. In the present study, some of the observed operating rooms which did not have earthed outlets in the pretest stage were found to have been equipped with such outlets after intervention.
Items 11, 13, 14, 15, 16, 17, 18, 19, 28, and 32 on the checklist are related to instructions which are intended to minimize the risk of burn injuries for patients. Other similar studies also stress that surgical teams must ensure that patients are not wearing any jewelry or metal belongings, check the security and placement of the return electrode, and examine patients' skin condition before and after surgery [7,16]. In the present study, the nurses' performance with regard to ensuring that the patients were not wearing any jewelry or metal belongings and that the return electrodes were securely placed was satisfactory both before and after intervention and there was not a significant difference between their pretest and posttest scores. The nurses' careful implementation of these procedures even before the educational intervention can be attributed to the obvious and immediate impact of incorrect use of electrosurgical units on patients' skin (burns). Another reason may be the imposition of regulations in the operating rooms of Shiraz which dictate that failure to perform the above-mentioned procedures will be recorded in the personnel's files and lead to a pay cut. With regard to examining and recording the skin condition of patients, the nurses' pretest and posttest behaviors were not significantly different, which could have been due to lack of a specialized skin examination checklist.
Item 12 deals with not using monopolar electrodes for patients with pacemakers. The interference of monopolar Electrosurgery with the pace making function of cardiac pacemakers can result in arrhythmia in patients with pacemakers [22]. This interference may change the sinoatrial rhythm to ventricular fibrillation and tachycardia, which can cause death [23].
In the present study, there was not a significant difference between the nurses' pretest and posttest behaviors in this regard, which can be attributed to the fact that their performance was acceptable both before and after intervention. The nurses' satisfactory performance even before the educational intervention can be due to the critical importance of this step, as failure to check whether or not a patient has a pacemaker before he/she undergoes electrosurgery can result in the patient's quick death.
Item 19 on the checklist addresses the use of specialized tools for cleaning the tips of electrosurgical monopolar pencils. These tips are coated with Teflon and must be cleaned with gauze soaked in saline, as impurities on the tips of the electrodes can prevent effective transfer of electrical currents to tissues [21]. In addition, the tips of the electrodes must not be cleaned with a scalpel as this can result in the spread of tissue particles in the atmosphere of operating rooms [16]. In the present study, the nurses' pretest and posttest behaviors in this regard were not significantly different, which can be due to lack of specialized polishers for the electrosurgical monopolar pencils.
Items 23 and 24 are related to the use of suction systems equipped with smoke absorber filters for the extraction of electrosurgical smoke and the application of high-filtration masks by the members of surgical teams. Electrosurgical smoke not only smells bad, but blocks surgeons' view [24]. Lack of a significant difference between the pretest and posttest results with regard to this aspect of Electrosurgery in the present study is due to lack of specialized suction equipment in the operating rooms under study. Sadly, it appears that the hospitals' authorities did not attach much value to the health and safety of the personnel—even though they invested in expensive advanced equipment to compete with other hospitals, they did allocate a budget for issues with long-term and inconspicuous adverse effects on the health of the personnel.
Item 31 is about removing the tips of electrosurgical pencils: since it is possible that these tips may come off and remain in patients' bodies, they must, according to standard guidelines, be counted at the end of surgery [16, 25].
In the present study, the nurses' pretest and posttest behaviors in this regard were not significantly different. This can be explained by the staff's inadequate awareness of the consequences of this occurrence or their dismissal of it due to its rarity.
In view of the serious risks of incorrect application of electrosurgical units to patients on the one hand and the human resources, the most important part of the healthcare system, on the other, effective education and strategies for easing financial pressure on hospitals should be taken more seriously. It appears that continuous education for a constant flow of information about the hazards of electrosurgery and ways of preventing them can prove effective in correcting the belief system of hospital personnel, managers, and surgeons. According to the Association of Perioperative Registered Nurses, educational posters are very economical and have many advantages, including reminding the personnel of the guidelines on a regular basis and saving hospitals money [16]. Overall, in the present study, the performance of the operating room nurses with regard to certain principles of the application of electrosurgical units as described in the checklist improved.
Limitations:
The limitations of the present study were the time-consuming process of observing the operations.
Strengths of the study:
The strengths of the study include: thorough and accurate observations of the operations for evaluation of the operating room nurses' application of electrosurgical units, development of an advanced educational poster, incorporation of up-to-date, standard educational content, employment of an easy-to-access, low-cost educational approach, and collection of data using a checklist with acceptable psychometric properties. Contribution to the body of professional knowledge: Development of a valid and reliable instrument for the evaluation of operating room personnel's application of electrosurgical units before, during, and after surgery. Development of an advanced educational poster of the guidelines for application of electrosurgical units which incorporates up-to-date, valid educational content for operating rooms. Increasing operating room Nurses knowledge and awareness regarding application of electrosurgical units and decreasing the hazards of incorrect application of these units for patients and surgical teams