The formerly developed behavioral marker systems to assess surgical team´s non-technical skills include some exemplar behaviors that are related to nursing sub-team and circulating nurse´s non-technical skills (24-30). Only one ethnographic study (11) has been conducted to extract the circulating nurse´s non-technical skills; however, the study not reported exemplar behaviors, so we studied the references that are related to nursing and operating room to extract more behaviors. After reviewing the related studies and textbooks, we extracted the circulating nurse´s nontechnical skills´ behaviors. We used the definition ¨social, cognitive, and personal recourse skills that contribute to safe task performance and complement technical expertise (10)¨ and known non-technical skills to categorize these skills.
Communication is the exchange of information among surgical team members (22). This category is a very important element in nursing jobs. The circulating nurse should communicate appropriately with the patient, surgical team members, and others in the surgical ward. They can talk to the patient to decrease his/her fear and stress before the start of surgery (31-33). Circulating nurses should use a proper tone of voice as they stand foots away from the surgical bed (34) and talk about only relevant issues to the surgery (12). They give necessary information to the team members during the surgery and hand-offs (35). Table one shows the circulating nurse´s communicational skills.
Regarding circulating nurse´s duties, his/her leadership is not defined as ¨the capability to lead the surgical team¨; instead, it’s better to describe it as ¨heading the surgical team members occasionally by guiding them toward corrective actions when they have deviated¨ (11). Circulating nurses have a crucial leadership role (36), as they are known as ¨in charge of the operating room¨ (37). They control the operating room traffic (31, 38) and do not let unnecessary entrances. They lead the time out process (39, 40) and orchestrate the surgery process within the operating room (31). Table 2 shows the circulating nurse´s leadership behaviors.
Operating room nurses are subject to stress, as there are several stressors in the operating room (41). Circulating nurses should be able to cope with stressful situations (11), as they are the most stressed team member in the peri-operative phase of surgery (42). They should adopt quickly to changes (23) because their reaction against stressful situations can affect other team members and the process of surgery. In such cases, they might reposition instruments smoothly (11). Staying calm and dominant facing emergency situations and complications, being able to adapt with unpredicted and new conditions, Concentrating on the task that should be done at that moment, and a problem-solving based approach in stressful circumstances are the behaviors that were mentioned in the literature.
Circulating nurses should be able to work within the surgical team, cooperate with others, and stay coordinated with them. They function as an extra pair of hands and legs for surgical team, (43) and they help to prepare the operating room before start the surgery (44). Circulating nurses help other team members; for example, they help anesthesiology technicians during changes in patient status (15), induction, and intubation(45) and supporting sterile team members by providing their needs (45, 46). They could do it actively by walking around the operating room and helping team members (47). Circulating nurses also play an important role in coordinating activities in the operating room. They coordinate sterile team members with anesthesiologists (46), coordinate whole team activities (23) and needs (48) with out of the operating room. Table 3 shows the circulating nurse´s extracted teamwork skills.
Situational awareness refers to the perception of elements in an environment within the volume of space and time, understanding and comprehension of their meaning, and projecting their status in the near future (49). People, tools, patient, and instruments are considered as the elements of the operating room. A circulating nurse attends to the patient and reminds behind him/her during the induction of anesthesia. During the surgery, they watch and seek surgical procedure and monitor the sterile team´s needs (45). They should be able to anticipate the process of surgery and adjust his/her roles to meet the needs (17). Circulating nurses should ensure the patient´s safety and comfort (31) and should gather information about the patient-related issues (16). They should check the presence (50) and the correct function of the devices (16, 45) in the operating room before the start of surgery. Table 4 shows the behaviors related to the circulating nurse´s situational awareness.
Task management refers to the capacity of organizing resources to achieve the surgical team´s goals (22) and also maintain operating room standards. Circulating nurses should remain in the operating room until the end of surgery, like other team members (51, 52). They need to manage and prioritize their tasks to do efficiently (53) and do housekeeping of the operating room (54). Circulating nurses should do their duties with precision, for example, in opening the sterile packs (55). They should manage the specimens properly and pay attention to counting protocols such as recording count results immediately and correctly (45). Circulating nurses review and prepare patient’s documents (56) and know their roles and act toward them (57). Table 5 shows the circulating nurses´ skills in managing their tasks.
Decision-making and problem-solving
Circulating nurses can help in decision-making and problem-solving when the team faces problems. Behaviors like ¨participating in decisions by raising their opinion¨, ¨offering alternatives when necessary, using analytical decision making regarding the events¨, and ¨trying to identify and solve problems¨ were indicated in the literature.
Through reviewing the literature, we found some inappropriate behaviors that are against the circulating nurse´s non-technical skills and could endanger patient safety by deviating the surgery process. Table 6 shows these behaviors.