| 33

Pensar Enfermagem / v.28 n.01 / March 2024

DOI: 10.56732/pensarenf.v28i1.289

Qualitative Original Article

How to cite this article: Pedro PR, Cerejo MN, Coelho AN. The preoperative nursing consultation:

constraints and suggestions for operationalisation - a qualitative study. Pensar Enf [Internet]. 2024 Mar; 28(1):

33-42. Available from: https://doi.org/10.56732/pensarenf.v28i1.289

The preoperative nursing consultation: constraints

and suggestions for operationalization - a qualitative

study

Abstract

Introduction

The preoperative nursing consultation can be seen as a privileged moment for transmitting

information to the person in a perioperative situation, to better prepare them for surgery

and promote their collaboration in perioperative care. As this procedure is not carried out

regularly, it is therefore important to carry out research into the reasons why it is not done.

Objective

To learn about the constraints to the operationalization of the preoperative nursing

consultation, through the perception of operating theatre nurses, as well as to identify their

suggestions for overcoming the constraints, and to analyse the strategies pointed out by the

nurses to prioritize this consultation.

Method

An exploratory, descriptive study of a qualitative nature. Data collection: focus group

interview using a semi-structured interview script, supplemented at the end with an

individual questionnaire containing socio-professional data and two open questions.

Participants: purposive sample - three groups of nurses from three operating theatres in a

central hospital in central Portugal. Content analysis was carried out according to Bardin's

framework. The study considered ethical principles and scientific integrity.

Results

It was possible to identify the constraints pointed out by the nurses: methodology for

operationalization, still undefined; shortage of available time; late bed allocation;

compromised privacy when carrying out the consultation; lack of recognition by

hierarchical structures; difficulties in adequate physical space; unpredictable prolongation

of intraoperative activities; distant residence of the person in a perioperative situation, and

deficient human resources. The following suggestions/strategies were identified to

overcome the constraints: allocation of more human resources; appropriate physical space;

the need for greater interdisciplinary coordination and to create visibility.

Conclusion

The preoperative nursing consultation is an autonomous procedure that nurses are

motivated to make operational, overcoming the constraints they point out and prioritizing

their suggestions.

Keywords

Qualitative Research; Preoperative Period; Nursing Consultation; Preoperative Care.

Paula Relvas Pedro1

orcid.org/0000-0001-5159-6586

Maria da Nazaré Cerejo2

orcid.org/0000-0001-7144-4571

Adriana Neves Coelho3

orcid.org/0000-0002-6381-71280

1 PhD student, Master. Universidade Católica

Portuguesa (UCP) | Faculty of Health Sciences and

Nursing, Lisbon. RN, Coimbra Local Health Unit,

E.P.E., Coimbra, Portugal.

2 Master. The Health Sciences Research Unit: Nursing

(UICISA:E), Nursing School of Coimbra (ESEnfC),

Coimbra. Portugal Centre for Evidence-Based

Practice: A JBI Centre of Excellence, Coimbra,

Portugal.

3 PhD. The Health Sciences Research Unit: Nursing

(UICISA: E), Nursing School of Coimbra (ESEnfC),

Coimbra. Portugal Centre for Evidence-Based

Practice: A JBI Centre of Excellence, Coimbra,

Portugal.

Corresponding author:

Paula Relvas Pedro

E-mail: pamarepe@hotmail.com

Received: 30.07.2023

Accepted: 20.12.2023

34 | Pedro, P.

Qualitative Original Article

Introduction

Nursing is undergoing a growing metamorphosis, bringing

about changes in clinical practice, a particularity that directly

influences the quality of health care provided to people with

illnesses.1

Because perioperative nursing (PN) is a central concept in

the study, it is critical that it be clarified in light of the

available literature. Thus, there are numerous concepts that

converge in the definition of PN as a specialized, diverse,

and increasingly complex area of expertise that encompasses

several subspecialties (authors). As Hicks2 points out, PN is

science and art that is constantly evolving.

The concept of PN has developed, with a greater emphasis

on the person in a perioperative situation (PPS) and

family/significant person experiencing health/disease

situations requiring anaesthetic-surgical interventions in a

perioperative context.3 Nursing care in this area of

specialization is also concerned with health promotion, the

prevention of complications, and the implementation of

disease-management strategies.3

During the surgical process, nurses evaluate the PPS, collect,

organize, prioritize data, develop nursing diagnoses, identify

expected results, evaluate the results obtained and the

person’s responses.4

Based on this premise, PN aims to: foster the development

of skills that provide quality care, as well as provide subsidies

for the optimization of the behaviours and attitudes of

perioperative nurses.4

The preoperative nursing consultation (PNC) is framed

within the scope of PN, incorporating a set of interventions

performed during the nursing process in various hospital

contexts to ensure the best and most favourable care for the

PPS.4 Promotes the humanization of care, self-care and a

healthy transition of the PPS/family/significant person,

towards a better and faster recovery.4

The operating room (OR) is currently understood as a unit

with an autonomous organic and functional structure, which

integrates human resources, material resources and

differentiated technologies to provide specialized surgical

care and anaesthesiology to the PPS.3.5

The guidelines of the Association of Perioperative

Registered Nurses (AORN)5 constitute important evidence-

based recommendations for the provision of safe

perioperative care to PPS, with the goal of achieving

workplace safety; they guide a perioperative care model

focused on the person and based on three dimensions:

safety of the person; their physiological response to surgery

and the behavioural response of the binomial person/family

to surgery;6,7 focus on surgical outcomes and advocate for

nurses to be legally qualified professionals, with a body of

knowledge and unique and recognized skills to implement a

PPS-centred model of care.7.8

The AORN Nursing Research Committee (NRC) has been

involved in developing scientific evidence considering the

AORN Research Priorities in PN 2023-2028.2,6 In this

regard, it purposefully emphasized two priorities; The first

priority is to build the science of PN practice by discovering

and translating evidence-based strategies in the clinical

setting; the second priority is to analyse and link

perioperative quality indicators in order to promote positive

outcomes for PPS through evidence-based practises.2,6

Perioperative nurses must be aware of these priorities in

order to conduct research that promotes safe perioperative

care and fosters the development of PN.2.6

The perioperative nurse has the important mission of

ensuring and providing the PPS with a quality clinical praxis,

guided by strategies that identify and assess their needs and

promote their satisfaction, always bearing in mind the three

dimensions of PN: the preoperative, the intraoperative and

the postoperative.8 At the same time, it is the perioperative

nurse's responsibility to prepare nursing records in

accordance with the PPS, to implement personalized

interventions, to evaluate the results obtained, and to

implement nursing care organization methodologies that

promote surgical quality and safety.8,9

The legislation, which refers to the specific competencies of

the specialist nurse in medical-surgical nursing, recommends

perioperative consultation as one of the five areas of

intervention, which also include preoperative and

postoperative consultations.3 The Association of

Portuguese Operating Room Nurses (AESOP)8 also

supports key PNC objectives, namely: the contribution to

the minimization of anxiety of the PPS; to evaluate the

surgery's expectations and knowledge; to allow knowledge

of the clinical history and the compromised needs,

facilitating the elaboration of diagnoses and the planning of

personalized care; to recall and clarify information already

provided, aimed at preoperative preparation and to provide

continuity of care.10,11,12 In light of the foregoing, it can be

stated that the preoperative evaluation serves as a

foundation for PNC support, providing subsidies for the

clarification of doubts regarding the surgical act and, in

particular, for greater reassurance of the PPS.

Each person's uniqueness will cause a nonlinear reaction to

surgery, which can be conditioned by psychosocial and

emotional factors, in which stress, to a greater or lesser

extent, conditions behaviours and expectations in the face

of a near future that is completely unpredictable and

unknown.10,11,12,13 The BO, on the other hand, can be

associated with the symbolic idea of a place of hope.11

During this time, different forms of communication

become important, so the perioperative nurse must use his

or her soft communication skills to foster a relationship of

help, proximity, and empathy, while also completing the first

stages of the Nursing Process.10,11,12,13

Regarding its operationalization, it is recommended, ideally,

that the PNC be performed by the nurse who will be

supporting the anaesthesia and in the 24 hours prior to the

surgery and should be scheduled with the inpatient nurse

and with the PPS.13

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DOI: 10.56732/pensarenf.v28i1.289

Qualitative Original Article

Despite the fact that the best and most recent scientific

evidence available emphasizes the importance of

implementing the PNC, which results in health benefits for

the person/family,4 it is found that its practice is not a

standardized procedure.14 The observation of this disparity

between theory and practice prompted the need to learn

more about the PNC's applicability and, more specifically,

the constraints to its operationalization from the perspective

of OR nurses. With this knowledge, findings may emerge

that help to operationalize this consultation as a regular

practice, considering that PNC is one of the most important

autonomous interventions of the PN that should be

highlighted, with a view to providing an excellent level of

care.3 As a result, it is critical to comprehend and respond

to the need to implement the PNC, capable of making a

better and more significant contribution to the PPS and the

family.

There are gaps in knowledge about the PNC, which has

received little scientific attention.14 The few studies in this

area suggest the importance of conducting future research

on the subject. Quantitative studies elucidate the importance

and benefits of PNC,4,9,10,11,12 however, no qualitative studies

specifically alluding to the theme under study have been

identified, which led to the need to develop a study with this

methodology, for a better understanding of the

phenomenon that was intended to be explored.

For the present study, the focus was on the synthesis of the

available evidence, taking into account the theoretical

framework of Meleis15, which advocates that the need to

promote a healthy transition is emerging, adapting the

strategies that facilitate improvement to the responses to the

processes of life, health and disease, with the nurse being a

facilitating agent of the process.15 This line of thought is

thought to underpin the phenomenon under investigation,

insofar as nursing interventions aim to enable the

PPS/family/significant person for a healthy and safe

transition, and, in this sense, should have the goal of helping

people manage transitions throughout their life cycle, in

order to prevent or minimize periods of crisis.15

In light of the foregoing, the following research questions

were developed: What, in the opinion of the OR nurses, are

the constraints to the PNC's operationalization? What are

their recommendations for dealing with the constraints?

What are the strategies that point to the PNC being

prioritized?

The objectives were: to know the constraints to the

operationalization of the PNC, through the perception of

the nurses of the OR; identify suggestions aimed at

overcoming the constraints to the implementation of the

PNC; to analyse strategies pointed out by nurses that allow

prioritizing the PNC. In this sense, the primary goal of the

current study aligns with the objectives in that it aims to

obtain consistent findings that can provide support for the

regular practice of PNC.

Methods

It was decided to conduct an exploratory, descriptive,

qualitative study for this research, based on the

constructivist paradigm, whose analytical scope seeks the

understanding of the phenomenon, the involvement of the

meaning of several participants, the historical and social

construction, and the generation of theories regarding the

phenomenon.16

In order to report the investigation, the translated and

validated guide Consolidated Criteria for Reporting

Qualitative Research (COREQ), according to Souza et al.17

COREQ is recommended for research reports in which data

are collected through interviews or focus groups.14 Its 32

items distributed in three domains, namely: characterization

and qualification of the research team, study design and

analysis of the results are part of its checklist, and all the

consolidated criteria for reporting qualitative research have

been addressed.17

The study involved participants invited from three operating

rooms (ORs) of a hospital in central Portugal. The ORs

were purposefully chosen with the following inclusion

criteria in mind: knowledge of the operating realities of the

three ORs in relation to the implementation of the PNC, the

OR where the principal researcher worked, being a part of

the study, and the development of the standard/recurrent

practice of the PNC in at least one of the ORs involved in

the study. In order to protect the identity of the ORs

involved, under Law No. 58/2019, of 8 August, which

concerns the General Data Protection Regulation, it was

decided to characterize the ORs in a succinct and concise

manner, through the following descriptive items: in OR1,

which was larger, the PNC was not usual practice; in OR2,

which was smaller, it was usual practice to have a PNC, and

in OR3, which was similarly small, the PNC was not

implemented at the time of the investigation. The sampling

method chosen was intentional because it allows the

selection of informants to participate based on the specific

knowledge of a given phenomenon.16 The nurse manager of

each OR played a significant role in the selection of

participants, acting as a liaison with the principal researcher

and disseminating information to potential participants via

e-mail. It should be noted that there is no relationship

between the principal researcher and the participants of two

of the ORs involved; however, regarding the participants

and the context in which the principal researcher worked,

the criteria of scientific rigor, described below, were

considered to prevent any type of bias in the ongoing

research.

Participants in the sample were those who worked in the

selected operating rooms and were divided into three groups

of 4 to 11 members based on the inclusion criteria: more

than two years of service in the current OR; greater

professional experience in the OR; preferential academic

training: postgraduate, specialization or master's degree.

36 | Pedro, P.

Qualitative Original Article

Exclusion criteria were nurses who were on prolonged sick

leave and nurses with less than two years of experience in

the OR. The sample was as follows: OR1, with 11

participants, coded from OR1 P1 to OR1 P11; OR2, with 8

participants, coded from OR2 P1 to OR2 P8 and OR3 with

4 participants, coded from OR3 P1 to OR3 P4. Two

members of OR3 declined to participate in the study, due to

unavailability on the date scheduled for data collection. The

nurses in the sample were those who worked in the hospital

institution's ORs between February 11 and March 4, 2022,

and met the inclusion criteria, totalling 23 nurses.

The data collection instrument was the semi-structured

focus group interview, this being "a type of group interview

designed to investigate the dynamics of the group".16(p.491)

Each focus group interview was moderated by the principal

researcher, who followed a script that had been previously

tested. For greater reliability and ease of transcription, the

focus group interviews were audio-recorded on a computer

platform and later validated by their participants. It was

decided to supplement the data collection with a Google

Forms questionnaire, which was made available to the group

participants at the end of each interview, to collect socio-

professional data and individual responses to two open

questions, allowing for greater data richness.16 The

interviews lasted between 45 and 70 minutes. A total of 3

focus group interviews were conducted, without repetition,

which culminated in the discussion of data saturation. The

transcripts were returned to the participants for clarification

and/or corrections.

For data treatment, the methodology of content analysis

based on Bardin was used.18 The focus group interviews

were transcribed in full, manually, including hesitations,

silences, and stimuli from the researcher, as well as the ORs’

and the participants’ codifications. Initially, a superficial

reading was carried out, to obtain a perception of the whole;

afterward, through the NVivo software - used as an aid in

the analysis process - the material was imported - interviews

and excel tables of the questionnaires. Subsequently, and

with a more attentive reading, coexisting units of meaning

were identified in the three focus group interviews, through

lexicographic textual analysis and similarity analysis. To

reflect the homogeneity of the corpus of the analysis, the

most frequently uttered words were used as a criterion for

the inclusion of words, which facilitated the processes of

filtering, coding, and categorizing, first in subcategories, and

only then, aggregating into categories; it also allowed for the

interpretation of the data and the highlight of the analysis's

conclusions.18

The ethical procedures for carrying out the investigation

were considered, according to Nunes.19 Authorization was

obtained from the Board of Directors of the hospital

institution for the development of the study, which included

the favourable opinion of the Ethics Committee (Official

Letter No. 017/CES, of 28/01/2022, alluding to Proc. No.

OBS. SF.163-2021). When they signed the informed

consent form, the participants were informed about the

purpose of the study, the voluntariness of their

participation, and the guarantee of data confidentiality.19

With regard to the criteria and strategies of quality and rigor

of the research, the criteria proposed by Lincon and Guba,

as mentioned by Velloso et al., were taken into account.20,

namely: credibility – through the triangulation of methods,

review anchored by faculty advisors and validation of

interviews; transferability – by the use of intentional

sampling, schematic presentation of results and provision

of the existence of a plan on the context and participants;

dependability – through the route's chronological and

systematic description, including interview notes and

observations, among others; Confirmability – by adopting

an inductive, neutral perspective, devoid of opinions, value

judgments and personal conclusions.20

Results

The total number of participants in the three ORs was 23

nurses, of which 22 were female and 1 was male. Regarding

age, 9 nurses were over 50 years of age, 10 were in the [40-

49] age group and 4 were in the [36-39] age group. Regarding

academic training, they were masters [n=3], specialists [n=9]

and graduates [n=11]. Regarding length of service, 4 nurses

had been working for more than 36 years; 8 were part of the

[26-35] year period, 9 were part of the [16-25] year period

and 2 were part of the [6-15] year period. Regarding the

length of service in the current service, 1 nurse had been

working in the current OR for more than 36 years, 6 nurses

were allocated in the [26-35] year period, 9 in the [16-25]

year period, 5 in the [6-15] year period and 2 in the [2-5] year

period. Regarding the type of working hours: shift working

hours [n=8]; fixed working hours with extensions [n=2];

fixed working hours (morning) [n=12], and other [n=1].

To have a better perception of the categorization process,

achieved by the analysis of the data obtained, it was decided

to present it in a schematic way. The identified units of

meaning, which emerged from the participants' discourse

and coexisted in the three groups, allowed us to guide the

codification into subcategories, which were then aggregated

into the categories listed below (Figure 1):

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DOI: 10.56732/pensarenf.v28i1.289

Qualitative Original Article

Figure 1 - Categorization. Source: NVivo

Thus, seventeen subcategories were named based on the

content's representativeness and the most evoked words,

and were organised as follows:

Beneficiaries, Importance attributed and Competence,

generated the category "Characterisation of the PNC". This

category reflects nurses' perceptions of the PNC, namely its

relevance, who has the competence to implement it, the

benefits arising from its practice and the beneficiaries

involved.

Methodology, Time, Absence from Service, Bed allocation,

Privacy, Recognition, Physical space, Intraoperative

activities, Residence and Human Resources, generated the

"Constraints" category. This category reflects the most

significant constraints expressed by nurses in achieving the

PNC, which include: the preference for scheduling over

face-to-face the day before; the limited time available; the

lack of recognition of its importance by higher hierarchical

structures; the lack of an appropriate physical space with the

necessary privacy; and the extensive intraoperative

programmes that retain nurses in the fulfilment of other

duties; If, on the other hand, the residence is nearby, the

PNC may only be able to travel to the hospital on the day

of the surgery, making the PNC impossible to perform,

according to the nurses. Finally, a lack of human resources

to carry out all nursing procedures, as well as an excessive

workload, are mentioned as major constraints by

participants.

Human resources; Physical space; Time/interdisciplinary

articulation and Create visibility generated the "Suggestions"

category. The suggestion of more human resources with

PNC practise competence is highlighted as an effective

strategy. The nurses, on the other hand, suggest that the

time set aside for the PNC be managed carefully, requiring

coordination with the interdisciplinary team to avoid

scheduling conflicts.

Finally, nurses believe that increasing visibility through the

PNC is a critical strategy for increasing the value of nursing

care and contributing to quality improvement.

The aggregation enabled the schematization of these three

categories in a conceptual structure that places the person at

the centre of nursing care (Figure 2).

Characterisation

of the PNC

Suggestions

Constraints

Benefficiares

Importance

attributed

Competence

Methodology

Time

Absenced from Service

Bed allocation

Privacy

Motivation / Recognition

Physical space

Intraoperative activities

Residence

Human resources

Physical space

Time /

Interdisciplinary

articulation

Create visibility

Characterisation

of the PNC

Constraints

Suggestions

PNC

Figure 2 - Conceptual structure – The person at the centre of nursing care. Source: NVivo

38 | Pedro, P.

Qualitative Original Article

Discussion

Considering the focus of the study (constraints and

suggestions of nurses in the operationalization of the

PNC), we cross-referenced it with the most recent

evidence, focusing on the words with the most relevance

within each subcategory.

"Characterization of the PNC" category – emerging

subcategories

Through the analysis, three subcategories alluding to the

category Characterization of the PNC were determined:

1 - Beneficiaries

Regardless of personal experiences, all participants

described the PNC as an important autonomous procedure

for providing personalized care, resulting in health gains for

the PPS, family, and significant contributions to nurses and

nursing.

".... Because we perceive that it is an added value for the

patient, for the professional (...), and for the

safety in the maintenance of the surgical process" (OR3 P4,

February 2022).

According to the participants' statements, the practice of

PNC has an underlying bilaterality of benefits for both the

PPS and family, as well as the nurse. Filho et al.21 support

this viewpoint, claiming that it benefits the nurse-PPS

relationship, promotes PPS comfort, and allows it to

"undergo the anaesthetic-surgical act in a safe, humanized

and risk-minimizing manner".(21 p5)

2 - Importance attributed "...It conveys significance (...) It

enables us to get to know the patient (...) the security we

provide him, the reduction of anxiety, for the surgery itself

(...) to bring our autonomous activities to light..." (OR3 P1,

February 2022).

The PNC is important, according to the participants,

because of the benefits to the PPS, the family, the nurse, and

the interaction established in a climate of person-centred

care humanization. Mendes et al.,9 in their study, corroborate

the same opinion; they also concluded that a higher level of

information contributed to a more active attitude on the part

of the PPS in its recovery. Other studies, such as those by

Gonçalves et al.,10 Breda et al.11 and Ruiz et al.,12 concluded

that the satisfaction of the psychological and informational

needs of PPS has impactful effects on minimizing anxiety

levels.

3 - Competence

"... the consultation does not have to be made by the

anaesthesia nurse (...) a nurse in the surgical area, yes,

because we must know how to answer the questions that are

posed to us (...) we must master the specificities of the

area..." (OR1 P5, January 2022).

Furthermore, the participants emphasized the importance

of competence in conducting the PNC, emphasizing the

need for expertise to answer people's specific questions

during the consultation. This concern is consistent with

previous research, such as that of Pedro et al.14, who suggest

that the anaesthesia support nurse is the best professional to

perform the PNC due to their frequent interaction with the

PPS during the intraoperative period.

"Constraints" category – emerging subcategories

The analysis revealed ten subcategories related to the

Constraints category:

1 - Methodology

".... We have already done this walk with the Pre-Operative

Visit many years ago, and we have not been able to get a

favourable opinion with the Boards..." (OR1 P3, January

2022).

Some participants claim that they have encountered

obstacles in their various attempts to operationalize the

PNC, which have always been rejected by the various

Boards of Directors, who have always claimed "unavailable

resources." The study by Pedro et al.14 supports these

considerations.

2 – Time

".... We have elements that are still being integrated (...)

integration in the Operating Room requires a lot of time and

availability (...). We do a lot of other functions right now that

take time away from us..." (OR3 P2, February 2022).

Time was cited as the most significant constraint, along with

work overload for the established schedule, late surgical

plans, and procedures that could be performed by other

professionals. According to Filho et al.,21 nurses should take

a more active role in the development of norms and

objectives that conquer space in their areas of expertise.

3 – Absence from Service

".... Patients are often absent to undergo tests: ECG,

scintigraphy, etc. (...) there is a high turnover of patients in

the wards, (...) the patient is absent, as he will only come on

the day of the surgery..." (OR2 P2, January 2022).

Some participants alleged high turnover/limitation of

available beds – The PPS's assigned bed is still assigned to

another PPS who has already been discharged. They

considered the need for articulation with the

multidisciplinary team to be urgent, which is consistent with

Lopes et al.5 claims, which uphold the importance of

organization and effective scheduling.

4 – Bed allocation

".... The patient not having a bed assigned at the time and us

walking around the ward looking for him (...) greatly

complicates the conditions under which the Visit is made."

(OR2 P3/OR2 P5, January 2022).

This constraint is expressed as likely to make the

implementation of the PNC unfeasible. Studies on

management models, which may include bed management

to improve efficiency, suggest subsidies to overcome this

difficulty; This is the case of the study by Silva et al.22

5 - Privacy

".... If there are other people in the space who have nothing

to do with the Visit, it will cause embarrassment and

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Qualitative Original Article

difficulties for the patients to express themselves..." (OR2

P6, January 2022).

Most of the participants allude that the lack of privacy

compromises PNC. There are ethical and legal issues that

must be addressed, in order to guarantee the anonymity,

confidentiality and security of the information

transmitted/received.10,21

6 – Motivation / Recognition

".... PNC is undeniably important, but are nurses truly

motivated to do it? (...) There will be constraints, and there

will be a lot of opposition..." (OR1 P6, January 2022).

In the analysis of constraints, the subcategory

"Motivation/Recognition" highlights a concern with the

possible lack of motivation of nurses to perform the PNC

without adequate recognition. Fauricio23, who emphasizes

the influence of professional recognition on the motivation

of health professionals, backs up this concern about

investment without subsequent recognition.

7 – Physical space

"... There is no proper space and space-time. (...) Then

there’s the constraint of where we are, which is [sensitive

data] ..." (OR3 P4, February 2022).

The absence of physical space is referred to as something

indispensable; a constraint to be overcome. In the opinion

of the participants, their absence interferes with the

performance and quality of the consultation; Interference

and interruptions in communication have also been

reported to be problematic. According to the study by

Lopes et al.5, the nurses' expectations include the creation of

a comfortable environment for the performance of the

PNC.

8 – Intraoperative activities

"... the lack of time, often due to the prolongation of

surgeries (...) elements still in integration (...). We take on

functions in the Sterilization Service that could be

performed by other professionals, with our supervision..."

(OR3 P1, January 2022).

All participants alleged excessive workload in the

performance of functions, and, for this very reason, argued

the need to prioritize interventions/procedures, "some of

which ended up not materializing" (sic).

The NAS - Nursing Activities Score - is an important

resource; however, as mentioned by Lorenzo et al.,24 there

are already studies that advocate the applicability of this

instrument in different scenarios, so its applicability in the

OR is something to consider, in the opinion of some nurses,

in order to justify the need to strengthen teams with more

human resources.

9 - Residence

"... Often patients come on the day of the surgery, in the

morning (...) it can happen if they are local and can easily

commute. We end up not contacting these patients before

the surgery... ". (OR2 P2, January 2022).

Some participants suggest that the distance from the

residence can cause constraints in the Residence

subcategory. In the case of a distant displacement, the family

accompaniment of the PPS can cause economic imbalances,

frequently affecting the family and affective structure.5.7

10 – Human resources

".... The argument of scarcity of human resources is one of

the most relevant in the discourse of [Hospital]

Administrations (...) it is one of the Service's most serious

shortcomings (...) Also, there's no telling who will

accompany the PPS on the day of surgery, as it might not be

the nurse who made the consultation... that familiar face."

(OR1 P6, January 2022).

In terms of the Human Resources subcategory, the absence

of these is pervasive in the discourse of all participants. They

refer to the issue of teams with low levels of secure

numbers. Filho et al.21 support the idea that a lack of human

resources negatively impacts the work of nurses, causing

physical and mental overload, with negative consequences

in the participants' level of satisfaction.

"Suggestions" category – emerging subcategories

Through the analysis, four subcategories alluding to the

category Suggestions were determined:

1 – Human resources

".... If there was a preoperative nursing consultation with a

schedule and with the availability of an element to perform

it (...) it would be ideal..." (OR2 P5, January 2022).

Within the scope of the Human Resources subcategory,

some participants propose the creation of a working group

containing experts from the various surgical areas, to outline

intervention strategies to be proposed to the higher bodies

to operationalize the PNC: who performs it? when is it

performed? where is it performed? The ADKAR

(Awareness; Desire; Knowledge; Ability; Reinforcement),

concomitantly used in the diagnosis of change management

in organizations, values team spirit for each stage of the

process25; In this sense, it is suitable for innovative changes

that imply teamwork.25 Lopes et al.5 argue that having a

nurse in an exclusive regime for nursing consultations, with

no other cumulative functions, is important.

2 – Physical space

"... We need a space, and it's not easy to get it; but it also

didn't necessarily have to be here, inside the Operating

Room (...) an outpatient or inpatient office (...) it would have

to be a space that we could occupy without constraints ..."

(OR1 P1, January 2022).

Regarding the Physical Space subcategory, the opinion of

the participants is consensual, and it is imperative to

determine a space that they can occupy during a certain

period, without interruptions. Breda et al.11 consider that

this measure provides the satisfaction of the information

needs of the PPS and the family, and the minimization of

anxiety levels.

3 – Time / Interdisciplinary articulation

"... That long-term consultation could be completed in a

timely manner if we had access to the Surgical Plan. (...), if

40 | Pedro, P.

Qualitative Original Article

there was this coordination between the medical and nursing

teams, we could reduce the time to a week or 15 days before

the operation..." (OR3 P4, February 2022).

The suggestion of "Time/Interdisciplinary Articulation"

highlights the importance of efficient collaboration between

the medical and nursing teams. This suggestion is in line

with the findings of Breda et al.11 and Pires et al.,13 who also

emphasize the need for solid coordination with surgeons

and anaesthesiologists to ensure consistent and safe

information during PNC.

4 – Create visibility

"... Our managers must understand the significance of being

involved as well (...) nurse managers with management

functions, nurse directors, the Board of Directors itself (...)

it is also important to create studies and obtain indicators".

(OR3 P4, February 2022).

The "Create Visibility" suggestion suggests involving

managers and conducting studies to support the importance

of PNC. This call for the creation of studies is supported by

Mendes et al.,4,5,9,10,11,14 who stress the importance of nurses

developing studies that demonstrate the cost-benefit and

efficacy of nursing consultations, providing tangible data to

persuade hierarchies and hospital administration.

According to the data analysis of the participants, most

nurses have innovative ideas, suggestions, and proactive

strategies planned and supported by evidence to achieve

their goals, which include: the implementation of awareness

and training programs for nurses to operationalize the PNC,

and the creation and implementation of quality

improvement projects with the same purpose. It is also

perceived that their prior experience with the PNC

interferes with the results obtained, to the extent that nurses

who work in the OR where the preoperative visit is

performed consider strategies to optimize it, such as

scheduling. Nurses who work in ORs where PNC is not

used, on the other hand, are more concerned with its

prioritization by hierarchical structures, adequate planning,

and operationalization. The study by Pedro et al.14 backs up

these findings.

Some participants argue that it is necessary to foster a spirit

of co-responsibility and collaboration among the hierarchies

at the top and middle of the organizational pyramid. In this

regard, some nurses propose: developing PNC training

based on the most recent evidence; developing indicators

sensitive to nursing care within the scope of the PNC;

developing studies and sharing the results to persuade the

hierarchies, and at the top, the Board of Directors, of the

impact of the PNC subsidies.14

Other studies, though not qualitative, report the following

main difficulties identified by nurses in the implementation

of the PNC: the time available for the procedure, the lack of

human resources, the overlapping of routines in the

inpatient units, the lack of planning, the lack of an

institutional protocol for performing the PNC, the routines

of the OR that decline the possibility of travel to the

inpatient within the working hours, unforeseen changes in

the operative plan, due to the need to adjust operative times,

the secondary priority assigned to the PNC, are some

examples.14 The more visible and recognized the nursing

consultation is in the organizational structure into which it

is inserted, the more successful it will be. To make the

implementation of this consultation easier, several factors

must be considered, including the potential number of

people to be tended, the procedures to be followed, the

human and material resources made available for its

implementation, and the expected time for the PNC to

achieve its goals. These points are supported by Lopes et al.5

and Farrely26, who state that it is possible to know the

production costs, obtain and provide data to the institution,

evaluate qualitative growth, know the costs of treatments

and procedures used, and allocate resources efficiently by

studying these issues. The perception that it is urgent for

nurses to develop studies that demonstrate the cost-benefit

and efficacy of nursing consultations is also supported by

evidence.4,5,9,10,11,14 Regardless of the obstacles that the

operationalization of nursing consultations may face, the

importance of this service justifies the effort required to

implement it, so nurses must make the commitment to work

in this direction.5,14,21

Because it is presented as an inaugural qualitative study in

terms of constraints and nurses' suggestions to the

operationalization of the PNC, the current study adds

scientific knowledge to the evidence. As a result, it is

believed that the findings obtained can be used as quality

improvement indicators.14,22,23

Conclusion

The PNC is a complex process that is influenced by a variety

of factors and has as its basic structure the provision of

nursing care. The findings allow for reflection on nurses'

professional interventions and the identification of potential

areas for change in order to improve clinical nursing practice

and health quality. It is critical to emphasize the role of the

nurse in the PNC in the context of elective surgery. This

professional must have PPS skills in a dimension that allows

them to provide excellent care, supported by evidence-

based practice. It is possible to find contributions that

favour the improvement of care quality and the

optimization of health outcomes in this dynamic between

professional experience and research.

In terms of constraints, participants in this study identify a

number of factors, including a lack of available time,

insufficient human resources, and a lack of appropriate

space, followed by: a lack of agreement on the methodology

to be used – whether in person, the day before, or by

appointment; PPS absent from the service, for the

performance of auxiliary diagnostic tests; delays in the

allocation of beds; privacy compromised at the time of the

PNC; lack of recognition of the PNC by the hierarchical

structures; unpredictable prolongation of intraoperative

activities; distant residence of the PPS.

Pensar Enfermagem / v.28 n.01 / March 2023 | 41

DOI: 10.56732/pensarenf.v28i1.289

Qualitative Original Article

Regarding the suggestions made by the participants to

circumvent the constraints they identify, the need for

interdisciplinary articulation with both the medical team and

the hierarchies of the organizational pyramid is emphasized;

the allocation of more human resources in the OR to

address needs that require immediate responses; the need

for an appropriate and reserved physical space for the PNC,

which may be external to the OR; and the need to create

visibilities are also highlighted.

In terms of practice recommendations, it is believed that the

findings obtained in this research are consistent for the

development of strategic plans appropriate to the contexts

of practice, inspired by change management theories -

transformational management -, capable of operationalizing

an innovative change that generates gains in health; As an

example, it is suggested that transformational leaders

implement the process management methodology, based on

Kotter's eight-step model, which allows the detail of the

change process to be implemented sequentially until the

intended innovative change is rooted, thus giving rise to a

new culture, so this may be the first measure to prioritize in

the PNC's operationalization.

This study is not an end in itself; it can serve as a guiding

thread for additional research, such as a study of nurses'

perceptions of the strategies to be implemented to

operationalize the nursing operative consultation (pre and

postoperative) and, in this sense, focus on nurses'

interventions, contributing to the improvement of care

quality.

This study is thought to have implications for the practice

of care in an inpatient elective surgery setting because of the

potential to increase the value of nursing care, with

replication possibilities in other operating rooms that

prioritize operationalizing the PNC.

Despite the limitations inherent in the research work,

namely the slowness and adequacy of the processes in the

methodological phase, this study can contribute to a greater

investment of the teams and management of the services,

enhancing the continuous improvement of the nursing

teams' performance, quality of care, and visibility of PN.

Authors’ Contributions

Pedro, PR: Conception and design of the study; data

collection; data analysis and interpretation; statistical

analysis; drafting the manuscript; critical revision of the

manuscript.

Coelho, AN: Analysis and interpretation of data; critical

revision of the manuscript.

Cerejo, MN: Critical revision of the manuscript.

Conflicts of Interest and Funding

No conflicts of interest were declared by the authors.

Sources of Support / Funding

The study was not funded.

References

1. Polit DF, Beck CT. Nursing research: generating and

assessing evidence for nursing practice. 11th ed.

Philadelphia: Wolters Kluwer; 2021.

2. Hicks RW. A Review of AORN's research priorities in

perioperative nursing 2023-2028. AORN Journal [Internet].

2023 Oct 26 [cited 2023 Oct 31]; 118(5): 284-286. Available

from: https://doi.org/10.1002/aorn.14027

3. Regulamento nº 429/2018 da Ordem dos Enfermeiros.

Diário da República [Internet]. 135(II série): 19359-19370

2018 Jul 16 [cited 2023 Jul 9]. Available from:

https://diariodarepublica.pt/dr/detalhe/regulamento/429

-2018-115698617

4. Mendes D, Ferrito C. Consulta de enfermagem pré-

operatória: Implementação e avaliação. Rev. Referência

[Internet]. 2021 Dec 29 [cited 2023 Jul 6];5(8):1-8. Available

from: https://doi.org/10.12707/RV20216

5. Lopes EC, Cerqueira MM, Rocha MC. As vantagens da

consulta de enfermagem presencial à pessoa submetida a

cirurgia ambulatória. Rev. Referência [Internet]. 2022 Set 14

[cited 2023 Jul 06];6(1):1-8: Available from:

https://doi.org/10.12707/RV21149

6. AORN. Association of Perioperative Registered Nurses:

Guidelines for Perioperative Practice. [Internet]. Denver:

AORN; 2023 [cited 2023 Jul 6]. Available from:

https://www.aorn.org/guidelines-resources/guidelines-

for-perioperative-practice

7. Roche SD, Reichheld AM, Demosthenes N, Johansson

AC, Howell MD, Cocchi MN et al. Measuring the quality of

inpatient specialist consultation in the intensive care unit:

Nursing and family experiences of communication. PLoS

One [Internet]. 2019 Apr 11 [cited 2023 Sep

30];14(4):e0214918. Available from:

https://doi.org/10.1371/journal.pone.0214918

8. Associação dos Enfermeiros de Salas de Operações

Portugueses. Enfermagem Perioperatória: da filosofia à

prática dos cuidados. Loures: Lusodidacta; 2012.

9. Mendes D, Ferrito C, Gonçalves M. A informação

transmitida na consulta de enfermagem pré-operatória:

perceção do cliente. Cadernos Saúde [Internet]. 2020 Jan 5

[cited 2023 Jul 9];12(1):47-3. Available from:

https://revistas.ucp.pt/index.php/cadernosdesaude/article

/view/7683

https://doi.org/10.34632/cadernosdesaude.2020.7683

10. Gonçalves MA, Cerejo MN, Martins JC. A influência da

informação fornecida pelos enfermeiros sobre a ansiedade

pré-operatória. Rev. Referência [Internet]. 2017 Jul [cited

42 | Pedro, P.

Qualitative Original Article

2023 Jul 09];4(14):17-26. Available from:

https://doi.org/10.12707/RIV17023

11. Breda LF, Cerejo MN. Influência da consulta pré-

operatória de enfermagem na satisfação das necessidades

informativas do doente. Rev. Referência [Internet]. 2020

[cited 2023 Jul 9];4(5):1-8. Available from:

https://doi.org/10.12707/RV20088

12. Ruiz HC, Gómez-Urquiza JL, Pradas-Hernández L,

Vargas RK, Suleiman-Martos N, Albendín-García L et al.

Effectiveness of nursing interventions for preoperative

anxiety in adults: A systematic review with meta-analysis. J

Adv Nurs [Internet]. 2021 Aug [cited 2023 Jul 9];77(8):3274-

3285. Available from:

https://onlinelibrary.wiley.com/doi/10.1111/jan.14827

13. Pires MAG, Rego A. Visita pré-operatória de

enfermagem: Importância da sua implementação. Servir

[Internet]. 2017 Dec 31 [cited 2023 Jul 9];59(5-6):54-9.

Available from:

https://revistas.rcaap.pt/servir/article/view/23467

14. Pedro PR, Cerejo MN, Coelho AN. Consulta pré-

operatória de enfermagem: Constrangimentos à

operacionalização na perceção dos enfermeiros [Internet]

[dissertation]. Coimbra (Portugal): Escola Superior de

Enfermagem de Coimbra; 2022 [cited 2023 Jul 26].

Available from:

https://web.esenfc.pt/pav02/include/download.php?id_fi

cheiro=140267&codigo=364

15. Im EO. Situation-specific theories from the middle-

range transitions theory. In: Im EO, Meleis AI (eds).

Situation specific theories: Development, utilization, and

evaluation in nursing [Internet]. Atlanta, GA, USA:

Springer, Charm; 2021 [cited 2023 Jul 6]; p. 71-87. Available

from: https://doi.org/10.1007/978-3-030-63223-6_6

16. Streubert HJ, Carpenter DR. Investigação qualitativa em

enfermagem: avançando o imperativo humanista. 5th ed.

Loures: Lusodidacta; 2013.

17. Souza VR, Marziale MH, Silva GT, Nascimento PL.

Tradução e validação para a língua portuguesa e avaliação

do guia COREQ. Acta Paul Enferm [Internet]. 2021 jun 1

[cited 2023 nov 6]; 34:eAPE02631. Available from

https://doi.org/10.37689/acta-ape/2021AO02631

18. Bardin L. Análise de conteúdo. Lisboa: Edições 70;

2016.

19. Nunes L. Considerações éticas a atender nos trabalhos

de investigação académica de enfermagem [Internet].

Setúbal: Departamento de Enfermagem ESSP|IPS; 2013 jul

[cited 2023 Jul 9]. Available from:

https://comum.rcaap.pt/bitstream/10400.26/4547/1/con

sid%20eticas%20na%20investig%20academica%20em%20

enfermagem.pdf

20. Velloso IS, Tizzoni JS. Criterios y estrategias de calidad

y rigor en la investigación cualitativa. Cienc Enferm

[Internet]. 2020 Dec. 19 [cited 2023 Sep 30];260:28.

Available from: https://doi.org/10.29393/CE26-

22CEIS20022

21. Filho, MAA, Batista RF, Cruz EA. Percepção dos

enfermeiros sobre a visita pré-operatória de enfermagem.

REAS [Internet]. 2022 mar 12 [cited 2023 Jul 18];(42):1-8.

Available from:

https://acervomais.com.br/index.php/saude/article/view

/2842

22. Silva GT, Góis RM, Almeida DB, Santos TB, Cantarino

MS, Queirós PJ. Evidence on nursing management models

in hospital services: an integrative review. Acta Paul Enferm.

[Internet] 2021[cited 2023 Jul 20]; (34):1-9. Available from:

http://dx.doi.org/10.37689/acta-ape/2021AR02095

23. Fauricio ACN. 8 Pasos de Kotter para la aplicación de

Cambios en un Proyecto. 2020 Oct 24 [cited 2023 Jul 20].

In: Zenodo [Internet]. Switzerland: CERN; 2020. Available

from: https://doi.org/10.5281/zenodo.4124345

24. Lorenzo LM, Takashi MH, Reis V, Cordeiro KJS, Costa

SF, Morais IFM. Aplicabilidade da Nursing Activities Score

para avaliação da carga de trabalho da enfermagem nas

unidades de terapia intensiva. REVISA [Internet]. 2023 Abr-

Jun [cited 2023 Jul 23]; 12(2): 313-20. Available from: Doi:

https://doi.org/10.36239/revisa.v12.n2.p313a320

25. Machado FLC, Siqueira MO, Figueiredo PS, Travassos

Junior XL. Quality management system adaptation process

in a crisis situation: An assessment from a change

management perspective. CLIUM [Internet]. 2023 mar 31

[cited 2023 Nov 6]; 23(4):248-262. Available from:

https://clium.org/index.php/edicoes/article/view/1051

26.Farrelly JS. The importance of explicit change

management in health care: An example from the operating

room. Jt Comm J Qual Saf [Internet]. 2022 Jan [cited 2023

Sep. 30];48(1):1-2. Available from:

https://doi.org/10.1016/j.jcjq.2021.11.004