Preventing well leg compartment syndrome among patients in the lithotomy position—Operating room nurses' perspectives: A qualitative study

Abstract

Aim

To describe operating room nurses' experiences of well leg compartment syndrome and how they work perioperative to prevent it during the lithotomy position.

Design

The study had a qualitative design.

Methods

Focus group interviews were performed with 10 operating room (OR) nurses. The interviews were semi‐structured and analysed by qualitative content analysis. The study complied with the Consolidated Criteria for Reporting Qualitative Research (COREQ).

Results

The main theme showed that the OR nurses shoulder duty and responsibility, independently and in the team, but they need more structural support and knowledge. The themes showed that they follow routines whenever possible and take responsibility for positioning; however, they have to balance between flexibility and strict routines. Although they also develop and participate in teamwork, they still need further knowledge.

Conclusion

The severe complication of well leg compartment syndrome (WLCS) can occur when the patient is in the lithotomy position. Maintaining the same routines and paying attention to the WHO's surgical safety checklist were described as actions that could prevent well leg compartment syndrome.

Patient or Public Contribution

No patient or public contribution. We have interviewed nurses but without financial support since the study was performed and supervised within a master programme.

1. INTRODUCTION

Operating Room (OR) nurses face daily challenges in terms of patient positioning. This requires both experience and routines to reach quality care. Since the lithotomy position is common for obtaining optimal access during various surgical procedures, it should be given close attention. The patient is exposed to risks when placed in leg support mode that can cause serious various complications of which well leg compartment syndrome (WLCS) is one. The healthcare system strives for patient safety, and therefore it is important to observe how the care around the patient and the surgery are carried out. In collaboration with the whole surgical team, the OR nurse has an important role when positioning the patient. It is therefore important to understand how OR nurses reason and work to prevent WLCS from occurring as a result of the lithotomy position.

2. BACKGROUND

Acute compartment syndrome is a condition in which increased muscle pressure inhibits blood flow in the affected muscle lodge. If compartment syndrome occurs, it is treated surgically by fasciotomy, which means that the fascia surrounding the muscle is opened to relieve the pressure. If not treated, it can lead to muscle damage and the release of myoglobin into the cardiovascular system, which can cause organ failure (Bauer et al., 2014). Clarke et al. (2017) describe WLCS as an iatrogenic injury inflicted on a healthy leg. WLCS is, however, quite unusual but nevertheless a serious complication of a leg support mode (Chow et al., 2007; Denholm & Downing, 2008; Krogh Christoffersen et al., 2017). Its frequency has been estimated at one in 500 cases involving compartment syndrome as a result of cystectomies (Simms & Terry, 2005). Several researchers (Krogh Christoffersen et al., 2017; Simms & Terry, 2005) state that even though the complication is probably continuously reported it is much underreported (Emiliani et al., 2016; Enomoto et al., 2016; Stornelli et al., 2016; Zekry et al., 2015).

Time, that is, long interventions in leg support mode, is crucial for the induction of WLCS (Enomoto et al., 2016; Zekry et al., 2015), but the length of time in leg support mode is not clearly regulated in the guidelines. The American Association of peri‐Operative Registered Nurses (AORN) (1984) made early recommendations for restrictions on leg support time. A recommendation was set to 6.5 h even if it was not possible to say exactly how long the patient could tolerate the leg support mode without complications. In addition, it was recommended that regular checks of distal status, oedema and colour should be carried out intraoperatively. Brouze et al. (2019) and Zekry et al. (2015) highlight patient cases where a hemi‐lithotomy position was used and compartment syndrome still occurred. Stornelli et al. (2016) have also reported a case with a shorter time of surgery, only 90 min that resulted in bilateral compartment syndrome in a young woman who underwent gynaecological surgery. Other factors that may increase the risk of WLCS are a high body mass index (BMI) and obesity in particular (Mizuno & Takahashi, 2016), even if these have also been questioned (Krogh Christoffersen et al., 2017). Mizuno and Takahashi (2016) also reported male sex and increased height as factors that increase risk.

In summary, the literature shows that leg support mode is associated with risks and that WLCS is particularly noted as a complication. It is an unusual but serious complication of the leg support mode, probably underreported and it is not always easy to observe its symptoms at the end of the surgery. Thus, preventive measures are of great importance since they cause great suffering to the patient. Since the OR nurses' work should be based on science and proven experience, it is considered important to explore how they prevent the onset of WLCS in clinical practice. Previous studies have called for guidelines and local routines for preventive work and quality development regarding positioning in a leg support mode, which justifies this study.

3. METHODS

3.1. Aim

The aim of this study was therefore to describe OR nurses' experiences of WLCS and how they work perioperative to prevent it from occurring during the lithotomy position.

3.2. Design

A qualitative design was chosen since we were interested in subjective experiences, and therefore qualitative design was seen as appropriate. Data were collected from focus group interviews and analysed using qualitative content analysis. The EQUATOR guidelines and COREQ checklist for qualitative studies were complied with (Tong et al., 2007).

3.3. Theoretical framework

The theoretical approach for this study was inspired by Rothorck and Smith (2000) description of the Perioperative Patient Focused Model. The patient is at the centre of the model. Patient safety includes outcome free from injury related to the surgical position. A goal is that perioperative nurses understand the risks of injury and take routine interventions to ensure patient safety.

3.4. Participants and settings

A strategic sample was chosen since we searched for a reasonable sample of participants with a variation of experience of the phenomena under study. Two medium‐sized hospitals were included from the middle part of Sweden. Participants were recruited through the National Association of Surgical Care and with help from managers at surgical departments and district coordinators.

The most important criterion for inclusion in the study was being an OR nurse working clinically where surgeries in the lithotomy position were performed. Other criteria were clinical work for at least 2 years and the nurses' ability to understand and express themselves in Swedish.

The two focus group interviews were performed by the first author with five OR nurses in each group. An individual pilot interview was rich in data and therefore also included in the analysis, resulting in 11 participants. All were women aged 35 to 62. Their experience of working as OR nurses varied between 3 and 32 years.

3.5. Data collection

The participants, who were informed by a contact person before the study, received written and verbal information at the start of the interview, and they signed an informed consent. In Sweden, performing interviews of staff about non‐sensitive topics is not requiring a regular ethical permission from the Swedish national review board. However, general rules regarding securing the participants' integrity, confidentiality and data management were followed. Managers of the surgical departments of the hospitals where the interviews took place were consulted, and they gave the study their approval. Data collection took into account the General Data Protection Regulation (GDPR).

The invitation to participate in the study was given verbally and by letter to the participants where the purpose, approach, risks and benefits of the study were described. The participants also had the opportunity to withdraw from the study at any time. They were guaranteed that all data collected were confidentially handled.

In the spring of 2019, the interviews took place at each hospital in a quiet room close to the operating clinic. Technical recording equipment, interview guide and the interview time were tested in a pilot interview that was made with an OR nurse selected through a convenient selection. The pilot interview took 35 min. The content was so interesting that it was decided that it should be included in the analysis. Thereafter, two focus group interviews were conducted, each of about an hour. Interviews were based on a semi‐structured interview guide with three main questions and follow‐up questions.

The three main open questions were: What are your experiences of compartment syndrome as a result of a leg support mode? Can you tell me about any situation when things have not gone very well? What do you do when there is good prevention of compartment syndrome, and are there any divergencies?

Recording of the interview was carried out digitally, and complementary notes taken during the interview were transcribed verbatim and deidentified. The recorded audio files and transcribed texts will be confidential for 10 years in accordance with the ethical regulations.

3.6. Analysis

Interviews were listened to thoroughly simultaneous with reading the transcripts. The transcribed text was then analysed line by line, using qualitative content analysis inspired by Graneheim and Lundman (2004). Initially, meaning units responding to the aim were identified and marked. These meaning units were then condensed when needed, that is, shortened, but core messages close to the text were kept. The meaning units were numbered so that they could be more easily linked to their origin during analysis. The condensed units were then coded and compared according to similarities and dissimilarities and grouped together based on their content and given tentative labels. The analysis continued until each group was perceived to be relatively comprehensive and did not overlap much with the others. The groups were then analysed hierarchically and relabelled and sorted into themes on various levels.

When the analysis of themes and subthemes was finished, the authors identified a pattern that formed a main theme and tied the results together. In all steps of the analysis, the first and second authors worked together to ensure trustworthiness and that a consensus was achieved regarding interpretations of the meaning units, condensations, labelling and sorting of themes and subthemes, and the identification of the main theme. For credibility, quotations are given as examples from the original interviews; and for transformability, a detailed description of the settings and the participants is given to the reader for consideration (Graneheim et al., 2017; Graneheim & Lundman, 2004).

4. FINDINGS

Our result describes OR nurses' experiences of WLCS and how they work perioperative to prevent it from occurring during the lithotomy position. The analysis of the interviews resulted in an overall main theme and five themes with two or three subthemes each. These are illustrated in Table 1 and described more in detail in written text where the subthemes are exemplified by quotations from the original text.

TABLE 1.

Themes at different levels.

Main theme: The operating room nurses shoulder duty and responsibility, independently and in the team, but they need more structural support and knowledge
Themes	Subthemes
Follow routines whenever possible	Ensure the use of the WHO checklist for safe surgery Follow and question guidelines Experience that routines about the time in the lithotomy position vary or are missing
Take responsibility for positioning	Take the time to position the patient in the lithotomy position Choose leg supports that are better for the patient in the given time Use materials and equipment that reduce the risk of pressure
Balance between flexibility and strict routines	Try to handle changing conditions wisely during surgery Deviate from the lithotomy position during certain operations
Develop and participate in teamwork	Ensure that the team around the patient works efficiently Share experiences with colleagues
Recognize the need for expanded knowledge	Too limited knowledge of factors causing complications after the lithotomy position Awareness of the risks related to certain procedures

The operating room nurses shoulder duty and responsibility, independently and in the team, but they need more structural support and knowledge.

This main theme was identified through the analysis of themes and subthemes. The OR nurses described that they had both a professional and personal responsibility for the patients which was, for example, shown when they strived to find out more information about the patients before surgery. Their duty and responsibility also highlighted by their efforts to strengthen teamwork. Many of the participants described that they usually followed strictly written routines and guidelines, but despite this they requested even stricter routines to follow. Similarly, among the vast majority of participants, it was described that they needed more knowledge of compartment syndrome related to lithotomy positioning.

Based on the main theme, five themes were constructed during the analysis: follow routines whenever possible; take responsibility for positioning; balance between flexibility and strict routines; develop and participate in teamwork; and recognize the need for expanded knowledge. The following themes are built on identified subthemes, which are described one by one and exemplified by quotations from the original text.

4.1. Follow routines whenever possible

The OR nurses described how patient safety increased when attention was paid to the WHO's checklist for safe surgery and the lithotomy position. Some followed clearly written routines and guidelines at their clinic, some worked with an aspiration to always work in the same way. Others documented the time the patient had been in the lithotomy position. An example of good preventive work was the importance of following the same routine, but some of the OR nurses described the routine regarding time in the lithotomy position as inadequate. They therefore tried to create their own routines for changed positions. The subthemes related to this theme are as follows: ensure the use of the WHO checklist for safe surgery; follow and question guidelines; and experience that routines about the time in the lithotomy position vary or are missing. These are described below.

4.1.1. Ensure the use of the WHO checklist for safe surgery

The WHO's checklist for safe surgery with calculated time for surgery and time for positioning was a help when planning the surgery. It was frequently used but may have needed to be developed regarding the prevention of compartment syndrome. Several participants expressed the need to also notice a change in the position and control of the legs after every hour.

“… [the importance of] that you have a point situation change for example.”

In the quotation, the point is associated with the importance of noticing when the tourniquet in the surgical field has been inflated for 2 h and has to be deflated, something they always strived to comply with. In relation to a future development of the WHO's checklist for safe surgery the OR nurses expressed that it should preferably mention controls of wounds or swellings, and a change of position after 1 h when the lithotomy position was used. By using the WHO's checklist for safe surgery, the whole team could more easily remember the risks of the lithotomy position. The use of a short checklist was suggested, for example, when professionals were switched during the operation, since it could be possible to miss reporting the length of time the leg had been in the leg support during long operations.

4.1.2. Follow and question guidelines

Since the participants strived to follow written guidelines, they became very frustrated the first time a severe complication such as compartment syndrome occurred and they did not find solutions in the guidelines. They also highlighted that it was positive when routines and guidelines were continuously updated and clarified, but at the same time it was also frustrating if they themselves were not updated.

“…we have the two‐hour rule now that we put legs down, it doesn't matter where we are in the operation. It is very rare in the day surgery that we have operations over two hours.”

Many described that when 2 h had passed, the legs were lowered 10 to 15 min and massaged. Some of the participants who did not work where the operations took so long time expressed hesitation about what was written in the routine or guideline at the clinic. They supposed that the guideline with a 2‐h limitation had probably been decided on as related to what applies to a blood‐free field and may therefore need to be investigated more. Even if they understood that the time and the pressure in the lithotomy position were correlated with risks, they also pronounced that the angle of the groin needed checking to determine if the patient's calf muscle was hard and tense.

4.1.3. Experience that routines about the time in the lithotomy position vary or are missing

The OR nurses expressed that they lacked some kind of reminder about the time the patient had spent in the lithotomy position to indicate that a change of position was needed. Some surgical clinics were described as having better routines concerning how long the patient could stay in leg supports, as, for example, the use of an alarm clock as a reminder after an hour.

“…you think this only takes half an hour, then you don't set the clock because you know you're done in a minute but then, if it doesn't, then there might be a little different focus.”

Some described that there existed verbal routines when it came to moving the legs, as, for example, every half hour but they were doubtful if these routines were written down. Routines also differed between hospitals, within the hospitals and between different surgical clinics, where some patients, for example, got leg massage at least once an hour when they were positioned in boots. Several described a lack of both written and verbal routines and therefore did not recognize any routines or guidelines for the lithotomy position. For example, they mentioned orthopaedic surgery as a particular problem in this context because the time in a leg support mode was rarely discussed.

“I don't feel like we ever talked about it, [such as] now we've been at it for half an hour now we have to make a position change.”

During orthopaedic surgery when the so‐called collum table was used, the position of the legs did not change often enough and sometimes the team did not lower the leg support, even when the need no longer existed to shorten the time in the lithotomy position. When the legs were covered with sterile draping, the control of the legs could easily be forgotten during surgery. The OR nurses experienced that routines were inadequate or were not written, and therefore they created routines about changes of position themselves. Several had a built‐in routine to change position once every half hour and gave examples of such approaches as during gynaecological surgery that continued for several hours. Other approaches were to choose lower leg supports and change the position a little during long surgeries. They described that previously, when leg supports were frequently used, the circulating nurse was advised to lower the legs, massage them and lift the calves. With the change to boots, this routine had changed and disappeared. The orthopaedic surgery of patients in leg supports is usually fast, but when the patient had been in leg supports for up to an hour, OR nurses were starting to think that the legs might be dropped. A conflict of interest was, however, built in, since surgeons wanted them to focus on the surgical wound and assisting, which could result in ignoring the change in the position of the leg support.

4.2. Take responsibility for positioning

To get as good positioning as possible, the OR nurses described that they checked the pressure on the legs and chose materials and equipment that decreased pressure against the legs. Sometimes, however, the surgery was acute, and there was no time to choose the best leg supports. Lithotomy positioning was usually prepared by OR nurses who were then informed if there was anything related to the patient that could make it more difficult to perform. When possible before sedation, the patient could describe how the pressure on the legs was perceived. The subthemes associated with this theme are as follows: take the time to position the patient in the lithotomy position; choose leg supports that are better for the patient in the given time; and use materials and equipment that reduce the risk of pressure.

4.2.1. Take the time to position the patient in the lithotomy position

The OR nurses described that if they could communicate with a conscious patient before sedation it would be easier to get a satisfactory lithotomy position.

“I usually raise the legs up and ask if it feels good, if it is possible to lie something like this… if the patient had a spinal anaesthetic, then it doesn't help, or if they're just going to sleep.”

The checks that were made concerned whether they tightened or pulled somewhere. Along with the checks, Tempur seat wedges were also used and it was noted that the heels were free. Some aspects could complicate the positioning in the leg supports as the anatomy of the patient's body, such as a person who was amputated, made an optimal lithotomy position difficult. By having knowledge in advance if it was a heavier patient, large boots could be selected. In addition, an inspection of the patient's legs was important to draw attention to wounds or leg ulcers that had to be taken into account when positioning. Also, other factors to consider were described, for example, older people who more often had worse circulation or if the patients had undergone previous surgeries in the leg, placing them in leg supports could contribute to poorer circulation.

“…if it is calculated on the operation program that it should take so long to get the operation started and it will be good for the patient, then maybe it must take more time.”

When it came to planned operations, the use of “blue legs” (boots) was described most. When using leg bowls, the OR nurses described that they paid attention to the squeezing of the legs and took the time to check for pressure on the legs. However, the same checks were not carried out when OR nurses used the blue legs (boots). During some orthopaedic surgeries, the operation was performed with only one leg in a leg support and the OR nurses described that the patient usually was not so comfortable. To reduce risks for the patient, OR nurses paid extra attention, for example, on X‐ray equipment that pinched or touched the leg support or if the legs were positioned very high, as this can increase the risk of compartment syndrome. Other important aspects to consider, they believed, were how the patients were transported when they were stuck in the leg supports.

4.2.2. Choose leg supports that are better for the patient at the given time

Many OR nurses described that they mostly used “blue legs”, which they also called boots or shoes because it was considered easier to get a better positioning of the leg. The boots were described as easy to handle and adjust. There was also a handle on the leg supports that even the sterile surgical staff could use to change the position. Since the operation previously was very heavy for the surgical staff, a change had been made in favour of these blue boots. In addition to this, OR nurses said that patients were more comfortable with them.

“I didn't think so when they arrived but they've really made a revolution I think.”

In the past, leg bowls were frequently used, but now they were not used as often. However, when there were emergency operations in gynaecology departments, OR nurses used leg bowls to make it quicker, and also during occasional on‐call operations. The leg bowls were available in different variants but felt too heavy and difficult to set up for the staff.

4.2.3. Use materials and equipment that reduce the risk of pressure

The OR nurses had used both leg bowls and leg boots (also called shoes) in a leg support mode. Previously, when they only used leg bowls and the operation was longer, gel pads were used as extra protection. They experienced that the material used in the newer blue boots was an improvement because it was softer for the legs. In addition, Tempur mattresses, which are softer, were used for the operation mode. Through the development of leg supports, OR nurses experienced the material as being softer over time and the risk of compartment syndrome reduced.

“…they are a little softer, anyway, we don't have any of these boots which are used now. They use them on longer operations.”

Those who had used leg supports in the past compared the newer boots to them and experienced that boots were softer for the legs. They constantly tried to think that it should be softer for the legs by using undercast padding, gel pads and sometimes using soft wrap, used when bandaging instead of hard straps when wrapping the leg. Furthermore, they tried not to tighten straps or windings too tightly on the leg in the leg support. In addition, they described that since all patients are different, a shoe or boot must be used that suits the patient, since they are made of materials that can be adapted for different patients. For example, there is the possibility of choosing larger shoes that better suit heavier patients.

4.3. Balance between flexibility and strict routines

The nurses tried to balance between being flexible and following strict routines. They were aware that changes during the operation make preventive work more difficult and the OR nurses therefore preferred avoiding changes. When it was possible to deviate from the leg support mode, they also tried to do so. It was difficult and created a conflict of interest when surgeons required an increase in height of the leg supports in order for them to carry out the operation. However, some operations were also performed in a different mode than originally planned. The subthemes associated with this theme are as follows: try to handle changing conditions wisely during surgery and deviate from the lithotomy position during certain operations.

4.3.1. Try to handle changing conditions wisely during surgery

The OR nurses described how they faced changes during operations, which meant that the operation could take longer time than expected. As a rule, the preparation of themselves and the patient was based on how long the operation was supposed to take. They were aware of the risk of complications that could increase if a situation changed and the operation did not go as planned. If there was sometimes a change in the operation and it became more complicated, it could cause the OR nurse to lose focus on how long the legs had been in the leg supports.

“…then we get a bleed, we get a hole in a vessel and there we stand a number of hours, then you have not prepared maybe as you would have if you had known that you were going to stand here for five hours.”

It was described as more difficult at very acute times, when it can even pose a danger to life when it comes to preventing complications such as compartment syndrome. If the OR nurses have set up the leg supports, they sometimes have to raise them for the operation to be carried out, especially during collum fracture surgery. It was also described as difficult to find the optimal position for the leg supports since different surgeons had different demands for positioning. The change of team members during the operation could make it more difficult to pay attention to how long the legs had been in the leg support position.

“I think then we changed for lunch, people come in and you go out and come in again, you don't say: now he's been in leg support for three hours… that report I don't think I've ever heard.”

4.3.2. Deviate from the lithotomy position during certain operations

The balance and flexibility also concerned the relation to and decisions by surgeons. In certain orthopaedic operations, they changed from the routines of the lithotomy position and chose the so‐called scissors mode instead. If the OR nurses believed that it was very difficult to get a good position in the leg support, the surgeons could perhaps find it possible to operate in a different position and thereby depart from the lithotomy position. Similarly, the OR nurses described that when the operation no longer required legs in the lithotomy position, it was important to return to the original position. This reduced the time patients would be placed in a leg support mode.

“I mean if the patient has his leg (raised) five minutes then that's the way it is, but when it is fixed you (must) go back to your original mode again.”

4.4. Develop and participate in teamwork

The OR nurses described how they in different ways led and participated in the teamwork around the patient. They described how the risk of compartment syndrome could be reduced through collaboration, and they assisted in positioning the patient in a leg support mode. Sometimes, but not often, the doctors were there to help, but they mainly mentioned the collaboration between the circulating nurse and the OR nurse. Similarly, the positive aspects of working with two OR nurses together were highlighted as this provided the opportunity for a transfer of competence. Effective teamwork was described as when the OR nurses choose to share important knowledge and experiences with others in the team. The subthemes in this theme are as follows: ensure that the team around the patient works efficiently and share experiences with colleagues.

4.4.1. Ensure that the team around the patient works efficiently

The OR nurses described that when the circulating nurse helped to put the leg in the leg support, a better position could be obtained for the patient. It was highly appreciated that the operating team was helped by the circulating nurse, who was responsible for observing the leg during the operation and lowering it when possible. The OR nurses, however, considered it important that everyone in the room who worked with patients in leg support had knowledge of the risks of a leg support mode.

“Then you think that it is good that even the nurses, who do not have OR nurse training, get it because it is not something that you might have thought about when you are studying a nursing course.”

If both the OR nurse and the circulating nurse checked the positioning, the safety of the patient increased. Sometimes, if the leg support position had changed during the operation and the leg hung more, the position had been adjusted during the operation, and it was described as the more people in the room who paid attention to the leg support position the better.

“I think I've experienced that you've changed the position, maybe at some point when you've seen that if the leg support has fallen out of position… that there is someone in the room who has said that now the leg hangs and that you have had to change the position during the operation.”

Sometimes they experienced that the surgeon also wanted to be present when placing the patient in the lithotomy position as he/she also shared responsibility for the positioning. During the operation itself though, the OR nurse experienced a great focus on the surgical procedure, and therefore someone else in the team could alert and remind the OR nurse concerning how long the leg had been in the lithotomy position.

4.4.2. Share experiences with colleagues

The OR nurses described that by discussing situations that arose with each other, experiences were shared and thereby could assume that care quality could be developed and make it better for the patients.

“…sometimes we discuss a situation between us, what someone has experienced as what we tried in relation to leg supports, so you try it further out.”

Experience was perceived as most important for preventing complications. Since experience and knowledge vary among the various OR nurses, it was seen as patient‐safe and led to professional development to work with two OR nurses together to be able to share their competence.

4.5. Recognize the need for expanded knowledge

Some of the OR nurses said that they had no experience with complications of leg support mode, while others had experience with compartment syndrome as a complication to the lithotomy position. The OR nurses though described that they were aware of the risks of certain procedures. They also made sure to use the knowledge they had gained through their training. The subthemes associated with this theme are as follows: too limited knowledge of factors causing complications after the lithotomy position and awareness of the risks related to certain procedures.

4.5.1. Too limited knowledge of factors causing complications after the lithotomy position

Some of the OR nurses were found to have no knowledge of complications such as compartment syndrome as a result of the lithotomy position. Since they had not heard of any situation when this had arisen as a result of the lithotomy position, some had difficulty understanding why the lithotomy position causes compartment syndrome. During the interview, it appeared that they wanted to know more about what causes compartment syndrome and whether the choice of leg bowls or boots had any impact.

“…is it when you use the leg bowls or is it with these boots, yes it would be nice to know.”

Since some had not previously heard anything about compartment syndrome as a result of the lithotomy position, it was something that experienced OR nurses seldom mentioned to the new ones.

4.5.2. Awareness of the risks related to certain procedures

Several OR nurses described the importance of making use of knowledge from their education. This was highlighted as particularly important since the OR nurses believed that their preventive work initiatives came from both their training and the experience they had gained. They described that in some operations, the position in the leg support was often overstretched and very high. The OR nurses knew that there was an increased risk to the patient in these cases, but not everyone knew why. Even though it means that the risks of a leg support mode increase in certain procedures, they followed the surgeon's instructions. Additional situations were described when they were aware that it was problematic as when a patient had received spinal anaesthesia and communication and evaluation of what it felt like to be in a leg support mode was difficult.

Several OR nurses described how they had knowledge and wanted to prevent the patient from lying too long in a bent position with boots, thus avoided getting too much pressure on the calf by the leg bowls given. They described how they checked if the leg supports were squeezing, if they felt too hard, used gel pads to make it softer and showed good insights into many of the risks that were related to patients lying for many hours. There were also some experiences shared, where compartment syndrome had occurred as a result of the lithotomy position and the participants described this insightfully. However, they also pointed out that it was usually only when something happened that the real insights came and routines were clarified.

“I think that it was after that incident that the rule came that one should lower the legs for ten or fifteen minutes so that the legs should be submerged.”

5. DISCUSSION

Our results showed in the main theme that the operating room nurses shoulder duty and responsibility, independently and in the team, but they need more structural support and knowledge. Responsibility is highlighted in Swedish law, SOSFS (2005:12). For example, adverse events must be reported, identified and documented. Furthermore, it is described in the National Board of Health and Welfare's regulations on management systems for quality and patient safety in healthcare (2005:12) that there should be local procedures prepared that define staff responsibilities. According to this regulation, it is the responsibility of the operations manager to decide with whom the responsibility of positioning rests.

The OR nurses said that it was their duty and responsibility to position the patient and also said that they had to balance flexibility and strict routines. Their responsibility for the patient and comprehensive care could sometimes be challenged. The result highlights that surgeon may be resistant to lowering legs for reperfusion of the limbs. OR nurses experience it quite difficult to consider with surgeons this need, and where power relations may be one problem.

However, the OR nurses tried to follow routines whenever it was possible, but it was not always easy. Jones (2010) describes the environment in which perioperative care is performed as complex, unique, often unpredictable and in constant development. In this environment, the OR nurses aim to provide quality and safe care based on the patients' individual circumstances. Often they are faced with situations they have never faced before, and as Jones suggests increased critical thinking could facilitate safe performance and qualitative and effective perioperative care. The OR nurses within this study suggested an expansion of the WHO's checklist and the use of a shorter version when staff changes during the operation so as to better focus on how long the legs have been in leg rests.

The basic rules for all healthcare are described in our Swedish Health Care Act (SFS 2017:30), which includes requirements for good care, good quality, meeting the patient's need for security and need for safety in care, preventing ill health, and developing and securing the task. Healthcare professionals must carry out their work on the basis of science and proven experience and are responsible for the performance of their duties. Evidence‐based practice is of great importance for patient safety and efficacy in care. A current article of Hara et al. (2021) suggests five interventions that can prevent WLCS, namely (1) changing from the lithotomy position to the open‐leg position; (2) removing lower leg pressure caused by the lithotomy position; (3) limiting leg elevation based on the height of the right atrium; (4) horizontally repositioning the operating table every 3 h and (5) decompressing the contact area of the lower leg in the lithotomy position during operation. However, our results showed that the OR nurses needed expanded knowledge, and neither time nor resources for education were always prioritized.

The OR nurses in our study requested written routines and strived to follow all routines when possible. The Association of peri‐Operative Registered Nurses, AORN, (1984) made recommendations for time in leg rests, but the OR nurses seemed to be unaware of them; however, they tried to create local routines about the change of position. Also, the Perioperative Patient Focus Model by Rothorck and Smith (2000)) shows the importance of following routines in perioperative care for patient safety. With unclear routines the risk for complications increases, the suffering of patients and costs for health care and community increase, which has to be dealt with.

Our results also showed that the OR nurses took responsibility for developing and participating in teamwork, which was seen as a necessity in the operating room. The OR nurses described the importance of knowing the team well, and an example of good teamwork was the sharing of experiences. As a team, they were helping and cooperating regarding positioning the patient. They, among other important factors, noticed and mentioned time in leg rests and noticed possible equipment that put pressure on the legs. Sandelin et al. (2019) described that most improvement in patient safety was made through professional, collegial teamwork and engaged leadership. Our results highlight the teamwork between the OR nurse and the circulating nurse as highly important to avoiding WLCS through controls and reminders about time. This is something that could also be developed through preoperative reflections in order to be prepared in advance. Sandelin et al. (2019) suggests a model for overall preoperative reflection where patients' health status, needs and details of surgery are included.

The importance of sharing knowledge with each other was highlighted. WLCS is uncommon and only experienced by a few; however, preventive strategies must be undertaken by everyone, and therefore sharing knowledge may be crucial for patient security. Bauer et al. (2014) consider a need for guidelines particularly when evidence is often based on case rapports and opinions from experts.

The OR nurses described different routines regarding time in the lithotomy position between hospitals and also between different surgical clinics at the same hospital. This leads to team insecurity. It was expressed that “something needs to happen before people act”, which is an ethical aspect concerning patient safety. The Health Care Act (2017:30) regulates and ranks ethical principles. In this case, effectiveness and reduced costs seem to have higher priority in healthcare than needs and human rights. Truly, an ethical problem that needs to be solved.

5.1. Limitations

Some limitations are worth mentioning. First, it was difficult to recruit participants. Many managers were unwilling to help us, and many did not have time to participate. A third focus group may have added relevant data to the findings. Another limitation was that the first author conducted the focus group interviews alone, when it is commonly recommended that two people are involved—one for interviewing and one for observation, and the reason was geographical distance to the second author. The interview guide and the interviews were though discussed in depth.

6. CONCLUSION

In conclusion, our result and main theme expressed that the OR nurses need more structural support and knowledge. This study highlights ethical problems to solve, where effectiveness and reduced costs seem to have higher priority in healthcare than both needs and human rights. Even though the OR nurses have the Health Care Act (2017:30) to follow which regulates and ranks ethical principles, they seem to struggle in their work.

7. RELEVANCE TO CLINICAL PRACTICE

Maintaining the same routines and paying attention to the WHO's surgical safety checklist was described as actions to prevent well leg compartment syndrome. If attention to the lithotomy position would be better acknowledged in the checklist and included the whole team, it would probably solve some of the problems, since teamwork has been described as important for problem‐solving.

FUNDING INFORMATION

The study was without financial support since it was performed and supervised within a master programme.

CONFLICT OF INTEREST STATEMENT

Neither of the authors has any conflict of interest.

ETHICS STATEMENT

According to Swedish Law ( SFS 2003:460) ethical approval was not needed since the interviews did not include vulnerable people, and no personal data was collected. Approval was given from participants and their managers.

Susanne, J. , & Åsa, H. (2023). Preventing well leg compartment syndrome among patients in the lithotomy position—Operating room nurses' perspectives: A qualitative study. Nursing Open, 10, 7092–7101. 10.1002/nop2.1971

DATA AVAILABILITY STATEMENT

Research data are not shared.