Nurses’ Priorities for Perioperative Research in Africa

Abstract

Background

Mortality rates among surgical patients in Africa are double that of surgical patients in high-income countries. Internationally there is a call to improve access to and safety of surgical and perioperative care. Perioperative research needs to be co-ordinated across Africa to positively impact perioperative mortality.

Methods

The aim of this study was to determine the top 10 perioperative research priorities for perioperative nurses in Africa, using a research priority-setting process. A Delphi technique with four rounds was used to establish consensus on the top 10 perioperative research priorities. In the first round, respondents submitted research priorities. Similar research priorities were amalgamated into single priorities where possible. In rounds two, respondents ranked the priorities using a scale from 1 – 10 (where 1 is the first/highest priority and 10 is the last/lowest priority). The top 20 (out of 31) were determined after round two. In round three, respondents ranked their top 10 priorities. The final round was an online discussion to reach consensus on the top 10 perioperative research priorities.

Results

A total of 17 perioperative nurses representing 12 African Countries determined the top research priorities were: (1) Strategies to translate and implement perioperative research into clinical practice in Africa, (2) Creating a perioperative research culture and the tools, resources, and funding needed to conduct perioperative nursing research in Africa, (3) Optimising nurse-led postoperative pain management, (4) Survey of operating theatre and critical care resources, (5) Perception of, and adherence to sterile field and aseptic techniques among surgeons in Africa (6) Surgical staff burnout, (7) Broad principles of infection control in the surgical wards, (8) The role of interprofessional communication to promote clinical teamwork when caring for surgical patients, (9) effective implementation of the surgical safety checklist and measures of its impact, and (10) Constituents of quality nursing care.

Conclusions

These research priorities provide the structure for an intermediate-term research agenda for perioperative research in Africa.

Glossary of Terms

APORG

African Perioperative Research Group

ASOS

African Surgical Outcomes Study

ASOS-2

African Surgical OutcomeS-2 Trial

CHERRIES

Checklist for Reporting Results of Internet E-Surveys

SAPORG

South African Perioperative Research Group

SSCL

Surgical safety checklist

Introduction

There is currently limited co-ordination of perioperative research in Africa. The South African Perioperative Research Group (SAPORG) previously used a Delphi technique (an anonymous consensus-building technique)¹ to determine the top ten national research priorities² for South Africa. This has been an unprecedented success which has addressed four of the 10 priorities^3–7, and others are currently being studied. Given that the primary uses of the Delphi technique is to generate consensus⁸ among experts and facilitate international collaboration, it is the ideal study design for determining African clinicians’ research priorities for perioperative research in Africa.

Internationally there is a call to improve access to and safety of surgical and perioperative care^1,9. To do this in Africa, we need to understand what researchers and clinicians in Africa consider research priorities that need to be addressed to improve surgical outcomes. The African Perioperative Research Group (APORG) network⁵, which includes researchers from over 30 countries, provides a unique opportunity to determine research priorities for Africa. Defining the research priorities for the continent will help to co-ordinate researchers in Africa on the most important issues that need to be addressed in the resource-limited African environment. Previously, we determined the top 10 perioperative research priorities for doctors in Africa¹⁰. However, what may be considered priorities for doctors may differ from other healthcare providers. Differing priorities may hamper the delivery of these research projects. To provide a more holistic picture of the perioperative research priorities for Africa, it is also essential to understand the priorities of perioperative nurses. Therefore, the aim for this study was to determine the top 10 research priorities for perioperative nurses in Africa, using a research priority setting process using a Delphi process.

Methods

Ethical approval was obtained from the Human Research Ethics Committee of the University of Cape Town (HREC 501/2019). All respondents provided written consent prior to participation. A Delphi technique¹¹ was used for this research priority setting project, which was conducted as an e-survey over three rounds with a final round virtual meeting. The Delphi was conducted between October 2020 and March 2021. This approach to consensus development for priorities was modelled on the previous priority setting processes conducted in South Africa², and Africa¹⁰.

We asked the national leaders of the African Surgical Outcomes Study (ASOS)⁵ and the African Surgical OutcomeS Trial-2 (ASOS-2) trial¹² to nominate one or two perioperative nurses in their surgical units (purposive sampling) to participate in this Delphi study. An email invitation including the participant information sheet was sent to all identified nurses (Appendix 1). This was a closed survey within this group and was not openly advertised. Participation was voluntary. There were no incentives for participation. The survey was piloted and checked by GJB on RedCap to ensure the scoring system was working accurately before each round. All survey data will be stored in a password protected Google Drive for 10 years after study completion.

In the first round, respondents were asked “what research questions do you think should be prioritised for perioperative research in Africa?”. They were requested to submit at least 6 potential priorities (i.e. research questions) via RedCap (https://www.project-redcap.org/ ) for perioperative research in Africa. The responses were collated into common themes and where appropriate, similar research priorities were amalgamated into a single priority by GJB and BMB. Conflicts were discussed until consensus between GJB and BMB was reached. In the second round, these potential research priorities were circulated to all respondents. They were asked to rank each priority on a scale from 1 – 10 (where 1 is the first/highest priority and 10 is the last/lowest priority). In the third round, the top 20 research priorities from round two were presented in rank order and respondents were asked to consider re-ranking their previous submissions from round two based on the grouped ranking results. If the respondents preferred not to change their previous rankings, they were encouraged to provide justifications for their decision.

The fourth and final round was held via an online meeting. We planned to present the top 10 (of the top 20 from round three) and confirm consensus with respondents on the final top 10 priorities. However, the mean score for the 9^th, 10^th and 11^th priorities were the same. Therefore, we deviated from protocol and respondents were presented with the top 11 research priorities from the results of the third round. Respondents were encouraged to openly discuss and negotiate these bottom three priorities and come to a consensus on the top 10 priorities.

The first round of the survey was conducted in English and French, with all communications, responses and proposed priorities communicated in both languages. In the first round, none of the respondents responded in French. Therefore, the remaining rounds were conducted in English only. All priorities were visible on a single screen in the second and third rounds, and all responses were captured electronically. If a response were incomplete, or the respondent wanted to change the response, they could resubmit a response during that round of the Delphi. The most complete response from a respondent in a round was included in the ranking. All responses were identifiable to GJB, who collated the responses per round for analysis, to ensure that the e-survey was completed only by the invited nurses, and to prevent inclusion of multiple e-surveys per round by a single respondent. Following collation of these responses, the database was then de-identified.

This e-survey is presented according to the Checklist for Reporting Results of Internet E-Surveys (CHERRIES) guidelines (Appendix 2)¹³.

Statistical analysis

The rank-order of the research priorities from the second and third rounds was calculated by using a reverse scoring system. A rank of one was assigned 10 points, with a descending point allocation down to a rank of 10, which was allocated one point. The scores of each respondent for each proposed priority were summed to present the research priority rank order. Incomplete responses (less than 10 priorities ranked) were included in the analysis, and no adjustments were made for incomplete responses.

Results

Twenty nurses working in surgical units across 17 African countries (Botswana, Democratic Republic of Congo, Egypt, Ethiopia, Kenya, Madagascar, Malawi, Mali, Niger, Nigeria, Rwanda, Sierra Leone, South Africa, Tanzania, Uganda, Zambia and Zimbabwe) were invited to participate in this Delphi study. Of the 20 invited nurses, seventeen participated, representing 12 African countries: Botswana, Egypt, Ethiopia, Kenya, Malawi, Mozambique, Nigeria, Rwanda, Sierra Leone, South Africa, Zimbabwe, and Zambia. The clinical and research characteristics of these respondents are shown in Table 1.

Table 1. Clinical and research characteristics of respondents.

Participate ID code	Full-time or part-time nurse.	Protected research time included in job description.	Years of nursing experience.	Postgraduate research training (e.g. research masters and/or PhD)
101	Full-time	Yes	16	No
102	Full-time	Yes	14	No
103	Part-time	Yes	17	Yes, PhD
104	Full-time	Yes	13	No
105	Full-time	Yes	16	No
106	Full-time	No	14	No
107	Full-time	Yes	7	Yes (courses in research methodologies)
108	Full-time	No	32	Yes (Postgraduate certificate in research)
109	Full-time	No	30	Yes (current Masters student)
110	Full-time	No	15	No
111	Not currently doing clinical work	Yes	32	Yes, PhD
112	Full-time	Yes	10	No
113	Full-time	Yes	19	Yes, PhD
114	Full-time	No	3	No
115	Full-time	No	25	Yes, Masters
116	Full-time	Yes	5	No
117	Full-time	Yes	32	Yes, Masters

Figure 1 summarises the Delphi process. In the first round, all 17 respondents proposed a total of 79 research priorities. Where appropriate, similar priorities were combined and grouped within seven themes: education and training, equipment and systems, preoperative, intraoperative, postoperative, staff collaborations, and quality of care. Similar research priorities were amalgamated into a single priority by GJB and BMB. A summary of this grouping and amalgamating process can be seen in Appendix 3. In the second round, 31 priorities were presented to all respondents. Eleven (of 17) provided a ranking (1 – 10, where 1 = first/highest priority and 10 = last/lowest priority) of all priorities. In the third round, the top 20 priorities ranked from round two were presented to all respondents. Thirteen (of 17) provided a ranking (1 – 10, where 1 = first/highest priority and 10 = last/lowest priority) for their top 10 priorities.

Figure 1. Flow chart depicting the Delphi process.

After the third round, there was a tie in the ranking for priorities 9, 10 and 11. Therefore, the top 11 priorities were presented to all respondents in the fourth round. Respondents discussed and reached consensus on the final agreed top 10 priorities, within six themes: education and training, equipment and systems, intraoperative, postoperative, staff collaboration, and quality of care, for perioperative research in Africa. These are shown in Table 2. None of the priorities within the ‘preoperative’ theme were ranked high enough to include in the final top 10 list.

Table 2. Top 10 priorities for perioperative nursing research in Africa.

Top 10 priorities for perioperative nursing research in Africa	Research theme
1.   Strategies to translate and implement perioperative research into clinical practice in Africa.	Education and training
2.   Creating a perioperative research culture and the tools, resources, and funding needed to conduct perioperative nursing research in Africa.	Education and training
3.   Optimising nurse-led postoperative pain management.	Postoperative
4.   Survey of operating theatre and critical care resources.	Equipment and systems
5.   Perception of and adherence to sterile field and aseptic techniques among surgeons in Africa.	Intraoperative
6.   Surgical staff burnout.	Staff collaboration
7.   Broad principles of infection control in the surgical ward.	Postoperative
8.   The role of interprofessional communication to promote clinical teamwork when caring for surgical patients.	Staff collaboration
9.   Effective implementation of the surgical safety checklists and measures of its impact.	Intraoperative
10.   Constituents of quality nursing care.	Quality of care

Discussion

Ten research priorities have been identified for perioperative research in Africa. These priorities, together with those identified from our previous research^2,10 provide the structure for an intermediate-term, African collaboration perioperative research programme. These priorities represent the consensus of perioperative nurses from 12 African countries, and they cover a broad range of topics which are context-sensitive to the challenges and needs of perioperative research in Africa¹⁴. Interestingly, our sample of nurses identified research priorities related to training and education, and quality of care. In contrast, doctors in our previous research¹⁰ identified research priorities mostly related to patient outcomes. Both this current study and our previous research identified staff collaboration as a perioperative research priority. Despite there being some commonalities, the nurses identified unique perioperative research priorities, emphasising the need for interdisciplinary collaboration in perioperative research.

Priority number 1: Strategies to translate and implement perioperative research into clinical practice in Africa

Given that this was the highest priority, it is likely that nurses are aware of research that is not being implemented into clinical practice. We have previously identified that the common barriers for conducting and implementing perioperative research in Africa are limited human resources and structural barriers, such as access to reliable internet access¹⁴. Clearly translation of research into clinical care is a neglected aspect of research in low- and middle-income countries. We need to address these barriers in tandem to achieve this priority.

Priority number 2: Creating a perioperative research culture and the tools, resources, and funding needed to conduct perioperative nursing research in Africa

This priority is consistent with our previous work: clinician-researchers across Africa believe that research is an important component of clinical practice and are motivated to contribute to collaborative African research¹⁴. The basic barriers explained under priority 1 need to be addressed to allow for the development of a perioperative research culture and establishment of ongoing perioperative research by nurses in Africa. In a human resource-limited environment, it is important that there is a focus on funding to provide research capacity, as the dual provision of clinical service, and perioperative research is unlikely to deliver quality research in this environment.

Priority number 3: Optimising nurse led postoperative pain management

Postoperative pain is poorly managed globally, however, poor postoperative pain management is particularly high in low-and middle-income countries^15,16. Poor postoperative pain management is associated with delayed mobilisation, compromised pulmonary function and chronic pain¹⁷. Nurses are ideal for leading postoperative pain management within the multidisciplinary team¹⁸. The implementation of nurse-led postoperative pain management has contributed to improved postoperative outcomes^19–21 and patient satisfaction with care²². However, inadequate training in pain assessment and management is a barrier to effective nurse-led postoperative pain management²³. A Nigerian study reported that pain management needs to be included in the undergraduate nursing curriculum²¹. There is a need for improved pain education among all members of the multidisciplinary team to effectively optimise nurse-led postoperative pain management and improve patient postoperative outcomes.

Priority number 4: Survey of operating theatre and critical care resources

There are well-established international guidelines for perioperative resource requirements from high-income countries²⁴. However, these guidelines are often inappropriate for the poorly resourced African settings due to the large disparities between the guideline, and the context on the ground. Our previous work¹⁰ and this current study indicate that both physicians and nurses in Africa want to know (1) what resources are currently available, (2) what resources are critically needed and most importantly (3) what resources are realistically attainable in their perioperative care setting. Our impression is that the international resource recommendations are far removed from the reality of the resources that are available, hence there is a call by clinicians¹⁰ and nurses to document this disparity, and develop a strategy to address this limitation.

Priority number 5: Perception of and adherence to sterile field and aseptic techniques among surgeons in Africa

Sepsis is a global health concern, contributing to postoperative morbidity and mortality. The incidence of sepsis is substantially greater in low- and middle-income countries than in high-income countries; additionally African countries may carry a higher rate of antibiotic resistance²⁴. Surgical site sepsis has been reported as the most common postoperative complication in Africa^5,25. To decrease the incidence of surgical site sepsis, it is vital for researchers to examine the perception of and adherence to sterile field and aseptic techniques intraoperatively among surgeons in Africa.

Priority number 6: Surgical staff burnout

Surgical staff burnout is common^26,27,28 and has been reported to be disproportionately high among South African anaesthetists^28,29. The Association of Anaesthetists has published guidelines for wellbeing, including resources on achieving a work/life balance, mindfulness, stress management, and coping with death³⁰. Importantly, this priority is vague when referring to ‘surgical staff’. It is unclear which surgical staff members respondents thought were specifically vulnerable to burnout. However, we suspect respondents are referring to surgical staff working in the theatres and perioperative wards, given that this priority was generated from the perspective of nurses working in the perioperative setting. The prevalence of burnout among perioperative nursing staff is unclear. Given the limited resources and staff shortages in low- and middle-income countries, it is likely that burnout among perioperative nurses is common^30,31. Identification of this priority suggests that burnout may be important in nursing in Africa, with further research into nursing staff burnout needed.

Priority number 7: Broad principles of infection control in the surgical ward

As stated above, surgical site sepsis is a major concern in Africa, and intraoperative sterility is a priority. This priority extends effective infection control to the postoperative ward setting. The emphasis on infection control intraoperatively (priority 5) and postoperatively (priority 7) in these 10 priorities may indicate nurses’ experience of poor adherence to aseptic techniques and a high incidence of surgical site sepsis, despite there being numerous national and international standards for infection control. These research priorities are consistent with the observations of high rates of sepsis in low resource environments.

Priority number 8: The role of interprofessional communication to promote clinical teamwork when caring for surgical patients

There is extensive literature to support the benefits of an interdisciplinary team approach to improve patient outcomes³² and satisfaction with care³³. Physicians also acknowledged the importance of effective communication and teamwork in our previous work¹⁰. Given that both nurses and physicians have both prioritised communication and teamwork suggests that ineffective communication may be impeding the teamwork necessary for quality perioperative research and care.

Priority number 9: Effective implementation of the surgical safety checklist and measures of its impact

The use of a surgical safety checklist (SSCL) has been associated with improved postoperative outcomes and decreases mortality^34–36. However, a SSCL is used in only 57% of surgeries in Africa⁶. The importance of the utilisation of a SSCL has also been prioritised by African clinicians^10,12. Further research is needed to identify the barriers to routine implementation of a checklist in Africa.

Priority number 10: Constituents of quality nursing care?

Postoperative mortality is substantially higher among patients in Africa than patients in high-income countries. Mortality rates among adult surgical patients⁵ and neonates⁷ in Africa are twice that of the global average. Maternal mortality after caesarean section is 50 times higher in African than in high-income countries⁷. Further, an 8 fold and 12 fold variation in outcomes due to the quality of maternal and neonatal care, respectively, has been reported between low-middle-income countries, and high-income countries³⁷. These data indicate the importance of improving the quality of perioperative care to successfully decrease mortality among surgical patients in Africa.

Strengths and limitations of the research priority-setting process

We are unaware of any other studies that have reported nurses’ priorities for perioperative research in Africa. This research echoes physicians’ priorities determined in our previous work^2,10, emphasising the importance of a survey of operating theatre and critical care resources, perception of and adherence to sterile field and aseptic techniques among surgeons in Africa, broad principles of infection control in the surgical ward, the role of interprofessional communication to promote clinical teamwork when caring for surgical patients, and how to ensure effective implementation of the SSCL and measure its impact. We would suggest that these common priorities should be addressed early to improve perioperative care in Africa. Limitations to this work are the small sample size and a lack of representation and unequal representation (e.g. 3 of 17 respondents were from Malawi) from all African countries. There is potential selection bias in this current study. Some respondents are involved in research-related activities and therefore could induce a bias related to their current research activities. Importantly, 10 (of 17) respondents have at least 10 years of clinical nursing experience and most (15 of 17) are full-time perioperative nurses. Therefore, these clinicians are well-versed to identify priorities for perioperative research to improve perioperative care.

The top 10 priorities for perioperative research in Africa are presented following a research priority setting process using the Delphi technique. Although there is some overlap in the research priorities among the respondents (nurses) in the current study and the doctors in our previous work¹⁰, the unique focus on training and education, and quality of care presented by the respondents in this study emphasises the need for ensuring interdisciplinary collaboration in perioperative research. These research priorities provide the structure for an intermediate-term research agenda for perioperative research in Africa. It is hoped that addressing these priorities will significantly improve perioperative outcomes in Africa.

Key points summary.

Question

What are nurses’ top 10 priorities for perioperative research in Africa?

Findings

Although there is some overlap in the research priorities among the respondents (nurses) in the current study and the doctors in our previous work⁹, the unique focus on training and education, and quality of care presented by the respondents in this study emphasises the need for ensuring interdisciplinary collaboration in perioperative research.

Meaning

These research priorities provide the structure for an intermediate-term research agenda for perioperative research in Africa.