Robin Riley

Establishing the shelf life of flexible colonoscopes.

This study was designed to establish a shelf life for processed (peracetic acid) flexible colonoscopes and to demonstrate the adequacy of manual cleaning procedures. The study challenges current practice in Australia where endoscopes are routinely reprocessed prior to use if the endoscope has been sitting at least overnight. The design was a simulated study in the clinical environment and involved artificial contamination of a colonoscope, cleaning validation, and a time series analysis after processing with peracetic acid in a Steris System 1 processor and drying with 100% isopropyl alcohol. The main outcome measure was the presence of bacteria in the internal channels of the colonoscope after cleaning and at 24 and 168 hours after processing with peracetic acid. The findings suggest that colonoscopes may be left for up to 1 week before needing to be reprocessed before use, provided all channels are thoroughly reprocessed and dried, resulting in cost savings and reduced wear and tear on the instruments. The findings also demonstrate the impact of providing feedback to staff on a regular basis about the efficacy of their cleaning techniques.

Governing the surgical count through communication interactions: implications for patient safety

Background: Intermittently, the incidence of retained surgical items after surgery is reported in the healthcare literature, usually in the form of case studies. It is commonly recognised that poor communication practices influence surgical outcomes. Aim: To explore the power relationships in the communication between nurses and surgeons that affect the conduct of the surgical count. Methods: A qualitative, ethnographic study was undertaken. Data were collected in three operating room departments in metropolitan Melbourne, Australia. 11 operating room nurses who worked as anaesthetic, instrument and circulating nurses were individually observed during their interactions with surgeons, anaesthetists, other nurses and patients. Data were generated through 230 h of participant observation, 11 individual and 4 group interviews, and the keeping of a diary by the first author. A deconstructive analysis was undertaken. Results: Results are discussed in terms of the discursive practices in which clinicians engaged to govern and control the surgical count. The three major issues presented in this paper are judging, coping with normalisation and establishing priorities. Conclusions: The findings highlight the power relationships between members of the surgical team and the complexity of striking a balance between organisational policy and professional judgement. Increasing professional accountability may help to deal with the issues of normalisation, whereas greater attention needs to be paid to issues of time management. More sophisticated technological solutions need to be considered to support manual counting techniques.

The 'time-out' procedure: An institutional ethnography of how it is conducted in actual clinical practice

Background The time-out procedure is a critically important communication interaction for the preservation of patient safety in the surgical setting. While previous research has examined influences shaping the time-out procedure, limited information exists on how actual time-out communication is performed by multidisciplinary surgical team members in the clinical environment. Methods An institutional ethnographic study was undertaken. The study was conducted over three hospital sites in Melbourne, Australia. In total, 125 healthcare professionals from the disciplines of surgery, anaesthesia and nursing participated in the study. Data were generated through 350 h of observation, two focus groups and 20 semi-structured interviews. An institutional ethnographic analysis was undertaken. Results Analysis revealed healthcare professionals adapted the content, timing and number of team members involved in the time-out procedure to meet the demands of the theatre environment. Habitually, the time-out procedure was partially completed, conducted after surgery had commenced and involved only a few members of the surgical team. Communication was restricted and stifled by asynchronous workflows, time restrictions, a hierarchical culture and disinclination by surgeons and anaesthetists to volunteer information and openly communicate with each other and nurses. Healthcare professionals became normalised to performing an abbreviated time-out procedure. Conclusions Patient safety was relegated in importance as productivity, professional and hierarchical discourses configured the communication practices of surgical team members to limit active, open and direct communication. Examining how the time-out procedure was conducted in the clinical environment enables possibilities to emerge for facilitating compliance with hospital and WHO guidelines.

Development and Validation of the Self-Administration of Medication Tool

Background: Consumer participation in planning and implementing health care is actively encouraged as a means of improving patient outcomes. In assessing the ability of patients to self-medicate, health professionals can identify areas in which patients need assistance, education, and intervention to optimize their health outcomes after discharge. Objective: To develop and validate a tool to quantify the ability of patients to administer their regularly scheduled medications while they are hospitalized. Methods: Past research enabled us to develop the Self-Administration of Medication (SAM) tool. Using a Delphi technique of 3 rounds, a panel of expert health professionals established the content validity of the tool. For determining level of agreement in using the SAM tool, 56 patients were selected; for each patient, 2 randomly selected nurses completed an assessment. Construct validity and internal consistency were examined by testing the tool in 50 patients and comparing with other validated scales. Results: The 29-item SAM tool had high content validity scores for clarity, representation, and comprehensiveness, with content validity index values ranging from 0.95–1.0. In testing the level of agreement between 2 nurses, out of 43 valid cases, 95.3% of nurses overwhelmingly agreed about the patients’ competence to self-administer their drugs. The intraclass correlation coefficient was 0.819 (95% Cl 0.666 to 0.902). Internal consistency for the SAM tool was high, with a Cronbachs alpha of 0.899. A moderate to strong correlation was obtained when comparing the SAM tool with other validated measures. Conclusions: The SAM tool is valid and reliable for quantifying patients’ ability to manage their regularly scheduled medications in the hospital setting.

Governing the Operating Room List

This chapter focuses on the power relationships in communication between nurses and surgeons as they struggle to structure work activities around the operating room list; that is, the schedule of surgical procedures to be performed each day in operating rooms. Drawing upon data from a larger ethnographic study that explored communication in operating rooms (Riley and Manias, 2001, 2003, 2004, 2005, 2006a, b), in this chapter we deconstruct the discursive communication practices that surround the operating list using the Foucauldian (1977, 1978, 1979, 1980, 1982) tools of discourse, power, knowledge and subjectivity. It is argued that nurses are positioned between competing organizational discourses that privilege time and efficiency and the hierarchical dominance of surgeons. However, despite this complex positioning, nurses challenge surgeons’ traditional and hierarchical right to determine the order of the operating list, and position themselves as active subjects in ways that challenge the traditional, handmaiden image of nurses who work in this setting.