According to the Global Patient Safety Action Plan 2021~2030 of the World Health Organization (WHO), “Patient safety is a framework of organized activities that creates cultures, procedures, behaviours, technologies and environments in health care that consistently and sustainably lower risks, reduce the occurrence of avoidable harm, make error less likely and reduce its impact when it does occur” [1]. In recent decades, patient safety has been under intensive focus globally and has become a global public health concern. The data from the WHO [1] show that in high-income countries, 1 in 10 patients experience adverse events during hospital treatment while in low- and middle-income countries, there are 134 million adverse events per annum due to unsafe hospital care, resulting in approximately 2.6 million deaths. Rochefort et al. [2] and Nilsson et al. [3] reported that 30% to 58% of adverse events are preventable and that 20% to 25% of these preventable adverse events result in permanent disability or death. Unsafe healthcare also leads to economic losses. Slawomirski and Klazinga [4] estimated the social cost of patient injuries to be US$ 1~2 trillion per year.

Among in-patient adverse events, those ascribed to surgical treatment are the most common. Surgery, which is designed to treat diseases and remove excess matter, is an invasive procedure that poses safety risks to patients. The reasons for this include the complex composition of the surgical team, complex surgical procedures, use of high-risk drugs during surgery, high surgical turnover rate, and time pressure for rapid surgical procedures during emergencies [5]. Potential patient safety incidents in operating rooms (ORs) include residual foreign body accidents after surgery, wrong-site surgery, surgical site infections, falls, and electrosurgical injuries [6, 7]. Hempel et al. [8] found 0.09 events related to wrong-site surgery and 1.32 events related to retained surgical items per 10,000 surgeries in the United States from 2004 to 2014. The most frequently reported adverse event reported in the Joint Commission International Alarm Event Database in 2015 was residual foreign body accidents after surgeries, the occurrence of which had been increasing year on year [9]. Although the number of patient safety incidents in surgeries is much smaller than the number of surgeries performed, the harm caused to patients, their families, healthcare staff, and the healthcare system can be devastating [10].

Although surgery-related adverse events are usually considered to be associated with the skills of surgeons, the complexity of surgical procedures, and patient conditions, these events are now known to be associated with many other factors, such as healthcare system design, teamwork, and organizational safety culture [11]. Safety culture refers to the values, attitudes, and beliefs of the members of an organization toward the life and safety of their staff or the general public; minimizes the harm to patients during medical services; and is an overall model of the attitude, ability, behavior, and value of a group, individual, and institution [12]. Furthermore, safety culture is considered a key factor in shaping the safety cognition, attitude, and belief of clinical medical staff. Meanwhile, the safety attitude of medical staff and their cognition and attitude toward adverse events also reflect the safety culture of medical institutions [13].

According to the Association of Perioperative Registered Nurses (AORN), OR nurses are registered nurses who work in hospital surgical departments, day surgery units, ambulatory surgery centers, and in-clinics or physician offices that perform invasive procedures; they also include scrub nurses and circulating nurses. OR nurses are different from nurses in other hospital units as they provide healthcare and assist in invasive procedures that directly involve critically ill patients and their work poses greater potential risk to patient safety. Building a safety culture in an OR requires fostering teamwork. Surgeons play a leading role in the OR; however, the role of OR nurses should not be ignored. OR nurses are responsible for coordination in the OR, observing changes in the patient’s vital signs and collaborating with the surgeon and anesthesiologist. OR nurses’ communication and coordination skills are directly associated with the success of surgery [5]. Hierarchies exist in the OR, with the surgeon generally having great freedom of expression and with OR nurses lacking opportunities to offer suggestions or make requests. As a result of poor communication, breakdowns in multidisciplinary teamwork in the OR are reported as one of the most common factors that contribute to the occurrence of wrong site surgeries and other surgical adverse events [14].

Birkmeyer et al. [15] showed that a low level of safety culture is associated with a high incidence of surgical adverse events. However, Rocha et al. [16] reported that OR nurses have a relatively poor overall perception of patient safety. Pimentel et al. [17] also reported that OR nurses have a lower level of understanding of safety culture than anesthesiologists and surgeons. The Patient Safety 2030 Report [18] by the National Institute for Health and Care Research shows that more training in safe patient care should be provided for healthcare professionals over the next 15 years to raise their awareness of this issue and thereby improve patient safety. Indubitably, nurses play a positive role in improving patient safety, but it should also be recognized that most nurses do not receive appropriate patient safety training. Hence, it is important to understand the types of patient safety education for nurses [19, 20]. As reported in several studies [21, 22, 23, 24], patient safety training positively improves the safety attitude of surgeons and OR nurses, changes doctors’ cognition and attitude toward patients falls, and improves nurses’ awareness of blood transfusion safety. Therefore, personal safety cognition, attitudes, and beliefs could be altered through education and training, which can in turn improve the safety culture of the whole organization. Considering that the establishment of safety culture requires the establishment of correct safety cognition, attitudes, beliefs, and values, we carried out patient safety training based on the knowledge–attitude–practice (KAP) theory for OR nurses through face-to-face lectures, case-based teaching, group discussions, scene simulation training, and online teaching. KAP theory revolves around health-related behavior change, arguing that healthcare knowledge and information are the basis for establishing health beliefs and forming a positive attitude toward change in health-related behavior while belief and attitude are internal motivations for behavior change [25]. Previous studies [26, 27, 28] have shown that KAP theory-based training for nurses with a focus on hospital-acquired infections and patients’ physical restraints has achieved good effects. In the current study, we hypothesized that a safety training program based on this theory enhances the patient safety awareness of OR nurses, strengthens safety beliefs, and promotes a strong sense of safety among nurses at work, thereby encouraging them to engage in rigorous nursing behavior.

Therefore, this study developed a surgical patient safety training program on the basis of KAP theory and employed a combination of various teaching methods. It aimed to evaluate the effect of the proposed program on improving the safety attitude, cognition, and attitude toward adverse event reporting of OR nurses.

The results of this study demonstrated that after the implementation of the patient safety training program using various teaching methods on the basis of KAP theory, the total scores and dimensions of the C-SAQ and the revised questionnaires of the cognitive and attitudes toward adverse event reporting of OR nurses were significantly higher than those before training, similar to the results of previous studies [21, 22, 40]. Our study shows that the proposed surgical patient safety training program based on KAP theory and delivered using a variety of teaching methods has positive effects on patient safety culture among OR nurses. Another study [21] conducted a one-day safety culture training for 90 surgeons and found that at 3 months after the training, the surgeons’ safety attitudes had changed significantly. The US Veterans Health Administration [40] created a safe operational environment by forming an interdisciplinary team to implement a medical team training program. Habahbeh and Alkhalaileh [22] conducted a 4 h safety education study on 66 OR nurses and reported the improved safety culture levels of the OR nurses.

In recent years, some patient safety intervention programs have emerged, and they focus on unsafe factors in medical techniques and processes. However, particularly in hospitals throughout China, safety promotion activities within an organizational culture have not been fully implemented and internalized, and there remains a large knowledge gap among healthcare staff in terms of their attitudes toward and cognition of patient safety. Habahbeh and Alkhalaileh [22] speculated that in view of the complexity and high risk of nursing work in the OR, OR nurses need to strengthen their safety awareness through group discussions, situational drills, and other forms. Biglan and Embry [41] demonstrated that the repetition and strengthening of individual behavior leads to cultural changes in group values, attitudes, abilities, and behavior. Therefore, in addition to developing OR nurses’ professional skills to meet patient safety needs, continuing education is crucial. Continuing education can reduce the problems caused by the gaps in education levels and help nurses bring their professional knowledge and attitude up to standard [42]. Thus, implementing patient safety education for individuals can alter individual cognition, attitudes, and values that would improve organizational safety culture. Therefore, the comprehensive model training of nurses based on the framework of KAP theory can constantly improve and update OR nurses’ knowledge and change their cognition. In addition, the training would help managers fully mobilize nurses’ enthusiasm to participate in safety management by prompting them to identify potential safety hazards, report patient safety incidents caused by nonhuman factors, and ultimately promote the formation of a safety culture atmosphere based on a collective upholding of safety management standards and mutual trust. In addition, our training program disseminates knowledge via a combination of online and offline learning, thereby enabling nurses to integrate emotion, knowledge, skills, and attitudes via knowledge sharing, acting, and discussing and ultimately realize the rapid transformation of knowledge into practical ability.

It is worth noting that our training program had a less positive effect on the nurses’ management perception, stress recognition, and job satisfaction in comparison with the other aspects of safety attitude (0.5 < Cohen’s d < 0.8); this result is similar to the those of Ameryoun et al. [21]. In a survey [43] on the safety attitude of nurses in the OR, the score of the cognitive dimension of stress was low, which might be due to tedious nursing work and complex surgery in the OR. This requires cooperation between surgeons and anesthetists, resulting in heavy workload, long overtime hours, and a complex working environment. The results of Park and Kim [44] showed that healthcare providers lack the ability to manage stress effectively or have limited ability to cope with stress. In addition, the social status of Chinese nurses is not high, resulting in greater pressure from all aspects related to work. Thus, in a high-pressure working environment, nurses are likely to make mistakes and experience negative emotions, resulting in low job satisfaction [45]. Our study showed that it is difficult to effectively ameliorate OR nurses’ work stress and improve their job satisfaction simply through patient safety training. Hospital managers should humanize the workplace and improve nurses’ job satisfaction via various means, such as creating a flexible scheduling system for alleviating workload; providing guarantees in terms of salary, vacations, and welfare; reappraising the value of nursing work; and improving hospital facilities. At the same time, teamwork is essential in ORs. It is necessary to provide interprofessional patient safety training for the entire surgical team, which could help overcome communication barriers among nurses, surgeons, and anesthesiologists and thereby increase nurse engagement.

In this study, nurses’ perception regarding adverse events had little effect on department culture (0.5 < Cohen’s d < 0.8). A key point in improving patient safety is the accurate monitoring of adverse events. However, when facing adverse events, nurses may fail to timely handle and report adverse events due to a lack of relevant knowledge, insufficient communication, or fear of being reprimanded by superiors [10, 46]. Kohn et al. [47] proposed that healthcare staff must be informed of the definition and classification of adverse events, types of reports and reporting system procedures, and the benefits of reporting in order to improve their cognition of adverse events. It is advisable to provide more training on adverse events to improve nurses’ cognition, develop correct attitudes, and promote adverse event reporting. Our study confirms that building a department culture involving an active reporting of adverse events in the OR cannot rely solely on nurse training programs. Lozito et al. [10] proposed that obstacles to reporting adverse events include poor communication, fear of punishment and legal sanctions, lack of knowledge of the reporting process, and lack of attention from superiors. If organizations can communicate sincerely in the face of adverse events, ensure smooth reporting channels, take nonpunitive responses to errors, actively organize learning, and improve continuously, the occurrence of the underreporting of adverse events can be reduced. Several studies have confirmed [48, 49] that the deep-rooted punitive consciousness and responsibility system are major factors affecting nurses’ initiative to report adverse events and that the blame culture not only affects the active reporting of adverse events but also exerts other negative effects. It is important to cultivate an organizational culture that enables nurses to identify and explain their mistakes and the causes, thereby preventing recurrence [50]. Thus, it was suggested that managers should examine safety issues from a systematic and overall point of view, improve the system, clarify the related declaration regulations and processes on adverse events, and optimize the reporting process or links to make the operation scientific, reasonable, and convenient. These parameters need to be based on a nonpenalty system, confidentiality mechanism, and appropriate incentive mechanism. In addition, diversified and multiple reporting channels should be established such that the information construction of safety management is accelerated to promote timely feedback. In addition, it is advisable to provide interprofessional patient safety training to hospital managers, surgeons, and anesthesiologists to establish the appropriate team communication channels.

Some important limitations of this study should be acknowledged. First, this study was conducted only in a single hospital in Sichuan, China, and a quasi-experimental design was used. Therefore, the sample size was small in this non-randomized controlled trial, which limits the generalizability of the results. Second, the training content of this study has not been strictly evaluated by experts; hence, there may be some deficiencies in the setting of training content. Finally, the indicator of the effect evaluation in this study was only the results of the subjective questionnaire filled out by the participants, and it did not include the objective results related to nurses’ behavior. Therefore, there were many uncontrollable factors in the results. In the future, the patient safety training on OR nurses can be carried out through more rigorous curriculum and study settings, and the effect of the training program can be evaluated through objective indicators.

The results of this study proved that the proposed patient safety training program based on KAP theory improves the cognition, attitudes, and beliefs related to the safety culture of OR nurses. This approach is expected to improve the safety and quality of nursing care for patients in ORs. Furthermore, carrying out a safety culture training project in an OR could increase the objective nursing process or outcome indicators for the evaluation of the training effect. The program could also facilitate the exploration of the training intervention methods, duration, and other related issues. It is suggested to carry out interprofessional patient safety training. However, to improve nurses’ job satisfaction, reduce work pressure, and support their active reporting of adverse events, in addition to strength training, hospital managers need to focus on the aspects of workflow, management systems, department culture, and other means to promote a positive and healthy OR safety culture.

Supplementary data to this article can be found online at https://doi.org/10.4040/jkan.22017.

Supplementary Figure 1

Video of the process of transferring pathological specimens.

Supplementary Figure 2

Video of procedures for patient identification.

Supplementary Figure 3

Video of counting of surgical instruments and materials.

Supplementary Figure 4

Operating room WeChat teaching platform.