**2. Perioperative work environment and working conditions: why is it unique?**

#### **2.1 Perioperative settings and perioperative care**

A perioperative setting refers to operating departments where multidisciplinary teams, comprising perioperative nurses, nurse assistants, anaesthesiologists, surgeons and surgical assistants work together. Perioperative nurses are specialist nurses, that

is, nurse anaesthetists (NA) and operating room nurses (OR nurses), who provide care to patients during the perioperative period: pre- (before), intra- (during) and post (after) operative phases of anaesthesia and surgery. Special training is required for those who work in perioperative settings, which varies in different countries [7].

#### **2.2 The physical work environment**

The physical work environment in operating departments and operating rooms is unique. These are special rooms requiring a clean environment, with the least number of microorganisms in the air; therefore, the airflow is regulated to minimise airborne microorganisms and to reduce the occurrence of infections. In other words, operating rooms are closed rooms, sometimes without windows; thus not always allowing access to daylight, where the air is exchanged 15–20 times per hour [8, 9], with an air temperature between 20°C to 23°C and as low as 17°C [10]. This can result in operating rooms being experienced as cold rooms for those working in them. As Golvani and Roos [11] described, access to daylight can lead to feelings of joy and a sense of time, whereas a lack thereof contributes to feelings of fatigue and stress among OR nurses. Moreover, perceived incompetence, lack of confidence, relational problems with regard to the surgeon, and team members' disruptive behaviour were described as sources of stress for OR nurses.

Operating rooms are high-tech environments. There are several devices and apparatus in the environment, for example, a ventilator/respirator to help the anaesthetised patient breathe; equipment to monitor the patient's vital parameters, such as blood pressure, heart rate and saturation; a device for blood suction; a tourniquet; a device to burn the micro blood vessels and control the blood loss and a device that keeps the patient warm by blowing hot air into a blanket that is placed on the patient. Each device has its own alarm system to give a warning when, for example, the vital signs are not in the normal range and when something is wrong with the device; they also make a noise when turned on for use. There are also computers used for documentation, x-ray devices and other apparatus needed for specific surgeries. Despite the World Health Organisation's (WHO) recommendations regarding maximum noise levels at workplaces (including ORs) of 55 decibels (dB), operating rooms reach mean, median and maximum decibel levels of 71.7 dB, 69.4 dB and 90.3 dB, respectively, as shown in a study by Dornbusch, Boston [12]. In their study, the author collected data from surgical oncology surgery, soft tissue surgery, ophthalmologic procedures and orthopaedic and neurologic surgeries, among which the neurologic surgeries were associated with higher levels of noise. The authors indicated that in operating rooms where music was played, greater noise levels (mean 73.3 and median 71.3 dB) were measured compared to those without music (mean 70.6 dB and median 68.2 dB). It is also important to consider that besides the type of surgery, the number of people in the room, comprising scrubs and anaesthesia personnel, also adds to the noise levels [12].
