Surgical Safety Checklist Implementation in a Tunisian University Hospital: A Mixed-Methods Study of Compliance and Nurses' Perspectives on Barriers, Facilitators, and Sustainability.

backgroundThe surgical safety checklist (SSC) is a valuable tool for promoting patient safety, but its implementation is complex and understudied, particularly in low- and middle-income countries. Perioperative nurses are critical to the SSC's successful implementation, but their experiences and the obstacles they encounter are underexplored under specific organizational systems.

objectiveThis study assessed SSC compliance and completion and investigated perioperative nurses' perspectives and experiences using it in a Tunisian university hospital.

methodsA sequential mixed-methods study was conducted over a 3-month period. For the quantitative part, a retrospective review of 760 patient medical records was performed over a 19-month period. Compliance and completion rates were analyzed and compared across all checklist phases and four surgical specialties. As for qualitative data, 13 semistructured interviews were conducted with perioperative nurses and then analyzed thematically to explore perceptions and experiences with the SSC. Participation was voluntary. Anonymity and confidentiality were ensured.

resultsQuantitative findings revealed an SSC compliance proportion of 39.7%, which peaked at 60% during the implementation phase but declined to 29.4% during follow-up. Compliance was significantly lower during night shifts and in emergency cases (p < 0.001). The "Sign-Out" section was the most frequently omitted. Qualitative analysis identified five key themes: initial skepticism shifting to acceptance, barriers including time pressure and lack of accountability, facilitators such as leadership engagement and nursing champions, perceived positive impacts on teamwork, and concerns about long-term sustainability.

conclusionsWhile the SSC is valued by nurses, its successful implementation and sustainability are critically dependent on the organizational culture within the operating room. Sustainable implementation requires formally integrating the SSC into hospital policy. This must be supported by strong leadership endorsement and strategic empowerment of nurse champions to overcome hierarchical barriers and foster a shared responsibility for patient safety. IMPLICATIONS FOR NURSING MANAGEMENT: Beyond policy and leadership commitment, sustaining SSC adherence requires psychological safety that enables staff to challenge unsafe practice, regular audit-and-feedback cycles to monitor compliance by specialty and shift, staffing and workflow that support SSC completion during high-pressure periods, ongoing training, and clearly assigned responsibility for SSC use at the unit level.