It is highly difficult to perform safe surgery without sterile instruments, yet the capacity to adequately clean, disinfect and sterilise surgical instruments in low-income and middle-income countries is largely unknown. Sterile Processing Education Charitable Trust developed an assessment tool and, in partnership with Mercy Ships, evaluated the sterile processing capacity in 59 facilities in Madagascar, Benin and the Republic of Congo. This data-driven analysis paper illustrates how lack of sterile processing capacity acts as a barrier to safe surgical care. Our tool identified widespread lack of knowledge of techniques and resources needed for sterile processing. Only 12% of workers in Republic of Congo and Benin had sterile processing training and none in Madagascar. None of the hospitals surveyed met basic standards for cleaning, disinfection and sterilisation as defined by the WHO/Pan American Health Organization. Examples of poor practice included lack of cleaning supplies (basic brushes and detergents), incorrect drying and storage of surgical instruments, and inattention to workflow causing cross-contamination. Bleach (sodium hypochlorite) solutions, damaging to instruments, were used universally. In our experience, using an assessment tool allowed identification of specific gaps in sterile processing capacity. Many of the gaps are amenable to simple solutions requiring minimal resources and achievable by most hospitals. We recommend that stakeholders seeking to strengthen surgical health systems in low-resource settings incorporate sterile processing capacity assessments and training into their programmes.

Findings showed that the CLE of Iranian nursing students may be inadequate for high-level learning and safe and effective teaching. Addressing these challenges will require academic and practice partnerships to examine the systems affecting the CLE, and areas to be addressed are described in the six themes identified.

Aim To develop a substantive theoretical explanation that makes sense of the decision‐making process that clinical instructors use to place students on a learning contract. Background Clinical instructors are challenged with the task of objectively evaluating students using subjective tools such as anecdotal notes, diaries, unstructured observations and verbal feedback from other nurses. Clinical instructors' assessment decisions have a considerable impact on a variety of key stakeholders, not least of all students. Design Grounded theory method and its heuristic tools including the logic of constant comparison, continuous memoing and theoretical sampling to serve conceptualisation were used in the process of data collection and analysis. Methods Seventeen individual semi‐structured interviews with clinical instructors in one university in Western Canada were conducted between May 2016–May 2017. Data were analysed using open, axial and selective coding consistent with grounded theory methodology. The study was checked for the Standards for Reporting Qualitative Research (SRQR) criteria (See Appendix S1). Findings Three subcategories, “brewing trouble,” “unpacking thinking” and “benchmarking” led to the study's substantive theoretical explanation. “Gut feeling” demonstrates how clinical instructors reason in their decision‐making process to place a student on a learning contract. Conclusion Placing a student on a learning contract is impacted by personal, professional and institutional variables that together shift the process of evaluation towards subjectivity, thus influencing students' competency. A system‐level approach, focusing on positive change through implementing innovative assessment strategies, such as using a smart phone application, is needed to provide some degree of consistency and objectivity. Relevance to clinical practice Making visible the objective assessments currently being done by clinical instructors has the potential to change organisational standards, which in turn impact patient and clinical outcomes.

Background The need for increased attention to surgical safety in low- and middle-income countries invited organizations worldwide to support improvements in surgical care. However, little is written about issues in instrument sterilization in low- and middle-income countries including Ethiopia. Objective The study aims to identify the impact of a sterile processing course, with a training-of-trainers component and workplace mentoring on surgical instrument cleaning and sterilization practices at 12 hospitals in Ethiopia. Method A mixed-methods research design that incorporates both qualitative and quantitative research approaches to address issues in sterile processing was used for this study. The quantitative data (test results) were validated by qualitative data (hospital assessments, including observations and participant feedback). Twelve hospitals were involved in the training, including two university teaching hospitals from two regions of Ethiopia. In each of the two regions 30 sterile processing staff were invited to participate in a three-day course including theory and skills training; 12–15 of these individuals were invited to remain for a two-day training of trainers course. The collected quantitative data were analysed using a paired t-test by SPSS software, whereas comparative analysis was employed for the qualitative data. Results Process, structural, and knowledge changes were identified following program implementation. Knowledge test results indicated an increase of greater than 20% in participant sterile processing knowledge. Changes in process included improved flow of instruments from dirty to clean, greater attention to detail during the cleaning and decontamination steps, more focused inspection of instruments and careful packaging, as well as changes to how instruments were stored. Those trained to be trainers had taught over 250 additional staff. Conclusions Increased attention to and knowledge in sterile processing practices and care of instruments with a short, one-week course provides evidence that a small amount of resources applied to a largely under-resourced area of healthcare can result in decreased risks to patients and staff. Providing education in sterile processing and ensuring staff have the ability to disseminate their learnings to other health care providers results in decreasing risks of hospital associated infections in patients.

In this paper, we examine the practicalities of nurse managers' work. We expose how managers' commitments to transformational leadership are undermined by the rationing practices and informatics of hospital reform underpinned by the ideas of new public management. Using institutional ethnography, we gathered data in a Canadian hospital. We began by interviewing and observing frontline leaders, nurse managers, and expanded our inquiry to include interviews with other nurses, staffing clerks, and administrators whose work intersected with that of nurse managers. We learned how nurse managers' responsibility for staffing is accomplished within tightening budgets and a burgeoning suite of technologies that direct decisions about whether or not there are enough nurses. Our inquiry explicates how technologies organize nurse managers to put aside their professional knowledge. We describe professionally committed nurse leaders attempting to activate transformational leadership and show how their intentions are subsumed within information systems. Seen in light of our analysis, transformational leadership is an idealized concept within which managers' responsibilities are shaped to conform to institutional purposes.