Training Needs and Practice Gaps in Perioperative Nursing in Low-Resource Settings: A Sequential Mixed-Methods Study Across Tertiary Hospitals in Ethiopia and Liberia

Background: Perioperative nursing is essential to surgical safety and patient outcomes, yet specialty training is limited in low-resource settings. Nurses without formal perioperative qualifications often work in these roles, creating safety and quality concerns.Purpose: To assess perioperative nursing training needs and identify major care process gaps across tertiary hospitals in Ethiopia and Liberia.Methods: A sequential mixed-methods study was conducted across two phases in seven hospitals (2023-2024). Phase 1 surveyed 77 participants (50 nurses, 27 multidisciplinary colleagues) with 12 semi-structured interviews using the Hennessy-Hicks Training Needs Analysis framework. Phase 2 included unit-specific surveys of 97 nurses at three Ethiopian facilities, complemented by facility assessments and perioperative process mapping. Data were analyzed descriptively (SPSS v27) and thematically (NVivo), then integrated through triangulation.Results: Training priorities varied significantly by clinical area. Surgical ward nurses prioritized the nursing process (42.7%), wound management (12.9%), and pain management (12.6%). PACU nurses ranked patient assessment (30.1%), basic PACU services (27.6%), and protocols (23.6%) highest. OR nurses emphasized safety checklists. A critical competency-perception paradox emerged: 100% of surveyed competencies were self-rated as satisfactory, yet qualitative data and audits revealed significant deficits in comprehensive assessments, documentation, leadership, and quality improvement. Major gaps included inconsistent preoperative assessments and handovers, inadequate WHO Surgical Safety Checklist adherence, absent PACU protocols, and underutilization of clinical audits.Conclusions: Perioperative nursing improvement requires structured, mentorship-based training integrated with institutional protocol standardization, leadership development, and quality improvement systems. Sustainable change demands alignment with national continuing professional development frameworks and multidisciplinary engagement.