This study aims to evaluate the effectiveness of a procedure manual-based simulation training program in improving the core competencies of operating room nurses in a Cambodian national hospital. Operating room nurses play a critical role in maintaining patient safety, assisting the surgical team, and ensuring efficient surgical workflow.

This study will use a single-group quasi-experimental pre-post design. Baseline data will be collected before the intervention to assess operating room nurses' core competencies, interprofessional collaboration, job satisfaction, and surgical procedure duration.

Participants will receive structured educational sessions and simulation-based training based on standardized surgical procedure manuals. After the training phase, nurses will implement the procedure manuals during real surgical procedures for six weeks. End-line data will be collected to evaluate improvements in competency levels, teamwork, job satisfaction, and surgical efficiency.

• Background and Rationale Nurses in Cambodia face significant challenges in achieving the government's goal of Universal Health Coverage, specifically regarding the quality of care and competency levels. This study addresses the need for standardized procedure manuals in the operating room (OR) to minimize practice variation, reduce adverse outcomes, and enhance the core competencies of OR nurses at the Cambodia-China Friendship Preah Kossamak Hospital (CCFKH).
• Study Design This is a quasi-experimental study utilizing a one-group pre- and post-test design. There is no control group or randomization involved. The study aims to recruit approximately 49 registered nurses currently working in the intraoperative phase at CCFKH.
• Intervention Protocol

The intervention is divided into three distinct phases:

1. Preparation: Standardized surgical procedure manuals and training videos were developed for two specific procedures: Total Hip Replacement (THR) in orthopedics and Retrograde Intrarenal Surgery (RIRS) in urology.

2. Training Phase (2 weeks): Participants are divided into six small groups of approximately eight members. Each group attends two sessions biweekly. Each session consists of a 1-hour lecture and 2 hours of simulation practice. An E-manual is provided for continuous self-study.

3. Implementation Phase (6 weeks): Following training, participants implement the standardized protocols during real surgical procedures. During this time, the research team provides follow-up support and consultation to address clinical concerns.

   • Data Collection and Outcomes

Data will be collected at baseline (pre-intervention) and after the intervention period (end-line) with primary outcome and secondary outcomes:

1. Primary Outcome: Core competency is measured using a 20-item researcher-developed questionnaire based on a 5-point Likert scale (total score range: 20-100).

2. Secondary Outcomes: These include Interprofessional Collaboration (Relational Coordination Survey), Job Satisfaction (Short Index of Job Satisfaction), and Surgical Outcome (measured as procedure duration/surgical time).

   • Analysis Statistical evaluation will include descriptive statistics and paired t-tests to analyze changes between baseline and end-line data.

Inclusion Criteria:

• Registered nurses who are appointed to work in the intraoperative phase of Cambodia-China Friendship Preah Kossamak Hospital.
• Registered nurses at Cambodia-China Friendship Preah Kossamak Hospital who are willing to participate in the study.

Exclusion Criteria:

• Registered Nurses Cambodia-China Friendship Preah Kossamak Hospital who are unable to participate in intervention requirements.
• Registered Nurses Cambodia-China Friendship Preah Kossamak Hospital who are scheduled to participate in hospital mission assignments.

Individual participant data (IPD) will not be shared publicly to maintain the confidentiality and privacy of the operating room nurses involved in the study, as required by the National Ethics Committee for Health Research (NECHR) in Cambodia. Results will be disseminated through a Master's thesis and peer-reviewed publications using aggregated data only.

This is an open-label, single-group educational intervention. Blinding is not feasible or applicable because the participants (Operating Room nurses) and the research team are actively engaged in the lecture-based learning, simulation practice, and manual implementation. Additionally, there is no control group involved in this quasi-experimental design, precluding the need for masking.