We searched several major electronic databases, including PubMed/MEDLINE, CINAHL (Cumulative Index to Nursing and Allied Health Literature), Scopus, and Google Scholar. The search was conducted to identify literature published between January 2010 and July 2025 to ensure a focus on contemporary and innovative practices. The search strategy employed a combination of keywords and Medical Subject Headings (MeSH) terms using Boolean operators (AND, OR). Key search terms included (“intraoperative nursing” OR “perioperative nursing” OR “theater nurse”) AND (“innovation” OR “technology” OR “advanced practice” OR “evidence-based practice”) AND (“surgical outcomes” OR “patient safety” OR “surgical efficiency”). Additional targeted searches were performed for specific topics, such as “Artificial Intelligence in surgery,” “robotics in nursing,” “Enhanced Recovery After Surgery (ERAS),” and “virtual reality in nursing education.”

Articles were selected for inclusion based on the following criteria:

The selected literature was analyzed using a narrative synthesis approach. The information extracted from the articles was organized thematically according to the core topics of this review: foundational nursing principles, technological innovations [AI, robotics, virtual reality (VR)/augmented reality (AR), etc.], ERAS protocols, specialty-specific practices, and challenges to implementation. The findings were critically evaluated and integrated to construct a cohesive narrative that identifies key trends, quantifies impacts where data were available, and outlines future directions for intraoperative nursing. This approach allowed for a broad and comprehensive exploration of the topic from multiple perspectives.

The bedrock of safe surgical practice is formed by several non-negotiable responsibilities: the meticulous setup and maintenance of the sterile field to prevent surgical site infections; the precise positioning of the client to prevent injury; and serving as the unwavering patient advocate to ensure safety and consent are verified when the patient is most vulnerable (15–18).

Intraoperative nursing excellence requires seamless integration within the multidisciplinary team. Nurses are central to facilitating clear and structured communication, a competency exemplified by the nurse-led implementation of standardized handoff protocols such as SHRIMPS to ensure continuity of care during personnel changes (1, 19). This extends to system-level coordination, where nurses play a pivotal role in implementing complex, evidence-based pathways such as ERAS. In this capacity, they coordinate actions across the entire surgical team to ensure adherence to protocols that accelerate recovery and reduce complications (20, 21).

The dynamic operating room environment demands constant critical thinking, which is structured through a clear and synergistic relationship between the nursing process, evidence-based practice (EBP), and documentation. The nursing process (assessment, diagnosis, planning, implementation, and evaluation) serves as the foundational framework for critical thinking, providing a systematic method for delivering individualized care (22, 23). This framework is then elevated by EBP, which informs every step of the process with the best available research, clinical expertise, and patient values (24). For example, when positioning a patient, the nurse uses the nursing process to assess risk, but it is EBP that guides them to select a specific, research-backed technique to prevent nerve damage (25, 26). Finally, meticulous intraoperative documentation serves as the indispensable record that captures the EBP-driven decisions made within the nursing process. This documentation provides legal proof of care, ensures continuity during handoffs, and supplies crucial data for quality improvement, making the entire cycle of thinking and action visible and verifiable (27, 28) (Figure 1).

A defining competency of the contemporary intraoperative nurse is the ability to manage and integrate advanced technologies. This role has shifted from manual assistance to that of a technology manager, responsible for preparing robotic systems, handling patient-specific 3D-printed guides, and interpreting data from an array of digital sources (29–31). As the subsequent sections will detail, this technological proficiency is not a separate skill but is woven into all other competencies to enhance surgical precision, improve efficiency, and elevate patient safety.

AI and robotics are revolutionizing perioperative nursing by enhancing efficiency and clinical decision-making (33, 34). A key application of AI is predictive analytics, which uses machine learning algorithms to analyze vast datasets and forecast potential adverse events. This empowers nurses to move from a reactive to a proactive model of care by identifying high-risk patients before complications arise (35). In practice, AI offers real-time decision support during surgery and helps optimize OR logistics such as scheduling and staff assignments, freeing nurses to focus on direct patient care (36–38).

Robotic systems, often guided by AI, enhance surgical precision, minimize invasiveness, and reduce the administrative burden on nursing staff (39). For nurses, the integration of these technologies marks a shift from manual assistance to the role of a technology manager. Key responsibilities now include preparing robotic equipment, interpreting data from predictive models, and applying critical thinking to ensure that all technological recommendations align with the patient's holistic needs (36, 39).

VR and AR are transforming nursing education and patient experience. These immersive technologies provide realistic, risk-free training simulations, allowing nurses to practice complex procedures and enhance their clinical reasoning (40, 41). For patients, VR can be used to reduce preoperative anxiety and manage postoperative pain (42, 43). AR provides real-time information overlays during procedures, aiding in anatomical visualization and procedural guidance (44). The primary impact is improved nursing proficiency and enhanced patient safety through better training and a reduction in surgical errors (45).

Wearable health technologies are creating a new continuum of patient data that directly impacts intraoperative nursing practice. While traditionally used for pre- and postoperative monitoring, these data provide a crucial baseline for the intraoperative period. The nurse can access a patient's pre-operative data from their personal wearable devices—such as activity levels, sleep patterns, or baseline heart rate variability—to create a more holistic and personalized intraoperative care plan (46). Furthermore, the emergence of intraoperative wearable sensors is creating a new stream of real-time data for which the nurse is responsible. These sensors can offer continuous monitoring of core body temperature, muscle oxygenation, or subtle hemodynamic shifts that may not be captured by standard monitors. The intraoperative nurse's role is to integrate this new data with traditional monitoring, interpret its clinical significance, and use it to anticipate needs and facilitate timely interventions (47–49). This transforms the nurse's function from periodic data collection to the continuous, proactive surveillance of a data-rich patient, directly connecting wearable technology to intraoperative safety and outcomes (31, 50–52).

3D printing enables the creation of patient-specific surgical guides and implants, shifting a portion of the surgical planning to the pre-operative phase (53–55). However, this innovation places a critical and high-stakes responsibility on the intraoperative nurse, who functions as the final point of safety verification within the sterile field. The nurse's specific contribution involves more than just instrument management; it is a crucial safety intervention. They are responsible for meticulously cross-referencing the unique identifiers on the sterile 3D-printed device against the patient's records and the surgical plan immediately before use. By confirming this match and communicating it to the team, the nurse provides a definitive safeguard against a potential wrong-site, wrong-procedure, or wrong-implant error. This direct nursing action is indispensable for the safe and effective application of personalized surgical technology, directly linking their vigilance to improved surgical precision and patient outcomes (56–58).

Blockchain technology enhances the security, integrity, and privacy of patient data by providing a decentralized and immutable ledger for health information (59, 60). For perioperative nurses, this means becoming familiar with advanced charting and documentation systems that leverage blockchain principles, ensuring that data are accurately recorded and securely accessible for continuity of care (61) (Table 1).

The success of ERAS is critically dependent on nursing leadership and meticulous execution of specific interventions at each phase (20, 21, 63):

The implementation of these nurse-driven ERAS interventions has yielded significant, quantifiable improvements in patient outcomes. Studies consistently show reduced length of hospital stay (LOS), decreased complication rates, and a dramatic reduction in opioid consumption (70, 71).

ERAS empowers nurses by positioning them as leaders and coordinators of the multidisciplinary team. It demands a high degree of autonomous clinical judgment and challenges traditional hierarchies, requiring strong institutional support to overcome resistance to changes such as early feeding or catheter removal (72). Ultimately, ERAS is a powerful example of how structured, evidence-based nursing practice can fundamentally elevate the standard of surgical care.

Within these innovative organizational structures, the core competencies of intraoperative nursing are adapted with specialized clinical reasoning to meet the unique demands of each surgical field. The nurse's role is not static; it requires dynamic application of skills and knowledge tailored to the specific technologies, procedures, and patient risks of the specialty.

While the literature extensively details technological innovations within various surgical specialties, there is a noticeable gap in explicitly detailing the nuanced nursing roles developed specifically for the intraoperative phase (93). The precise contributions of nurses in integrating technologies such as robotics and 3D printing often remain implicit rather than explicitly documented (1, 97). This underscores the critical importance of dedicated nursing research to articulate and validate these unique and often “unsung” contributions, ensuring that the full scope of nursing innovation is recognized.

Despite the increasing technological sophistication across different surgical fields, a consistent and profound theme remains: the unwavering commitment to holistic patient care, encompassing both physical and psychological wellbeing (98, 99). The humanistic aspects of nursing—providing comfort, managing anxiety, and addressing patient fears—remain a constant and innovative imperative. This highlights that technological progress must always be balanced with compassionate, comprehensive care to achieve the best possible patient outcomes (97, 100–102).

The implementation of innovative nursing practices and technologies in the operating room is fundamentally a change management challenge. Technical solutions alone are insufficient; success hinges on addressing the psychological, cultural, and systemic factors that influence human behavior and organizational readiness. This means that strategic planning for innovation must prioritize human-centered design, robust training, and empowering frontline nurses as co-creators and champions of change (Table 3).

The integration of advanced technologies into intraoperative care presents profound ethical challenges that extend beyond technical implementation to the core of nursing practice. While frameworks such as the ANA's “5 Rights of AI” offer guidance (112), a deeper critical appraisal is necessary to navigate the complex dilemmas nurses face. This requires operationalizing core bioethical principles—beneficence (acting for the patient's good), non-maleficence (do no harm), and justice (ensuring equitable care)—within the high-stakes surgical environment.

Concrete ethical dilemmas frequently emerge in practice. For example:

Operationalizing an ethical response requires nurses to act as vigilant patient advocates. This involves treating AI tools as adjuncts, not arbiters, of care; questioning and reporting potential biases in technology; and championing robust data security measures. The nurse's role is to serve as the essential “human firewall,” ensuring that technological advancements are always applied through a lens of ethical reasoning, clinical expertise, and unwavering commitment to patient safety and equity (115, 116).

Overcoming these barriers requires a multi-faceted and integrated approach:

While innovation is crucial for advancing healthcare, its adoption must be rigorously guided by evidence and an unwavering commitment to patient safety. The literature highlights that “haphazard adoption of new surgical technologies without proper evaluation has the potential to cause significant harm” (109). Therefore, nurses are advised to consider innovation “in the context of evidence-based practice” (134, 135). A significant challenge lies not only in developing innovations but also in systematically evaluating their efficacy and integrating them into practice through robust evidence-based implementation strategies. This is particularly relevant for protocols such as ERAS, where, despite an “extensive evidence-base,” nurses may still hesitate to fully implement elements without explicit clinician “permission” due to ingrained traditional mindsets (72, 136). This situation underscores the need for strong leadership to champion evidence-based approaches, overcome resistance to change based solely on tradition, and ensure that new practices are not just adopted but are sustained through continuous auditing and feedback loops. This ensures that innovation truly translates into improved patient outcomes and becomes a permanent feature of perioperative care.

The integration of AI and advanced technologies is redefining the perioperative nurse's role from a technical assistant to a clinical data curator and technology manager (137, 138). This shift requires a proactive response from healthcare organizations. To ensure nurses can meet these future demands, institutions must invest in comprehensive, continuous training programs. These programs must extend beyond technical operation to include data literacy, critical evaluation of AI outputs, and the ethical implications of new technologies (139). Simultaneously, organizations must foster a culture of nurse-led innovation by providing the time, resources, and institutional support for nurses to lead the change (117, 118). True integration also demands strengthening multidisciplinary collaboration through standardized communication protocols and shared technological platforms that ensure seamless teamwork across the entire surgical journey.

As surgical care becomes highly personalized through genomics and data-intensive technologies, profound ethical challenges emerge regarding equitable access, data privacy, and the potential for algorithmic bias to worsen health disparities (140, 141). Nursing profession's core commitment to patient advocacy mandates an ethically grounded approach to technology adoption (115, 116). Therefore, organizations must develop and implement clear ethical frameworks for all advanced technologies, ensuring that patient privacy, data security, and human accountability remain paramount. As patient advocates, nurses should be central to the development and review of these frameworks. Furthermore, there is an imperative to address health equity by creating strategies that ensure advancements in surgical care and training are accessible to all patients and clinicians, including those in rural or under-resourced settings. Ultimately, technology adoption must be prioritized through a human-centered lens, involving nurses in the design and selection of tools to guarantee they augment, rather than impede, the essential clinical judgment and compassionate care that define the nursing profession.