EMPIRICAL STUDIES
doi: 10.1111/scs.12172
Making the invisible visible – operating theatre nurses’ perceptions of caring in perioperative practice Ann-Catrin Blomberg RN, RNT, RNOR, MSc (PhD Student), Birgitta Bisholt RN, PhD (Senior Lecturer), Jan Nilsson RN, PhD (Senior Lecturer) and Lillemor Lindwall RN, PhD (Professor) Department of Health Sciences, Karlstad University, Karlstad, Sweden
Scand J Caring Sci; 2015; 29; 361–368 Making the invisible visible – operating theatre nurses’ perceptions of caring in perioperative practice The aim of this study was to describe operating theatre nurses’ (OTNs’) perceptions of caring in perioperative practice. A qualitative descriptive design was performed. Data were collected with interviews were carried out with fifteen strategically selected operating theatre nurses from different operating theatres in the middle of Sweden. A phenomenographic analysis was used to analyse the interviews. The findings show that operating theatre nurses’ perceptions of caring in perioperative practice can be summarised in one main category: To follow the patient all the way. Two descriptive categories emerged: To ensure continuity of patient care and keeping a
Introduction This study presents operating theatre nurses’ (OTNs’) perceptions of caring in perioperative practice. According to Richardson (1), the profession is considered to be medically and technically oriented. Blegeberg et al. (2) revealed that other professionals within health care perceived OTNs as fragmented carers who were present only during the patient’s surgery. Since the 1960s, different education reforms and an increased demand on OTNs led to various training initiatives, meaning OTNs were less involved in patient preand postoperative care (3). There is a clear requirement for productivity in today’s perioperative practice, and patients in surgery have limited opportunities to converse with OTNs. The OTNs’ responsibility for patients’ nursing care is based on their specific knowledge, and it is therefore important to highlight the caring that takes place in perioperative practice.
Correspondence to: Ann-Catrin Blomberg, Department of Health Science, Karlstad University, Karlstad, Sweden. E-mail: [email protected] © 2014 Nordic College of Caring Science
watchful eye. The operating theatre nurses got to know the patient and as a result became responsible for the patient. They protected the patient’s body and preserved patient dignity in perioperative practice. The findings show different aspects of caring in perioperative practice. OTNs wanted to be more involved in patient care and follow the patient throughout the perioperative nursing process. Although OTNs have the ambition to make the care in perioperative practice visible, there is today a medical technical approach which promotes OTNs continuing to offer care in secret. Keywords: care, perioperative nursing, operating theatre nurse. Submitted 25 February 2014, Accepted 7 July 2014
Nursing has a long tradition, and working in an operating theatre was identified as the first area of specialisation for nurses (4). The foundation of perioperative practice was laid by Nightingale (5) who made efforts to maintain patient health by stressing the importance of clean water and sanitation as well as ventilation in the room where the patient was treated. In the late 19th century, progress in medicine led to increased knowledge and awareness in prevention and control of infections, and OTNs were considered a suitable profession to take the responsibility for hygiene in the operating theatre. According to Holder (6), nurses were recruited during the First World War to the armed forces to be responsible for patients’ perioperative nursing care. During the Second World War, more advanced surgery was performed in field hospitals and required more technical equipment, which resulted in a reinforced professional function for OTNs (4). A new group of health professionals was developed, called technicians, whose role was to perform the OTNs’ technical tasks in the operating theatre. The OTN was the scrub nurse responsible for assisting and instrumentation during surgery, while technicians worked as circulating staff. The OTN was responsible for the coordination of the surgical team and the patient’s pre-, intraand postoperative care (7, 8). The trend of training
361
362
A.-C. Blomberg et al.
technicians continued after the war ended and resulted in replacing the scrub nurse with technicians because of their technical knowledge (7). Several studies (8–10) discussed that this development may have contributed to the fact that the OTN profession is considered to be technically oriented. The Association of Operating Room Nurses (AORN) defined perioperative nursing in order to change the perception of the OTN profession as technically oriented (11). During the 1970s, there were revisions meaning OTNs would follow the nursing process (12, 13). After a few years, the perioperative ‘role’ was changed to ‘practice’ because ‘role’ did not describe who the OTN was, and the OTN’s care function was unclear (14). The Lindwall and von Post (15) work on perioperative practice concluded that it is something more than working technically and carrying out ordinations. A further attempt was made to develop the profession towards a nursing process-based approach although OTNs still only cared for patients intra-operatively (13). Since perioperative nursing is organised differently in Sweden, it had to be defined in relation to Swedish conditions (15). Some intervention studies with the perioperative dialogue have shown that patients considered it valuable to receive information about the surgery and possibility to describe feelings about the situation and felt that the operating theatre nurse took personal responsibility for them (16, 17). Previous research about OTN caring focussed on the intra-operative phase and from different perspectives to promote patient safety. Mitchell and Flin (18) described the OTN function in the surgical team and pointed to the importance of effective communication between the OTN and surgeon which influences their collaboration (19). Riley and Manias (20, 21) pointed to the importance of having knowledge about the surgeon’s wishes for being aware of the situation (22, 23). The fact that OTNs operate behind closed doors in the operating theatre means that their value is based on their work in relation to the surgeon (10). Blegeberg et al. (2) showed that OTNs are perceived by other professionals as doctors’ assistants. According to Meretoja et al. (24), OTNs have little contact with patients despite the fact that they have a professional responsibility for patient care during the intra-operative phase. The literature review revealed that there is international research that focused on patients’ care in operating theatre nursing, but there were no studies and empirical research on the care of the patient.
The study
Design This qualitative study had a phenomenographic method, which is derived from Swedish pedagogical research and has been used extensively in nursing research (25). The focus of the method is directed towards meaning rather than explanations, connections and frequencies and aims to describe the qualitative variations in people’s experiences of a phenomenon (26). Phenomenography distinguishes between ‘what something is’ and ‘how it is perceived to be’. The former directs interest towards what the phenomenon is, which is called the first-order perspective. The latter focuses attention on how people perceive or experience the phenomenon, that is how the phenomenon appears and is known as the second-order perspective (27). It is the second-order perspective that is unique to the phenomenographic variations, that is the variations in how the phenomenon is perceived (28).
Sample The sample consisted of 15 strategically selected OTNs (14 women and one man) from 34 to 60 years (md = 45 years), and work experience ranged from 6– 36 years (md = 20 years). The participants were identified by the head nurse of the operating theatre, and selection was based on the following criteria: having at least three years experience in perioperative practice, both women and men and working in operating theatres at university, central and county hospitals in the middle of Sweden. The participants were RNs and had different educational backgrounds. Some had clinical training to become a theatre nurse, and others had postgraduate education in theatre care. Only three OTNs had an academic degree.
Data collection In this study, the data collection took the form of individual interviews. All interviews were conducted by the first author (ACB). The interviews commenced with a general discussion to establish a relation with the respondents followed by an open question: What is caring for you as an OTN? Additional follow-up questions were then posed to deepen the understanding of nursing and to catch unreflective thoughts among the participants (29). The interviews took place from June to September 2012 and were carried out in a secluded room within the operating theatre. They lasted between 45–60 minutes. The interviews were digitally recorded and transcribed verbatim.
Aim
Data analysis
The aim was to describe operating theatre nurses’ perceptions of caring in perioperative practice.
The analysis of the data was conducted according to Dahlgren and Fallsberg’s (30) seven steps: (i) © 2014 Nordic College of Caring Science
Making the invisible visible Familiarisation – all interviews were read several times to become familiar with the material; (ii) Condensation – the analysis of the material initiated by each interview was entered into an analysis scheme, and specific statements about the phenomenon of caring in perioperative practice were identified and separated from the text. The attention was on WHAT the participants focused on and HOW they described the phenomenon that was shown; (iii) Comparison – the various statements were compared to find similarities and differences in the material; (iv) Grouping – Similar statements were grouped into perceptions. Differences and similarities were compared, and the possible categories were tested by comparing them with the interview material. A new document was created where the statements were sorted into preliminary categories. These steps were performed by the first author (ACB); (v) Articulating – meant finding similarities between the statements in the various categories and discussing how great the variation within a category could be without creating a new category; (vi) Labelling – naming the descriptive categories took time, and different names were tried to capture the meaning of the different perceptions of caring in perioperative practice; (vii) Contrasting – the descriptive categories were compared with each other to ensure that each category had a unique character. The different perceptions related to each other, and after many discussions and reflections in the research group, a main category emerged ‘To follow the patient all the way’. The main category with descriptive categories each containing two perceptions was organised hierarchically and horizontally in an outcome space. Quotations were chosen based on enhancing meaning; the fourth step of seven needed to be repeated several times by all co-authors.
Rigour The concepts of credibility, fittingness, auditability and conformability have been suggested as valuable in describing rigour in qualitative studies (31). The credibility of this study is supported by the use of quotations that have enriched the results. A good fittingness has been determined based on the fact that the results of the study have been presented to active OTNs who affirmed the results of the study. The OTNs recognised themselves and confirmed that the results reflected their perceptions of caring in perioperative practice. The study’s auditability was strengthened by the use of a well-defined research process, and a consistent use of an open question posed to all participants through interviews to capture different views of the phenomenon. Comparing results from the current study with other equivalent studies has demonstrated conformability. Throughout the analysis process, the authors were aware of their pre-understanding as nurses in perioperative practice and caring science. © 2014 Nordic College of Caring Science
363
The main category describes: ‘To follow the patient all the way’. There were two descriptive categories: To ensure continuity of the patient care and keeping a watchful eye. These descriptive categories were built on four perceptions that are described below and elucidated by quotations from the interviews (see Table 1). To ensure continuity of patient care. This descriptive category consists of two perceptions: getting to know the patient and to be responsible for the patient. Getting to know the patient. The perceptions consist of how the OTNs acquired knowledge of the patient through being present for each other and how the OTNs created continuity. OTNs had the ambition to get to know the patient as a human being by reading medical records and becoming involved in the patient’s history as well as the current operation. OTNs looked for the opportunity for a brief meeting and conversation in order to pre-operatively prepare the patient before surgery. In the meeting, they received confirmation that the planning was consistent with the patient’s problems, needs and desires. An important factor was that it took courage for OTNs to meet the patient in this situation. Time to read the journal and talk to the patient is very important. There is only this conversation. The longer you have worked and the more secure you are in your routines the more you can find the time; if you are that way inclined. I think you should talk to the patient and have the courage for the meeting. The participants came forward by meeting patients face-to-face. At that moment, patients might have perceived the OTNs’ presence and the desire to do well. The participants requested that all OTNs should have this ability. When the patient did not want to have a relationship, they kept in the background. It can be eye contact, to see and confirm. That you are present; that they feel that you see them and that you want to do the best for them. You can convey a lot with body language and I think that is important. Sometimes I can feel that the patient does not want contact. Another issue that emerged was the ability of OTNs to implement perioperative conversation. They asked for Table 1 Operating theatre nurses’ perceptions of caring The main category: to follow the patient all the way Descriptive categories
To ensure continuity of patient care Keeping a watchful eye
Operating theatre nurses’ perceptions of caring in perioperative practice Getting to know the patient To be responsible for the patient To protect the patient’s body To preserve the patient’s dignity
364
A.-C. Blomberg et al.
more time to meet with patients both pre- and postoperatively and above all to meet the anxious patients preoperatively as well as to exist in the intra- and postoperative phase. Participants wanted to follow the patient from the time they arrived at surgery to the moment of delivery to the postoperative department as well as evaluating the completed care. OTNs believed that they had important knowledge that contributed to a different understanding of the patient’s postoperative care. Then I had the opportunity to follow the patient all the way and the patient had the opportunity to talk to me if there was anything special that they were thinking about. It may be a previously experienced situation and make it something bad again. Such time, I’d really like to have a perioperative conversation. It must be gold. . . I also had the opportunity afterwards to know how they had perceived me and the situation . . . would like to have more time to meet patients before and after, maybe even a little more. To be responsible for the patient. The perceptions consisted of how OTNs could be responsible and promote safety in patient care through knowledge. Responsibility for patient care started for OTNs in the pre-operative phase when they were told which patient they would care for during surgery. Important aspects were if the patient was overweight, infectious, had allergies or ongoing medical treatment that risked increased bleeding. The pre-operative patient preparation was extensive, and OTNs felt it was an important part in patients’ care. Patients are of different sizes and different ages, and that can dictate what you take to the surgery even though it is the same operation; it can be clothing and things like that, that you should not tape too much if the patient has fragile skin, things like that you think a lot of so that it will be as good as possible. Intra-operatively, the OTNs strove to ensure that the patient’s time in the operating theatre would be minimised and took responsibility for the coordination of the surgical team. The intention was to prevent subsequent patients being at risk of removal from the operating programme. They considered that the efficiency included accuracy and speed to avoid unnecessary waiting time for the patient. Patients should not be put to sleep unnecessarily. The circulating nurse wants to find the surgeons but the OTNs said no, because she was not ready. At the same time, the situation is that if you do not seek in time, it is not we who wait but the patient . . . It is not good care when the patient gets dismissed because things have been too slow. One aspect of caring is that OTNs kept track of instruments and other materials and conveyed information to
other members of the surgical team about what was happening in the surgical wound. The OTNs responsibilities included being prepared for the unexpected. I always set up in the same way regardless of whether it is the right or left side to be operated on, so I know where everything is. Ensuring that you have enough dressings and that you have things inside the operating theatre . . . you always want to be one step ahead and be there if something happens. Based on the OTNs’ specific knowledge, skills and topographic anatomy, they had responsibility to select the right operating table with accessories and for patient positioning based on the patient’s individual needs. Patient positioning on the operating table was conducted jointly in the surgical team, but the surgical team always wanted confirmation from the OTNs before the pre-operative preparation was started, in order to avoid intra-operative consequences. The function of all medical equipment was checked in order to ensure patient safety. It is my job to choose the right operating table, and ensure that the patient is placed in the right position. I think that the rest of the surgical team often relies on us. The ultimate responsibility is on me, because when the patient is sterilely gowned I have to answer how the patient is positioned. I am responsible for making sure that the equipment works that is connected to our care for the patient, this cannot go wrong. Another safety aspect was to verify the patient’s identity, and when operating on a paired organ that the correct side was selected, which was a joint responsibility of the surgical team. The OTNs assured themselves further by ensuring that patient data were consistent with the planning. Checking all the material and ensuring that nothing was left inside, the patients was included in the professional responsibility and was a part of their care of the patient. I have to check that I have the right patient and am prepared with the right things, for me it’s important to know. Patients might be premeditated so they are not aware of anything, but I am there in any case and look in the anaesthesia record that the ID is checked and that it is marked on the side to be operated on. You must have the whole picture. Keeping a watchful eye. This descriptive category consists of two perceptions: To protect the patient’s body and to preserve patient’s dignity. To protect the patient’s body. The perceptions consist of how OTNs respect the patient’s autonomy and protect the patient’s body from injury and risks. The patient’s need was to feel well in a high-tech environment, and this was met by the OTNs who set the © 2014 Nordic College of Caring Science
Making the invisible visible conditions for peace and quiet. There was an ambition to meet the patient’s wishes and needs. Continuous information was given about occurring activities in the operating theatre. The OTNs’ notions of what good care was formed the basis of planning the patient’s care. The patient may choose whether he wants radio or headphones when he goes to sleep, so we ask if they want it. Just a little thing like information can calm things down tremendously. We do not do anything dangerous here but now we are rustling because we are picking up things . . . it’s important to put yourself in the patient’s situation and treat the patient as you would want to be treated yourself. By protecting patients from undergoing postoperative infections, the OTNs kept ‘a watchful eye’ over the sterility of the surgical area and the operating theatre. To prevent the spread of infection, they had control of the traffic flow in the operating theatre. Assistants and students who attended the operation were supervised by the OTNs, dictating how they should behave in order to maintain sterility. They reacted intuitively when they felt that someone or something was unsterile. The number of health professionals present during the surgery, increased the risk of postoperative infections and the OTNs decided when the number should be reduced. Sterility is up to me, and then you are very careful to check . . .not only that you are there close to the wound, but you should also have full control of what others are doing so they do not contaminate. I also decide if there is a student or someone else in the theatre. I am involved by saying you cannot go there, you cannot stand there. The patient’s body temperature was monitored to prevent cooling. The patient received a warm quilt, warm fluids and moist towels to cover the wound. Protecting the patient from being cold could reduce the risk of postoperative infections. Acts such as fixing pillows and heat cost little and are pure thoughtfulness. I raise the temperature of the operating theatre. I make sure that he does not bleed in vain, cover with moist compresses so that it does not cool down the patient unnecessarily if you have an open abdomen. It is caring, to maintain body temperature. The patients were continuously monitored, in order to protect against perioperative pressure and nerve damage. The OTN expressed the importance of looking at the whole human being during draping and being aware of the risks associated with different positions on the operating table. At certain times during the operation, the surgeon needed better access to the surgical site. In these cases, the OTN protected the patient so they were not subjected to unnecessary risks for a long time. They gave the patient massage during the
© 2014 Nordic College of Caring Science
365
operation and took the initiative to interrupt lengthy operations for exercise. The OTN was observant if any of the surgical team pushed or placed heavy instruments on the patient. The whole time I check for leaks, that the draping holds and that no one stands and presses when the patient has leg supports. Even when the patient has leg supports we raise and lower the legs every half hour. To preserve patients’ dignity. The perceptions consisted of how patient dignity was preserved and integrity respected. The patient is in a vulnerable position, and the OTN ‘kept a watchful eye’ over the whole patient. The OTN prevented unprofessional conduct in front of the patient involving unnecessary talk and condescending comments in the operating theatre and noted afterwards that it was not appropriate behaviour. I monitor the patient and have to take into account the patient’s interests; I am probably the one who thinks from the patient’s perspective. It is not perceived as safe and secure if you have three people rambling on around you and talking about various things. It should not be too playful around the patient. You make signs or somehow say that now we have to keep it down. All were focused on the patient’s body but on different parts. The OTN respected the patient’s privacy in the context of intimate interventions. They considered themselves more intimate with the patient because they were involved in the surgical wound. They prevented the patient’s body from being uncovered and had an ethical stance, whether the patient was awake or anesthetised. The nurse anaesthetist is focused on head and arms. We do a lot more involving the patient’s body. The body is more intimate and sensitive to a patient. Head and arms, that is more public. It is important to cover the patient, maintaining integrity. When we have someone in the operating theatre lying in leg supports, we pull down the blinds whether they are sleeping or not. We do not have them lying naked if we do not have to but just when we need to have access, otherwise we try to cover them. Various aspects of caring in the perioperative practice showed that the OTN had the ambition to get to know the patient in order to acquire knowledge about the patient in order to plan patient care. When the OTN had knowledge of the patient, she was responsible for providing continuity of patient care. She protected the patient by keeping a watchful eye on them so that the patient’s body was not put at risk and the patient’s dignity was preserved. The prerequisite was that she could follow the patient the whole way.
366
A.-C. Blomberg et al.
Discussion The results show different aspects of care in the perioperative practice where the widespread desire of OTN’s is to follow the patient all the way through the perioperative process. Breakiron (32) showed the importance of caring acts where the OTNs were present for the soldiers when they needed a shoulder to cry on. This historic development of being visible later became more invisible as medical technological progress advanced, a claim for greater productivity and an increased demand for trained OTNs in perioperative practice (7). The training has been influenced by various organisational and policy decisions that resulted in the OTNs of today being merely responsible and involved in the patient’s intra-operative care (3). McGarvey (4, 33) showed that active OTNs had difficulty in describing their care of the patient, although they described care from various medical and technical functions and how their collaboration with the surgeon contributed to good patient care. OTNs got to know the patient by reading medical records and giving priority to meet and having conversations with the patient. There was a desire to see the whole person but also to convey that they were present through eye contact. According to Martinsen (34), health professionals are present in the moment and at the same time pay attention to what the patient wants to convey with his body language. OTNs see themselves as listening and receptive and become involved in the moment. You can never fully understand another human being without having a relationship, there is always something that remains unknown to us. It turned out that the meeting with the patient brought OTNs knowledge that changed or confirmed the planning of patient care. The participants perceived caring as being able to ‘read the patient’ and respond to tasks that required experience, which Benner (35) states newly qualified graduates lack. The study revealed that meeting with the patient pre-operatively was usually organisationally impossible for the OTNs. There was an opportunity to meet and talk to the day surgery patients, but participants perceived that there was a lack of time and too much stress that prevented having more. Perioperative practice is characterised by a production approach that shapes care culture that is not perceived to be in line with ethical values (36). The care culture is created from traditions, rituals and values as Rytterstr€ om et al. (37) state that each care culture has their own values. OTNs were present when the patients needed them but were organisationally prevented from following the patient ‘all the way’. Experience helped to set aside time for a meeting with the patient, but also personality emerged as a factor for wanting or not wanting to meet the patient. The OTNs desire was to have the opportunity to get to know the
patient pre-operatively and participating in the reporting of the patient postoperatively. Some OTNs reported that their knowledge was not used in the patient’s postoperative care (33). There was the desire to implement perioperative conversations with patients and contribute to the continuity of patient care (38). In Sweden, OTNs are given the opportunity to work with an ideal model ‘the perioperative dialogue’ (38, 39), and it showed that patients experienced continuity in care by meeting a known face in perioperative practice (38, 40). Several attempts have been made by AORN to introduce a nursing process in perioperative practice, but OTNs even internationally continue to only care for the patient intra-operatively (33, 41). The OTNs cooperated in the surgical team with specific knowledge of hygiene and topographic anatomy, medical technology, surgical methodology and nursing, which involved responsibility for the patient’s care. According to previous research, OTNs have their own planning (2) which includes preparing materials and performance testing of medical devices pre-operatively, which Bull and FitzGerald (10) state combines technical competence with caring aspects. Intra-operative OTNs have full control and keep track of the instruments to be prepared for the unexpected which according to Mitchell et al. (23) is used to be aware of the situation or ‘to being ahead’ (22). Martinsen (34) argues that nurses get an idea that is preceded by concentrated work which starts mental activity, and the OTN sees the situation in a different way and acts intuitively for the patient. To be effective in caring meant according to Arakelian et al. (42) to coordinate the surgical team by ‘doing things right’ and to have personal knowledge of the surgeon’s requirements and preferences for surgery (20). The goal was that surgery time would be better used, and the patients’ time in the operating theatre minimised. In conjunction with positioning on the operating table, OTNs perceived that their knowledge of operating methodology helped to avoid intra-operative consequences. Even if the patient expressed that they were in a good position, OTNs considered that they took responsibility that the positioning was optimal. Seeing with the heart is like wanting the best for the other person (43). According to Andersson et al. (44), the traffic flow in the operation theatre increases the risk for the patient to be subjected to a postoperative infection. OTNs considered it to be a big part of their care of the patient under surgery (19). OTNs kept a watchful eye on the patient during the perioperative process. Martinsen (34) argues that imagination needs thinking about and is preceded by putting yourself in another person’s situation, ‘the golden rule’. They showed an ethical responsibility by their desire to do good for the patient, and this may, according to von Post (45), be related to OTNs professional natural care. The results reveal how OTNs protect the patient’s body © 2014 Nordic College of Caring Science
Making the invisible visible and maintain the patient’s dignity in a vulnerable situation. Lindstr€ om et al. (46) describe Erikssons theory of caritative caring which emphasises that good care is based on the innermost core of caring, the core of caring involves a caring relationship between nurse and patient, it is an open invitation that contains affirmation that the patient is welcome. According to Baillie (47), it is important in the perioperative caring to welcome the patients and preserve dignity. The participants described how they were present and saw when the patient’s dignity was violated, and through their caring responsibility drew attention to those concerned to show respect for the patient’s integrity. Patients that must undergo surgery usually find themselves in a vulnerable situation (48). The OTNs considered the importance of an ethical stance, whether the patient was asleep or awake.
367
a watchful eye during surgery to protect the patient’s body from being exposed and preserved the dignity of the patient when the patient no longer had control over their body. They stated that they had a desire to be more involved in patient care and wanted to follow the patient throughout the perioperative nursing process. Although OTNs have the ambition to make care visible in perioperative practice, organisations today advise a medical technical approach which promotes OTNs continuing to nurture in secret.
Acknowledgement Thanks to all participants who shared valuable time and stories in the study.
Author contributions Limitations The selection of participants was guided by set criteria, though the head nurse in each county conducted the actual procedure to identify whom to ask for potential participation in the study. The limitation with this selection process was that the first author did not have full control over the selection of the participants.
Ann-Catrin Blomberg was responsible for the study conception and design. She collected and analysed the data and wrote the manuscript. Lillemor Lindwall acted as the main supervisor, participated in analysing the data and took the main responsibility for writing the manuscript. Birgitta Bisholt and Jan Nilsson acted as co-supervisor and participated in analysing the data and in writing the manuscript.
Conclusion This study has confirmed that the phenomenon caring in the perioperative practice described when OTNs got to know the patient as a human being. OTN caring in perioperative practice became visible by gaining knowledge about and from the patient, and they wanted to follow the patient all the way and to continue in the patient’s care. The OTNs caring was given a new meaning through the act of caring; care for, to protect and to preserve the patient’s dignity. The meeting with the patient gave rise to them feeling responsible for the continuity of patient care. OTNs kept
References 1 Richardson-Tench M. The scrub nurse: basking in reflected glory. J Adv Perioper Care 2008; 3: 125–31. 2 Blegeberg B, Blomberg A, Hedelin B. Nurses conceptions of the professional role of operation theatre and psychiatric nurses. Vard Nord Utveckl Forsk 2008; 28: 9–13. 3 SOU 1962:4.Arbetsuppgifter Och Utbildning F€or Viss Sjukv ardspersonal. Bet€ankande Av Utredningar Ang aende Visssa Sjuksk€ oterskors Och Undersk€ oterskors
© 2014 Nordic College of Caring Science
Ethical approval The local university ethics committee approved the study (Dnr C2012/306). The study followed research ethical principles in accordance with the Helsinki Declaration.
Funding This research received no specific grant from any funding agency in the public, commercial or not-for-profit sectors.
Arbetsuppgifter M. M. Stockholm: Inrikesdepartementet (Statens offentliga utredningar 1962:4). 4 McGarvey HE, Chambers MGA, Boore JRP. Development and definition of the role of the operating department nurse: a review. J Adv Nurs 2000; 32: 1092–100. 5 Nightingale F. Notes on Nursing: What it is, and What it is Not. 2003, Barnes & Noble, New York. 6 Holder VL. From handmaiden to right hand – world war I and advancements in medicine. Sixth in an ongoing
7
8 9
10
series about the history of perioperative nursing. AORN J 2004; 80: 911– 23. Sigurdsson HO. The meaning of being a perioperative nurse. AORN J 2001; 74: 202–17. Nelson D. Perioperative nursing and it’s history. The Dissector 2007; 35: 19–23. Wagner VD, Kee CC, Gray DP. A historical decline of educational perioperative clinical experiences. AORN J 1995; 62: 771–82. Bull RM, FitzGerald M. Nursing in a technological environment: nursing
368
11
12
13
14
15
16
17
18
19
20
21
22
23
A.-C. Blomberg et al.
care in the operating room. Int J Nurs Pract 2006; 12: 3–7. AORN Statement Committee. Definition and objective for clinical practice of professional operating room nursing. AORN J 1969; 10: 43–48. AORN Statement Committee. House of delegates - implications and directions. AORN J 1978; 27: 1153–78. Kneedler JA, Dodge GH. Perioperative Patient Care - the Nursing Perspective, 3rd edn. 1994, Jones and Bartlett Publishers, Boston. Nursing Practices Committee. A model for perioperative nursing practice. AORN J 1985; 41: 188–90, 192– 4. Lindwall L, von Post I. Perioperativ V ard: Att F€orena Teori Och Praxis. (Perioperative Care: Reconciling Theory and Practice),2nd edn. 2008, Studentlitteratur, Lund. Rudolfsson G, von Post I, Eriksson K. The expression of caring within the perioperative dialogue: a hermeneutic study. Int J Nurs Stud 2007; 44: 905–15. Westerling K, Bergbom I. The importance of nursing in perioperative care: a patient’s perspective. J Adv Perioper Care 2008; 3: 133–44. Mitchell L, Flin R. Non-technical skills of the operating theatre scrub nurse: literature review. J Adv Nurs 2008; 63: 15–24. € en J, Gustafsson B Kelvered M, Ohl A. Operating theatre nurses experience of patient-related, intraoperative nursing care. Scand J Caring Sci 2012; 26: 449–57. Riley R, Manias E. Governance in operating room nursing: nurses’ knowledge of individual surgeons. Soc Sci Med 2006; 62: 1541–51. Riley R, Manias E. Governing time in operating rooms. J Clin Nurs 2006; 15: 546–53. Bj€ orn C, Bostr€ om EL. Theatre nurses’ understanding of their work: a phenomenographic study at a hospital theatre. J Adv Perioper Care 2008; 3: 149–55. Mitchell L, Flin R, Yule S, Mitchell J, Coutts K, Youngson G. Thinking
24
25
26
27
28
29
30
31
32
33
34
35
36
37
ahead of the surgeon. An interview study to identify scrub nurses’ nontechnical skills. Int J Nurs Stud 2011; 48: 818–28. Meretoja R, Leino-Kilpi H, Kaira A. Comparison of nurse competence in different hospital work environments. J Nurs Manag 2004; 12: 329–36. Sj€ ostr€ om B, Dahlgren LO. Applying phenomenography in nursing research. J Adv Nurs 2002; 40: 339–45. Larsson S. Kvalitativ Analys: Exemplet Fenomenografi. (Qualitative Analysis: The Example of Phenomenography). 1986, Studentlitteratur, Lund. Marton F, Booth S. Learning and Awareness. 1997, Erlbaum, Mahwah, N.J. Uljens M.Fenomenografi: Forskning Om Uppfattningar. (Phenomenography: Exploring Perceptions). 1989, Studentlitteratur, Lund. Kvale S, Brinkmann S, Torhell S. Den Kvalitativa Forskningsintervjun. (The Qualitative Research Interview), 2nd edn. 2009, Studentlitteratur, Lund. Dahlgren LO, Fallsberg M. Phenomenography as a qualitative approach in social pharmacy research. J Soc Adm Pharm 1991; 8: 150–6. Sandelowski M. The problem of rigor in qualitative research. ANS 1986; 8: 27–37. Breakiron M. A salute to the nurses of world war II. AORN J 1995; 62: 710–22. McGarvey HE, Chambers MGA, Boore JRP. The influence of context on role behaviors of perioperative nurses. AORN J 2004; 80: 1103–20. Løgstrup Martinsen K, Sygepleien Og. Logstrup and Caring. 2012, Klim, Aarhus. Benner PE, Tanner CA, Chesla CA. Expertise in Nursing Practice: Caring, Clinical Judgment & Ethics, 2nd edn. 2009, Springer, New York. Lindwall L, von Post I. Habits in perioperative nursing culture. Nurs Ethics 2008; 15: 670–81. Rytterstr€ om P, Cedersund E, Arman M. Care and caring culture as experienced by nurses working in different
38
39
40
41
42
43
44
45
46
47
48
care environments: a phenomenological–hermeneutic study. Int J Nurs Stud 2009; 46: 689–98. Lindwall L, von Post I. Continuity created by nurses in the perioperative dialogue – a literature review. Scand J Caring Sci 2009; 23: 395–401. Lindwall L, von Post I, Bergbom I. Patients’ and nurses’ experiences of perioperative dialogues. J Adv Nurs 2003; 43: 246–53. Rudolfsson G, Hallberg L, Ringsberg KC, von Post I. The nurse has time for me: the perioperative dialogue from the perspective of patients. J Adv Perioper Care 2003; 1: 77–84. AORN Statement Committee. Perioperative Standards and Recommended Practices. 2011, AORN J, Denver. Arakelian E, Gunningberg L, Larsson J. How operating room efficiency is understood in a surgical team: a qualitative study. Int J Qual Health Care 2011; 23: 100–6. Øjet Martinsen K, Kaldet Og. The Eye and Call. 2000, Fagbokforlaget, Bergen. Andersson AE, Bergh I, Karlsson J, Eriksson BI, Nilsson K. Traffic flow in the operating room: an explorative and descriptive study on air quality during orthopedic trauma implant surgery. Am J Infect Control 2012; 40: 750–5. von Post I.Professionell Naturlig V ard Ur Anestesi- Och Operationssjuksk€oterskors Perspektiv. (Professional natural health care from anesthesia and surgical nurses’ perspective). Hammar€ o: Irene von Posts f€ orl., 1999. Lindstr€ om U A, Lindholm L, Zetterlund JE. Theory of Caritative Caring. In Nursing Theorists and their Work, 7th edn (Alligood MR, Tomey AM eds), 2009, Mosby, Maryland Heights, 190–221. Baillie L, Ilott L. Promoting the dignity of patients in perioperative practice. J Perioper Pract 2010; 20: 278– 82. Edlund M, Lindwall L, von Post I, Lindstr€ om U A. Concept determination of human dignity. Nurs Ethics 2013; 20: 851–60.
© 2014 Nordic College of Caring Science
doi: 10.1111/scs.12172
Making the invisible visible – operating theatre nurses’ perceptions of caring in perioperative practice Ann-Catrin Blomberg RN, RNT, RNOR, MSc (PhD Student), Birgitta Bisholt RN, PhD (Senior Lecturer), Jan Nilsson RN, PhD (Senior Lecturer) and Lillemor Lindwall RN, PhD (Professor) Department of Health Sciences, Karlstad University, Karlstad, Sweden
Scand J Caring Sci; 2015; 29; 361–368 Making the invisible visible – operating theatre nurses’ perceptions of caring in perioperative practice The aim of this study was to describe operating theatre nurses’ (OTNs’) perceptions of caring in perioperative practice. A qualitative descriptive design was performed. Data were collected with interviews were carried out with fifteen strategically selected operating theatre nurses from different operating theatres in the middle of Sweden. A phenomenographic analysis was used to analyse the interviews. The findings show that operating theatre nurses’ perceptions of caring in perioperative practice can be summarised in one main category: To follow the patient all the way. Two descriptive categories emerged: To ensure continuity of patient care and keeping a
Introduction This study presents operating theatre nurses’ (OTNs’) perceptions of caring in perioperative practice. According to Richardson (1), the profession is considered to be medically and technically oriented. Blegeberg et al. (2) revealed that other professionals within health care perceived OTNs as fragmented carers who were present only during the patient’s surgery. Since the 1960s, different education reforms and an increased demand on OTNs led to various training initiatives, meaning OTNs were less involved in patient preand postoperative care (3). There is a clear requirement for productivity in today’s perioperative practice, and patients in surgery have limited opportunities to converse with OTNs. The OTNs’ responsibility for patients’ nursing care is based on their specific knowledge, and it is therefore important to highlight the caring that takes place in perioperative practice.
Correspondence to: Ann-Catrin Blomberg, Department of Health Science, Karlstad University, Karlstad, Sweden. E-mail: [email protected] © 2014 Nordic College of Caring Science
watchful eye. The operating theatre nurses got to know the patient and as a result became responsible for the patient. They protected the patient’s body and preserved patient dignity in perioperative practice. The findings show different aspects of caring in perioperative practice. OTNs wanted to be more involved in patient care and follow the patient throughout the perioperative nursing process. Although OTNs have the ambition to make the care in perioperative practice visible, there is today a medical technical approach which promotes OTNs continuing to offer care in secret. Keywords: care, perioperative nursing, operating theatre nurse. Submitted 25 February 2014, Accepted 7 July 2014
Nursing has a long tradition, and working in an operating theatre was identified as the first area of specialisation for nurses (4). The foundation of perioperative practice was laid by Nightingale (5) who made efforts to maintain patient health by stressing the importance of clean water and sanitation as well as ventilation in the room where the patient was treated. In the late 19th century, progress in medicine led to increased knowledge and awareness in prevention and control of infections, and OTNs were considered a suitable profession to take the responsibility for hygiene in the operating theatre. According to Holder (6), nurses were recruited during the First World War to the armed forces to be responsible for patients’ perioperative nursing care. During the Second World War, more advanced surgery was performed in field hospitals and required more technical equipment, which resulted in a reinforced professional function for OTNs (4). A new group of health professionals was developed, called technicians, whose role was to perform the OTNs’ technical tasks in the operating theatre. The OTN was the scrub nurse responsible for assisting and instrumentation during surgery, while technicians worked as circulating staff. The OTN was responsible for the coordination of the surgical team and the patient’s pre-, intraand postoperative care (7, 8). The trend of training
361
362
A.-C. Blomberg et al.
technicians continued after the war ended and resulted in replacing the scrub nurse with technicians because of their technical knowledge (7). Several studies (8–10) discussed that this development may have contributed to the fact that the OTN profession is considered to be technically oriented. The Association of Operating Room Nurses (AORN) defined perioperative nursing in order to change the perception of the OTN profession as technically oriented (11). During the 1970s, there were revisions meaning OTNs would follow the nursing process (12, 13). After a few years, the perioperative ‘role’ was changed to ‘practice’ because ‘role’ did not describe who the OTN was, and the OTN’s care function was unclear (14). The Lindwall and von Post (15) work on perioperative practice concluded that it is something more than working technically and carrying out ordinations. A further attempt was made to develop the profession towards a nursing process-based approach although OTNs still only cared for patients intra-operatively (13). Since perioperative nursing is organised differently in Sweden, it had to be defined in relation to Swedish conditions (15). Some intervention studies with the perioperative dialogue have shown that patients considered it valuable to receive information about the surgery and possibility to describe feelings about the situation and felt that the operating theatre nurse took personal responsibility for them (16, 17). Previous research about OTN caring focussed on the intra-operative phase and from different perspectives to promote patient safety. Mitchell and Flin (18) described the OTN function in the surgical team and pointed to the importance of effective communication between the OTN and surgeon which influences their collaboration (19). Riley and Manias (20, 21) pointed to the importance of having knowledge about the surgeon’s wishes for being aware of the situation (22, 23). The fact that OTNs operate behind closed doors in the operating theatre means that their value is based on their work in relation to the surgeon (10). Blegeberg et al. (2) showed that OTNs are perceived by other professionals as doctors’ assistants. According to Meretoja et al. (24), OTNs have little contact with patients despite the fact that they have a professional responsibility for patient care during the intra-operative phase. The literature review revealed that there is international research that focused on patients’ care in operating theatre nursing, but there were no studies and empirical research on the care of the patient.
The study
Design This qualitative study had a phenomenographic method, which is derived from Swedish pedagogical research and has been used extensively in nursing research (25). The focus of the method is directed towards meaning rather than explanations, connections and frequencies and aims to describe the qualitative variations in people’s experiences of a phenomenon (26). Phenomenography distinguishes between ‘what something is’ and ‘how it is perceived to be’. The former directs interest towards what the phenomenon is, which is called the first-order perspective. The latter focuses attention on how people perceive or experience the phenomenon, that is how the phenomenon appears and is known as the second-order perspective (27). It is the second-order perspective that is unique to the phenomenographic variations, that is the variations in how the phenomenon is perceived (28).
Sample The sample consisted of 15 strategically selected OTNs (14 women and one man) from 34 to 60 years (md = 45 years), and work experience ranged from 6– 36 years (md = 20 years). The participants were identified by the head nurse of the operating theatre, and selection was based on the following criteria: having at least three years experience in perioperative practice, both women and men and working in operating theatres at university, central and county hospitals in the middle of Sweden. The participants were RNs and had different educational backgrounds. Some had clinical training to become a theatre nurse, and others had postgraduate education in theatre care. Only three OTNs had an academic degree.
Data collection In this study, the data collection took the form of individual interviews. All interviews were conducted by the first author (ACB). The interviews commenced with a general discussion to establish a relation with the respondents followed by an open question: What is caring for you as an OTN? Additional follow-up questions were then posed to deepen the understanding of nursing and to catch unreflective thoughts among the participants (29). The interviews took place from June to September 2012 and were carried out in a secluded room within the operating theatre. They lasted between 45–60 minutes. The interviews were digitally recorded and transcribed verbatim.
Aim
Data analysis
The aim was to describe operating theatre nurses’ perceptions of caring in perioperative practice.
The analysis of the data was conducted according to Dahlgren and Fallsberg’s (30) seven steps: (i) © 2014 Nordic College of Caring Science
Making the invisible visible Familiarisation – all interviews were read several times to become familiar with the material; (ii) Condensation – the analysis of the material initiated by each interview was entered into an analysis scheme, and specific statements about the phenomenon of caring in perioperative practice were identified and separated from the text. The attention was on WHAT the participants focused on and HOW they described the phenomenon that was shown; (iii) Comparison – the various statements were compared to find similarities and differences in the material; (iv) Grouping – Similar statements were grouped into perceptions. Differences and similarities were compared, and the possible categories were tested by comparing them with the interview material. A new document was created where the statements were sorted into preliminary categories. These steps were performed by the first author (ACB); (v) Articulating – meant finding similarities between the statements in the various categories and discussing how great the variation within a category could be without creating a new category; (vi) Labelling – naming the descriptive categories took time, and different names were tried to capture the meaning of the different perceptions of caring in perioperative practice; (vii) Contrasting – the descriptive categories were compared with each other to ensure that each category had a unique character. The different perceptions related to each other, and after many discussions and reflections in the research group, a main category emerged ‘To follow the patient all the way’. The main category with descriptive categories each containing two perceptions was organised hierarchically and horizontally in an outcome space. Quotations were chosen based on enhancing meaning; the fourth step of seven needed to be repeated several times by all co-authors.
Rigour The concepts of credibility, fittingness, auditability and conformability have been suggested as valuable in describing rigour in qualitative studies (31). The credibility of this study is supported by the use of quotations that have enriched the results. A good fittingness has been determined based on the fact that the results of the study have been presented to active OTNs who affirmed the results of the study. The OTNs recognised themselves and confirmed that the results reflected their perceptions of caring in perioperative practice. The study’s auditability was strengthened by the use of a well-defined research process, and a consistent use of an open question posed to all participants through interviews to capture different views of the phenomenon. Comparing results from the current study with other equivalent studies has demonstrated conformability. Throughout the analysis process, the authors were aware of their pre-understanding as nurses in perioperative practice and caring science. © 2014 Nordic College of Caring Science
363
The main category describes: ‘To follow the patient all the way’. There were two descriptive categories: To ensure continuity of the patient care and keeping a watchful eye. These descriptive categories were built on four perceptions that are described below and elucidated by quotations from the interviews (see Table 1). To ensure continuity of patient care. This descriptive category consists of two perceptions: getting to know the patient and to be responsible for the patient. Getting to know the patient. The perceptions consist of how the OTNs acquired knowledge of the patient through being present for each other and how the OTNs created continuity. OTNs had the ambition to get to know the patient as a human being by reading medical records and becoming involved in the patient’s history as well as the current operation. OTNs looked for the opportunity for a brief meeting and conversation in order to pre-operatively prepare the patient before surgery. In the meeting, they received confirmation that the planning was consistent with the patient’s problems, needs and desires. An important factor was that it took courage for OTNs to meet the patient in this situation. Time to read the journal and talk to the patient is very important. There is only this conversation. The longer you have worked and the more secure you are in your routines the more you can find the time; if you are that way inclined. I think you should talk to the patient and have the courage for the meeting. The participants came forward by meeting patients face-to-face. At that moment, patients might have perceived the OTNs’ presence and the desire to do well. The participants requested that all OTNs should have this ability. When the patient did not want to have a relationship, they kept in the background. It can be eye contact, to see and confirm. That you are present; that they feel that you see them and that you want to do the best for them. You can convey a lot with body language and I think that is important. Sometimes I can feel that the patient does not want contact. Another issue that emerged was the ability of OTNs to implement perioperative conversation. They asked for Table 1 Operating theatre nurses’ perceptions of caring The main category: to follow the patient all the way Descriptive categories
To ensure continuity of patient care Keeping a watchful eye
Operating theatre nurses’ perceptions of caring in perioperative practice Getting to know the patient To be responsible for the patient To protect the patient’s body To preserve the patient’s dignity
364
A.-C. Blomberg et al.
more time to meet with patients both pre- and postoperatively and above all to meet the anxious patients preoperatively as well as to exist in the intra- and postoperative phase. Participants wanted to follow the patient from the time they arrived at surgery to the moment of delivery to the postoperative department as well as evaluating the completed care. OTNs believed that they had important knowledge that contributed to a different understanding of the patient’s postoperative care. Then I had the opportunity to follow the patient all the way and the patient had the opportunity to talk to me if there was anything special that they were thinking about. It may be a previously experienced situation and make it something bad again. Such time, I’d really like to have a perioperative conversation. It must be gold. . . I also had the opportunity afterwards to know how they had perceived me and the situation . . . would like to have more time to meet patients before and after, maybe even a little more. To be responsible for the patient. The perceptions consisted of how OTNs could be responsible and promote safety in patient care through knowledge. Responsibility for patient care started for OTNs in the pre-operative phase when they were told which patient they would care for during surgery. Important aspects were if the patient was overweight, infectious, had allergies or ongoing medical treatment that risked increased bleeding. The pre-operative patient preparation was extensive, and OTNs felt it was an important part in patients’ care. Patients are of different sizes and different ages, and that can dictate what you take to the surgery even though it is the same operation; it can be clothing and things like that, that you should not tape too much if the patient has fragile skin, things like that you think a lot of so that it will be as good as possible. Intra-operatively, the OTNs strove to ensure that the patient’s time in the operating theatre would be minimised and took responsibility for the coordination of the surgical team. The intention was to prevent subsequent patients being at risk of removal from the operating programme. They considered that the efficiency included accuracy and speed to avoid unnecessary waiting time for the patient. Patients should not be put to sleep unnecessarily. The circulating nurse wants to find the surgeons but the OTNs said no, because she was not ready. At the same time, the situation is that if you do not seek in time, it is not we who wait but the patient . . . It is not good care when the patient gets dismissed because things have been too slow. One aspect of caring is that OTNs kept track of instruments and other materials and conveyed information to
other members of the surgical team about what was happening in the surgical wound. The OTNs responsibilities included being prepared for the unexpected. I always set up in the same way regardless of whether it is the right or left side to be operated on, so I know where everything is. Ensuring that you have enough dressings and that you have things inside the operating theatre . . . you always want to be one step ahead and be there if something happens. Based on the OTNs’ specific knowledge, skills and topographic anatomy, they had responsibility to select the right operating table with accessories and for patient positioning based on the patient’s individual needs. Patient positioning on the operating table was conducted jointly in the surgical team, but the surgical team always wanted confirmation from the OTNs before the pre-operative preparation was started, in order to avoid intra-operative consequences. The function of all medical equipment was checked in order to ensure patient safety. It is my job to choose the right operating table, and ensure that the patient is placed in the right position. I think that the rest of the surgical team often relies on us. The ultimate responsibility is on me, because when the patient is sterilely gowned I have to answer how the patient is positioned. I am responsible for making sure that the equipment works that is connected to our care for the patient, this cannot go wrong. Another safety aspect was to verify the patient’s identity, and when operating on a paired organ that the correct side was selected, which was a joint responsibility of the surgical team. The OTNs assured themselves further by ensuring that patient data were consistent with the planning. Checking all the material and ensuring that nothing was left inside, the patients was included in the professional responsibility and was a part of their care of the patient. I have to check that I have the right patient and am prepared with the right things, for me it’s important to know. Patients might be premeditated so they are not aware of anything, but I am there in any case and look in the anaesthesia record that the ID is checked and that it is marked on the side to be operated on. You must have the whole picture. Keeping a watchful eye. This descriptive category consists of two perceptions: To protect the patient’s body and to preserve patient’s dignity. To protect the patient’s body. The perceptions consist of how OTNs respect the patient’s autonomy and protect the patient’s body from injury and risks. The patient’s need was to feel well in a high-tech environment, and this was met by the OTNs who set the © 2014 Nordic College of Caring Science
Making the invisible visible conditions for peace and quiet. There was an ambition to meet the patient’s wishes and needs. Continuous information was given about occurring activities in the operating theatre. The OTNs’ notions of what good care was formed the basis of planning the patient’s care. The patient may choose whether he wants radio or headphones when he goes to sleep, so we ask if they want it. Just a little thing like information can calm things down tremendously. We do not do anything dangerous here but now we are rustling because we are picking up things . . . it’s important to put yourself in the patient’s situation and treat the patient as you would want to be treated yourself. By protecting patients from undergoing postoperative infections, the OTNs kept ‘a watchful eye’ over the sterility of the surgical area and the operating theatre. To prevent the spread of infection, they had control of the traffic flow in the operating theatre. Assistants and students who attended the operation were supervised by the OTNs, dictating how they should behave in order to maintain sterility. They reacted intuitively when they felt that someone or something was unsterile. The number of health professionals present during the surgery, increased the risk of postoperative infections and the OTNs decided when the number should be reduced. Sterility is up to me, and then you are very careful to check . . .not only that you are there close to the wound, but you should also have full control of what others are doing so they do not contaminate. I also decide if there is a student or someone else in the theatre. I am involved by saying you cannot go there, you cannot stand there. The patient’s body temperature was monitored to prevent cooling. The patient received a warm quilt, warm fluids and moist towels to cover the wound. Protecting the patient from being cold could reduce the risk of postoperative infections. Acts such as fixing pillows and heat cost little and are pure thoughtfulness. I raise the temperature of the operating theatre. I make sure that he does not bleed in vain, cover with moist compresses so that it does not cool down the patient unnecessarily if you have an open abdomen. It is caring, to maintain body temperature. The patients were continuously monitored, in order to protect against perioperative pressure and nerve damage. The OTN expressed the importance of looking at the whole human being during draping and being aware of the risks associated with different positions on the operating table. At certain times during the operation, the surgeon needed better access to the surgical site. In these cases, the OTN protected the patient so they were not subjected to unnecessary risks for a long time. They gave the patient massage during the
© 2014 Nordic College of Caring Science
365
operation and took the initiative to interrupt lengthy operations for exercise. The OTN was observant if any of the surgical team pushed or placed heavy instruments on the patient. The whole time I check for leaks, that the draping holds and that no one stands and presses when the patient has leg supports. Even when the patient has leg supports we raise and lower the legs every half hour. To preserve patients’ dignity. The perceptions consisted of how patient dignity was preserved and integrity respected. The patient is in a vulnerable position, and the OTN ‘kept a watchful eye’ over the whole patient. The OTN prevented unprofessional conduct in front of the patient involving unnecessary talk and condescending comments in the operating theatre and noted afterwards that it was not appropriate behaviour. I monitor the patient and have to take into account the patient’s interests; I am probably the one who thinks from the patient’s perspective. It is not perceived as safe and secure if you have three people rambling on around you and talking about various things. It should not be too playful around the patient. You make signs or somehow say that now we have to keep it down. All were focused on the patient’s body but on different parts. The OTN respected the patient’s privacy in the context of intimate interventions. They considered themselves more intimate with the patient because they were involved in the surgical wound. They prevented the patient’s body from being uncovered and had an ethical stance, whether the patient was awake or anesthetised. The nurse anaesthetist is focused on head and arms. We do a lot more involving the patient’s body. The body is more intimate and sensitive to a patient. Head and arms, that is more public. It is important to cover the patient, maintaining integrity. When we have someone in the operating theatre lying in leg supports, we pull down the blinds whether they are sleeping or not. We do not have them lying naked if we do not have to but just when we need to have access, otherwise we try to cover them. Various aspects of caring in the perioperative practice showed that the OTN had the ambition to get to know the patient in order to acquire knowledge about the patient in order to plan patient care. When the OTN had knowledge of the patient, she was responsible for providing continuity of patient care. She protected the patient by keeping a watchful eye on them so that the patient’s body was not put at risk and the patient’s dignity was preserved. The prerequisite was that she could follow the patient the whole way.
366
A.-C. Blomberg et al.
Discussion The results show different aspects of care in the perioperative practice where the widespread desire of OTN’s is to follow the patient all the way through the perioperative process. Breakiron (32) showed the importance of caring acts where the OTNs were present for the soldiers when they needed a shoulder to cry on. This historic development of being visible later became more invisible as medical technological progress advanced, a claim for greater productivity and an increased demand for trained OTNs in perioperative practice (7). The training has been influenced by various organisational and policy decisions that resulted in the OTNs of today being merely responsible and involved in the patient’s intra-operative care (3). McGarvey (4, 33) showed that active OTNs had difficulty in describing their care of the patient, although they described care from various medical and technical functions and how their collaboration with the surgeon contributed to good patient care. OTNs got to know the patient by reading medical records and giving priority to meet and having conversations with the patient. There was a desire to see the whole person but also to convey that they were present through eye contact. According to Martinsen (34), health professionals are present in the moment and at the same time pay attention to what the patient wants to convey with his body language. OTNs see themselves as listening and receptive and become involved in the moment. You can never fully understand another human being without having a relationship, there is always something that remains unknown to us. It turned out that the meeting with the patient brought OTNs knowledge that changed or confirmed the planning of patient care. The participants perceived caring as being able to ‘read the patient’ and respond to tasks that required experience, which Benner (35) states newly qualified graduates lack. The study revealed that meeting with the patient pre-operatively was usually organisationally impossible for the OTNs. There was an opportunity to meet and talk to the day surgery patients, but participants perceived that there was a lack of time and too much stress that prevented having more. Perioperative practice is characterised by a production approach that shapes care culture that is not perceived to be in line with ethical values (36). The care culture is created from traditions, rituals and values as Rytterstr€ om et al. (37) state that each care culture has their own values. OTNs were present when the patients needed them but were organisationally prevented from following the patient ‘all the way’. Experience helped to set aside time for a meeting with the patient, but also personality emerged as a factor for wanting or not wanting to meet the patient. The OTNs desire was to have the opportunity to get to know the
patient pre-operatively and participating in the reporting of the patient postoperatively. Some OTNs reported that their knowledge was not used in the patient’s postoperative care (33). There was the desire to implement perioperative conversations with patients and contribute to the continuity of patient care (38). In Sweden, OTNs are given the opportunity to work with an ideal model ‘the perioperative dialogue’ (38, 39), and it showed that patients experienced continuity in care by meeting a known face in perioperative practice (38, 40). Several attempts have been made by AORN to introduce a nursing process in perioperative practice, but OTNs even internationally continue to only care for the patient intra-operatively (33, 41). The OTNs cooperated in the surgical team with specific knowledge of hygiene and topographic anatomy, medical technology, surgical methodology and nursing, which involved responsibility for the patient’s care. According to previous research, OTNs have their own planning (2) which includes preparing materials and performance testing of medical devices pre-operatively, which Bull and FitzGerald (10) state combines technical competence with caring aspects. Intra-operative OTNs have full control and keep track of the instruments to be prepared for the unexpected which according to Mitchell et al. (23) is used to be aware of the situation or ‘to being ahead’ (22). Martinsen (34) argues that nurses get an idea that is preceded by concentrated work which starts mental activity, and the OTN sees the situation in a different way and acts intuitively for the patient. To be effective in caring meant according to Arakelian et al. (42) to coordinate the surgical team by ‘doing things right’ and to have personal knowledge of the surgeon’s requirements and preferences for surgery (20). The goal was that surgery time would be better used, and the patients’ time in the operating theatre minimised. In conjunction with positioning on the operating table, OTNs perceived that their knowledge of operating methodology helped to avoid intra-operative consequences. Even if the patient expressed that they were in a good position, OTNs considered that they took responsibility that the positioning was optimal. Seeing with the heart is like wanting the best for the other person (43). According to Andersson et al. (44), the traffic flow in the operation theatre increases the risk for the patient to be subjected to a postoperative infection. OTNs considered it to be a big part of their care of the patient under surgery (19). OTNs kept a watchful eye on the patient during the perioperative process. Martinsen (34) argues that imagination needs thinking about and is preceded by putting yourself in another person’s situation, ‘the golden rule’. They showed an ethical responsibility by their desire to do good for the patient, and this may, according to von Post (45), be related to OTNs professional natural care. The results reveal how OTNs protect the patient’s body © 2014 Nordic College of Caring Science
Making the invisible visible and maintain the patient’s dignity in a vulnerable situation. Lindstr€ om et al. (46) describe Erikssons theory of caritative caring which emphasises that good care is based on the innermost core of caring, the core of caring involves a caring relationship between nurse and patient, it is an open invitation that contains affirmation that the patient is welcome. According to Baillie (47), it is important in the perioperative caring to welcome the patients and preserve dignity. The participants described how they were present and saw when the patient’s dignity was violated, and through their caring responsibility drew attention to those concerned to show respect for the patient’s integrity. Patients that must undergo surgery usually find themselves in a vulnerable situation (48). The OTNs considered the importance of an ethical stance, whether the patient was asleep or awake.
367
a watchful eye during surgery to protect the patient’s body from being exposed and preserved the dignity of the patient when the patient no longer had control over their body. They stated that they had a desire to be more involved in patient care and wanted to follow the patient throughout the perioperative nursing process. Although OTNs have the ambition to make care visible in perioperative practice, organisations today advise a medical technical approach which promotes OTNs continuing to nurture in secret.
Acknowledgement Thanks to all participants who shared valuable time and stories in the study.
Author contributions Limitations The selection of participants was guided by set criteria, though the head nurse in each county conducted the actual procedure to identify whom to ask for potential participation in the study. The limitation with this selection process was that the first author did not have full control over the selection of the participants.
Ann-Catrin Blomberg was responsible for the study conception and design. She collected and analysed the data and wrote the manuscript. Lillemor Lindwall acted as the main supervisor, participated in analysing the data and took the main responsibility for writing the manuscript. Birgitta Bisholt and Jan Nilsson acted as co-supervisor and participated in analysing the data and in writing the manuscript.
Conclusion This study has confirmed that the phenomenon caring in the perioperative practice described when OTNs got to know the patient as a human being. OTN caring in perioperative practice became visible by gaining knowledge about and from the patient, and they wanted to follow the patient all the way and to continue in the patient’s care. The OTNs caring was given a new meaning through the act of caring; care for, to protect and to preserve the patient’s dignity. The meeting with the patient gave rise to them feeling responsible for the continuity of patient care. OTNs kept
References 1 Richardson-Tench M. The scrub nurse: basking in reflected glory. J Adv Perioper Care 2008; 3: 125–31. 2 Blegeberg B, Blomberg A, Hedelin B. Nurses conceptions of the professional role of operation theatre and psychiatric nurses. Vard Nord Utveckl Forsk 2008; 28: 9–13. 3 SOU 1962:4.Arbetsuppgifter Och Utbildning F€or Viss Sjukv ardspersonal. Bet€ankande Av Utredningar Ang aende Visssa Sjuksk€ oterskors Och Undersk€ oterskors
© 2014 Nordic College of Caring Science
Ethical approval The local university ethics committee approved the study (Dnr C2012/306). The study followed research ethical principles in accordance with the Helsinki Declaration.
Funding This research received no specific grant from any funding agency in the public, commercial or not-for-profit sectors.
Arbetsuppgifter M. M. Stockholm: Inrikesdepartementet (Statens offentliga utredningar 1962:4). 4 McGarvey HE, Chambers MGA, Boore JRP. Development and definition of the role of the operating department nurse: a review. J Adv Nurs 2000; 32: 1092–100. 5 Nightingale F. Notes on Nursing: What it is, and What it is Not. 2003, Barnes & Noble, New York. 6 Holder VL. From handmaiden to right hand – world war I and advancements in medicine. Sixth in an ongoing
7
8 9
10
series about the history of perioperative nursing. AORN J 2004; 80: 911– 23. Sigurdsson HO. The meaning of being a perioperative nurse. AORN J 2001; 74: 202–17. Nelson D. Perioperative nursing and it’s history. The Dissector 2007; 35: 19–23. Wagner VD, Kee CC, Gray DP. A historical decline of educational perioperative clinical experiences. AORN J 1995; 62: 771–82. Bull RM, FitzGerald M. Nursing in a technological environment: nursing
368
11
12
13
14
15
16
17
18
19
20
21
22
23
A.-C. Blomberg et al.
care in the operating room. Int J Nurs Pract 2006; 12: 3–7. AORN Statement Committee. Definition and objective for clinical practice of professional operating room nursing. AORN J 1969; 10: 43–48. AORN Statement Committee. House of delegates - implications and directions. AORN J 1978; 27: 1153–78. Kneedler JA, Dodge GH. Perioperative Patient Care - the Nursing Perspective, 3rd edn. 1994, Jones and Bartlett Publishers, Boston. Nursing Practices Committee. A model for perioperative nursing practice. AORN J 1985; 41: 188–90, 192– 4. Lindwall L, von Post I. Perioperativ V ard: Att F€orena Teori Och Praxis. (Perioperative Care: Reconciling Theory and Practice),2nd edn. 2008, Studentlitteratur, Lund. Rudolfsson G, von Post I, Eriksson K. The expression of caring within the perioperative dialogue: a hermeneutic study. Int J Nurs Stud 2007; 44: 905–15. Westerling K, Bergbom I. The importance of nursing in perioperative care: a patient’s perspective. J Adv Perioper Care 2008; 3: 133–44. Mitchell L, Flin R. Non-technical skills of the operating theatre scrub nurse: literature review. J Adv Nurs 2008; 63: 15–24. € en J, Gustafsson B Kelvered M, Ohl A. Operating theatre nurses experience of patient-related, intraoperative nursing care. Scand J Caring Sci 2012; 26: 449–57. Riley R, Manias E. Governance in operating room nursing: nurses’ knowledge of individual surgeons. Soc Sci Med 2006; 62: 1541–51. Riley R, Manias E. Governing time in operating rooms. J Clin Nurs 2006; 15: 546–53. Bj€ orn C, Bostr€ om EL. Theatre nurses’ understanding of their work: a phenomenographic study at a hospital theatre. J Adv Perioper Care 2008; 3: 149–55. Mitchell L, Flin R, Yule S, Mitchell J, Coutts K, Youngson G. Thinking
24
25
26
27
28
29
30
31
32
33
34
35
36
37
ahead of the surgeon. An interview study to identify scrub nurses’ nontechnical skills. Int J Nurs Stud 2011; 48: 818–28. Meretoja R, Leino-Kilpi H, Kaira A. Comparison of nurse competence in different hospital work environments. J Nurs Manag 2004; 12: 329–36. Sj€ ostr€ om B, Dahlgren LO. Applying phenomenography in nursing research. J Adv Nurs 2002; 40: 339–45. Larsson S. Kvalitativ Analys: Exemplet Fenomenografi. (Qualitative Analysis: The Example of Phenomenography). 1986, Studentlitteratur, Lund. Marton F, Booth S. Learning and Awareness. 1997, Erlbaum, Mahwah, N.J. Uljens M.Fenomenografi: Forskning Om Uppfattningar. (Phenomenography: Exploring Perceptions). 1989, Studentlitteratur, Lund. Kvale S, Brinkmann S, Torhell S. Den Kvalitativa Forskningsintervjun. (The Qualitative Research Interview), 2nd edn. 2009, Studentlitteratur, Lund. Dahlgren LO, Fallsberg M. Phenomenography as a qualitative approach in social pharmacy research. J Soc Adm Pharm 1991; 8: 150–6. Sandelowski M. The problem of rigor in qualitative research. ANS 1986; 8: 27–37. Breakiron M. A salute to the nurses of world war II. AORN J 1995; 62: 710–22. McGarvey HE, Chambers MGA, Boore JRP. The influence of context on role behaviors of perioperative nurses. AORN J 2004; 80: 1103–20. Løgstrup Martinsen K, Sygepleien Og. Logstrup and Caring. 2012, Klim, Aarhus. Benner PE, Tanner CA, Chesla CA. Expertise in Nursing Practice: Caring, Clinical Judgment & Ethics, 2nd edn. 2009, Springer, New York. Lindwall L, von Post I. Habits in perioperative nursing culture. Nurs Ethics 2008; 15: 670–81. Rytterstr€ om P, Cedersund E, Arman M. Care and caring culture as experienced by nurses working in different
38
39
40
41
42
43
44
45
46
47
48
care environments: a phenomenological–hermeneutic study. Int J Nurs Stud 2009; 46: 689–98. Lindwall L, von Post I. Continuity created by nurses in the perioperative dialogue – a literature review. Scand J Caring Sci 2009; 23: 395–401. Lindwall L, von Post I, Bergbom I. Patients’ and nurses’ experiences of perioperative dialogues. J Adv Nurs 2003; 43: 246–53. Rudolfsson G, Hallberg L, Ringsberg KC, von Post I. The nurse has time for me: the perioperative dialogue from the perspective of patients. J Adv Perioper Care 2003; 1: 77–84. AORN Statement Committee. Perioperative Standards and Recommended Practices. 2011, AORN J, Denver. Arakelian E, Gunningberg L, Larsson J. How operating room efficiency is understood in a surgical team: a qualitative study. Int J Qual Health Care 2011; 23: 100–6. Øjet Martinsen K, Kaldet Og. The Eye and Call. 2000, Fagbokforlaget, Bergen. Andersson AE, Bergh I, Karlsson J, Eriksson BI, Nilsson K. Traffic flow in the operating room: an explorative and descriptive study on air quality during orthopedic trauma implant surgery. Am J Infect Control 2012; 40: 750–5. von Post I.Professionell Naturlig V ard Ur Anestesi- Och Operationssjuksk€oterskors Perspektiv. (Professional natural health care from anesthesia and surgical nurses’ perspective). Hammar€ o: Irene von Posts f€ orl., 1999. Lindstr€ om U A, Lindholm L, Zetterlund JE. Theory of Caritative Caring. In Nursing Theorists and their Work, 7th edn (Alligood MR, Tomey AM eds), 2009, Mosby, Maryland Heights, 190–221. Baillie L, Ilott L. Promoting the dignity of patients in perioperative practice. J Perioper Pract 2010; 20: 278– 82. Edlund M, Lindwall L, von Post I, Lindstr€ om U A. Concept determination of human dignity. Nurs Ethics 2013; 20: 851–60.
© 2014 Nordic College of Caring Science
