Article
Student nurses’ experiences of preserved dignity in perioperative practice – Part I
Nursing Ethics 2015, Vol. 22(6) 676–687 ª The Author(s) 2014 Reprints and permission: sagepub.co.uk/journalsPermissions.nav 10.1177/0969733014542675 nej.sagepub.com
Ann-Catrin Blomberg Karlstad University, Sweden
Elin Willassen Oslo and Akershus University College of Applied Sciences, Norway
Ire´ne von Post
˚ bo Akademi, Finland A
Lillemor Lindwall Karlstad University, Sweden; Oslo and Akershus University College of Applied Sciences, Norway
Abstract Background: In recent years, operating theatre nurse students’ education focussed on ethical value issues and how the patient’s dignity is respected in the perioperative practice. Health professionals are frequently confronted with ethical issues that can impact on patient’s care during surgery. Objective: The objective of this study was to present what operating theatre nurse students experienced and interpreted as preserved dignity in perioperative practice. Research design: The study has a descriptive design with a hermeneutic approach. Data were collected using Flanagan’s critical incident technique. Participants and research context: Operating theatre nurse students from Sweden and Norway participated and collected data in 2011, after education in ethics and dignity. Data consisting of 47 written stories and the text were analysed with hermeneutical text interpretation. Ethical considerations: The study was conducted accordance with the Declaration of Helsinki and approved by a local University Ethics Research Committee. Findings: The findings revealed that students experienced that operating theatre nurses perserved patient’s dignity in perioperative practice by being present for each other and making themselves known to the patient. Operating theatre nurses caring for the patient by being compassionate and preserved the patient privacy. The new understanding that emerged was that the operating theatre nurse students understood that the operating theatre nurse wanted to care for the patient like a human being. Discussion: In the discussion, we have illuminated how professional ethics may be threatened by more pragmatic and utilitarian arguments contained in regulations and transplant act. Conclusion: Preserved dignity is an ethical and caring act. Ethical questions and how to preserve dignity in perioperative practice should be discussed more both in educations of healthcare professionals and in clinical practice.
Corresponding author: Ann-Catrin Blomberg, Department of Health Sciences, Karlstad University, SE-651 88 Karlstad, Sweden. Email: [email protected]
Downloaded from nej.sagepub.com at Stockholm University Library on November 14, 2015
Blomberg et al.
677
Keywords Caring science, hermeneutic, human dignity, operating theatre nurse, perioperative practice
Introduction This article presents operating theatre nurse (OTN) students’ experience of preserved human dignity, in the light of their experiences of the OTNs’ caring and ethical acts during their clinical practice education. OTN students’ education takes place in a perioperative practice described as a high-technology environment1 where the ethos is based on production.2 Patients who arrive in an operating theatre are vulnerable young or old human beings who need emergency or planned surgery and expect to be treated with respect and dignity.3 The patient, the suffering human being, is understood as an entity of body, soul and spirit.4 Patients who are to undergo surgery meet health professionals (physicians, OTNs and nurse anaesthetists) with different knowledge, competence, experiences and ethos. This study was conducted during the OTN students’ first clinical practice education, before habits of culture had become a part of them.5 The study seeks to answer what OTN students experience as caring acts aiming to preserve the patient’s dignity in a perioperative practice. The OTNs in Sweden and Norway have a specialist nursing education in operating theatre nursing. They have knowledge of medical technical equipment, surgical methodology, hygiene and asepsis in order to manage the responsibility of taking care of the patient in a high-technology environment.6 It takes courage and humility to be close to another human being in a caring situation.2,7 The caring acts are understood as ethical acts, based on caring knowledge, skills, experience, ethics and morals and are always conscious choices that the OTN is responsible for.7 In perioperative practice, nurses accept the safeguarding of the patient’s rights and their decisions and actions are determined by the code of ethics8 and the ability to preserve the patient’s dignity. The purpose of all caring is to alleviate suffering and serve life and health.7 Caring in perioperative practice includes showing respect and preserving for the patient’s dignity.9 Eriksson10 describes dignity as the deepest value in caring ethics. Dignity is manifested by attitudes, actions and attributes that are adapted to different situations. Health professionals who have an ethical attitude and language can preserve the patient’s dignity. Their professional caring ethos allows a patient to experience the feeling of being comfortable on the operating bed.11 According to Edlund et al.,12 there are two forms of dignity. The first form absolute dignity means that a patient has the right to be considered as a unique human being. The second form is relative dignity, which refers to an inner ethical behaviour and provides awareness that one’s own dignity, and others’, changes throughout life and is dependent on the culture in which people live. Gallagher13 explains that dignity can also be seen as a two-part professional value: Value to the other and to one self. Le´vinas et al.14 link dignity to humanity and responsibility for the other by meeting the other face to face, something the OTN is invited into by the patient in a vulnerable situation. Being there for the other is especially important in a perioperative practice where patients lose control of their body and meet unfamiliar faces in a high-technology environment.2 A dignified demeanour means that nurses are genuine in their demeanour. The will to be there for the patient comes from the heart.15 It is the OTNs’ duty to preserve patient dignity through their conduct, and to do well, to do right and to meet the patient with dignity. The OTNs observe and witness and hence become ethically responsible.16 Research on preserved dignity has been published in some studies, but they have primarily been conducted in other contexts, such as older people care,13,17 medical care18 and surgical care.19 It is less common to find studies on preserved dignity within the perioperative practice, in which research has focussed on promoting patient safety.20–22 Mitchell and Flin21 considered the importance of frequent communication
Downloaded from nej.sagepub.com at Stockholm University Library on November 14, 2015
678
Nursing Ethics 22(6)
between health professionals and the significance of this for operation results. According to Bjo¨rn and Bostro¨m,23 it is necessary for the OTNs to have control over the situation. Lindwall et al.9 show that many health professionals have focussed on increased productivity, which can mean that ethical values are not always taken into account. Baillie and Ilott24 described how health professionals promote patients’ dignity in perioperative practice by protecting the patients from others’ health professional’s behaviour. In studies by Timmons and Tanner25 and Kelvered et al.,26 the OTNs described their role as being responsible for the atmosphere in the operating theatre. Rudolfsson and Flensner27 suggested that the OTN is the one who ensures that the care does not cause suffering. On the basis of International Council of Nurses’s (ICN) ethical codes for nurses and the evidence from earlier studies about human dignity in care, the actual study emanates from promoting and persevering dignity. Ethical reflections are needed for healthcare practice and can help develop good perioperative practices. Therefore, this study may contribute to answer how OTN students, at the beginning of their clinical practice education, experience how the OTN preserves the patients’ dignity during the perioperative process. The aim of this study was to present what OTN students experienced and interpreted as preserved dignity in perioperative practice.
Methodology Design The study has a hermeneutical approach inspired by Gadamer’s28 philosophy of understanding and interpretation. Gadamer focussed on prejudgement, pre-understanding and fusion of horizons and emphasised that those who express themselves and understand are connected by a common human consciousness that makes understanding possible.
Sample and data collection The participants were 60 registered nurses (RNs) undertaking specialised OTN education (32 from Sweden and 28 from Norway). The participating students aged from 25 to 48 years and had different levels of professional nursing experience ranging from 1 to 16 years. All invited students accepted participation and completed the study. Before starting the study, all students participated in the same theoretical education in ethics and dignity. Data were collected by critical incident technique, a self-reporting technique that focuses on critical events that have affected the participants positively or negatively. Flanagan30 describes the critical incident technique as ‘The critical incident technique should be thought of as a flexible set of principles which must be modified and adapted to meet the specific situation at hand’ (p. 335). The students were asked to provide written critical incidents, which Gallagher39 argues can help the students to develop the ability to see the patient’s perspective. The following information was given to the students: Please describe one situation where OTNs preserved patient dignity, a critical incident from your clinical practice education reality. Critical incidents are descriptions of actions and ways of acting that you have experienced and that have been of importance to the caring situation which you have participated in. The critical incidents were described using the following steps: It all started like this and developed like this. Flanagan30 describes that the critical incident technique is seen as credible as the research subjects have experienced the incidents themselves. In this article, the data only covered 47 positive events. In total, 13 incidents were excluded because they did not focus on preserved dignity. In this study, part I presents the positive incidents and part II the negative incidents, related to the caring situation. The study was conducted during the autumn of 2011.
Downloaded from nej.sagepub.com at Stockholm University Library on November 14, 2015
Blomberg et al.
679
Ethical considerations The study was conducted in accordance with the Declaration of Helsinki,31 which is a set of ethical principles that protect research subjects’ anonymity, privacy and maintain public confidence. In this study, which is based on narratives, the privacy of informants, patients and staff has been protected by not mentioning names, dates of birth, type of surgery or hospital. The students were asked to provide informed consent and asked whether the material could be used for research purposes. The project was approved by a local University Research Ethics Committee.
Hermeneutic text interpretation The critical events were combined into a text that became a voice from reality. Hermeneutic text interpretation28,29 was selected, as it seeks to understand the substance of the text before declaring the speaker behind the text. Gadamer28 highlighted the meaning of language for the creation of a world in which reality can be revealed and interpreted. According to Gadamer,28 all people have an existential pre-understanding of life. However, professional pre-understanding should not be understood as only existential pre-understanding but rather as preunderstanding rising from the profession one investigates. The researchers’ professional preunderstanding is made up of a caring science encompassing OT nursing, medical knowledge and ethical values. The students’ pre-understanding derives from experiences of nursing as OTN students, clinical context experiences, ethical values and knowledge of caring and medical sciences. The profession can aid or veil seeing.32 It is a laborious process to push aside the veil, that is, to chase away the prejudices that block one’s vision, and see what actually appears in practice. Pushing the veil aside means that researchers try to go beyond the obvious and reflect on what they really saw and what they overlooked.29 The researchers are not free from tradition’s horizon of understanding.28 The interpretation of the text began with an examination of the text as the original source and its relevance to practice. The text was regarded as the original source since the events came from our time and from a context known to us. The students used caring language relevant within a perioperative practice. Integrating the text with the reader. In order to approach the text in an, as much as possible, unprejudiced way, the text was not read, compared or interpreted before data collection was completed. The text was read from beginning to end, because the last part can change everything. The first step began as an open reading during which questions emerged such as follows: Is this reality? The text answered: Yes it is reality. Professional pre-understanding made the text understandable. Fusion of horizons. The text was read carefully and was allowed to present itself in all its otherness.29 Professional pre-understanding had to be taken into account in relation to the context that was unfamiliar, and new questions emerged: Is it so or so? Gadamer stated that dialogue with a text leads to a fusion of horizons, in other words: The reality of the text becomes part of the reader. In the fusion of horizons, it became obvious that the text talked about preserved dignity. New questions to the text. The following question arose when the researchers transcended the horizon of the text, as well as their own horizon: What does the text have to say about how OTN students experienced preserved dignity in a perioperative practice? Movements back and forth throughout the text took place in order to discover answers to the question. The answers were significant expressions and quotations with common and distinguishing qualities.
Downloaded from nej.sagepub.com at Stockholm University Library on November 14, 2015
680
Nursing Ethics 22(6)
Summarising the main themes and subthemes. The text was carefully read through to search for common features in all significant expressions. The common feature was formed into two main themes, after which distinctive qualities were sought, which resulted in four subthemes. Each subtheme has received its design using quotes from the text. The new understanding. The entire text was read again to reconfirm the themes and to search for a new understanding by moving back and forth between the parts and the whole. This process of understanding involved abstraction of the main themes and subthemes to form a new understanding, a coherent whole (Figure 1), which was deemed valid and free from contradictions.
Results The results revealed that OTN students understood that OTNs want to preserve patient dignity in a perioperative practice through caring acts such as OTN and patient being present for each other and OTN caring for the patient.
OTN and patient being present for each other The main theme consists of two subthemes: The OTNs getting to know the patient and making themselves known to the patient. The OTN getting to know the patient. The students understood that the OTNs wanted to know more about the patient before the first meeting, and therefore, they collected information from the medical records. When they met the patient, they listened to his or her story about their life, body, problems and needs: . . . they first read about the patient in the medical record, then go and see the patient at the day surgery department. They greet the patient, ask a bit about previous surgeries, if she has problems with her hips or has implanted material in the body. (Participant 1)
When patients came from other cultures, it was valuable to know about them before the first meeting. OTNs needed to have knowledge about the patient’s culture in order to understand the patient’s situation and language, so they could explain what happened during the time they spent together: . . . the OTN understands the situation because she read the journal and found that the patient came from another culture, where abuse is not unusual. The OTN explains that she understands and will take care of the patient, in the best way. (Participant 5)
In order to preserve the patient’s dignity, the OTN took time to get to know the patient and learned about his or her culture before surgery. Making themselves known to the patient. The students understood making themselves known to the patient as an act aiming to protect the patient’s dignity. The OTNs welcomed the patient and introduced themselves with name and profession. They removed their face masks before greeting the patients because they considered it worthwhile to meet each other face to face: . . . the nurses in the operating theatre waited until the patient arrived before putting on their masks so that he would not be frightened and so that the first thing he saw were their faces. (Participant 28)
Downloaded from nej.sagepub.com at Stockholm University Library on November 14, 2015
Blomberg et al.
681
By being a known person, the OTN became a present person who took the patient’s feelings seriously, someone who wanted to alleviate the patient’s suffering: I felt that the patient’s nervousness disappeared through the care . . . It felt like the patient appreciated the presence when she was in an uncomfortable situation. (Participant 6)
The OTN wanted to be there for the patient during the time the patient was awake and slept. She allowed the patient’s voice to be heard and listened to: The OTN was present with the patient while the patient was awake. She lingered a moment, so that the patient had the opportunity to ask if there was anything else she wondered about. (Participant 18)
During the ongoing preparations, the patient and the OTN talked to each other about everyday things. When the OTN allowed himself or herself to be known to the patient, a relationship and trust developed between them: . . . my supervisor and I began to wash and dress the patient. We continued to talk about ‘everyday things’ with him and the conversation flowed in a fun, healthy way. (Participant 4)
The OTN wanted to know the child and also the parents, who had the chance to have any ambiguities clarified. By being present, the OTN could focus on the child and take care of the parents: The OTN had focus on the baby. They talked to Teddy and Teddy had electrodes glued to the same parts of the body as the boy. The mother had been informed and had the opportunity to ask if something was unclear . . . (Participant 27)
The OTN students understood being present for each other before surgery as a caring act. The OTN learned from the patient and promised to be there during the whole time. They chose ethical acts and preserved the patient’s dignity. A relationship would develop between them and they would trust each other and be able to plan the time together.
OTNs care for the patient This main theme consists of two subthemes: The OTNs are compassionate and the OTNs preserve the patient’s privacy. The OTNs are compassionate. The students regarded the OTNs as being compassionate when they talked to the patient with a respectful and friendly voice. The patients were given the opportunity to talk about their worries and fears. The OTNs’ hands were soft and caring and their eyes and smiles conveyed that they were compassionate: . . . during the whole situation, I felt a warm feeling of satisfaction. It really felt like the OTN was dedicated to making the whole thing a good experience for the patient. (Participant 2) The woman was allowed to express her concern and fear and was met with respect. The nurses used touch to provide security. Their glances and smiles conveyed that they cared. (Participant 17)
The compassionate OTN preserved the patient’s dignity by devoting time to the patient and holding the patient’s hand when he or she was in a situation of dependence. Facing a vulnerable patient in an exposed situation required courage from the OTN:
Downloaded from nej.sagepub.com at Stockholm University Library on November 14, 2015
682
Nursing Ethics 22(6)
. . . the patient appreciated the presence and that someone took the time to hold her hand while she was in an embarrassing situation. (Participant 14)
Being compassionate entailed observing the patient’s body language to notice whether the patient was in pain during surgery. At the same time, it also meant answering questions honestly: The OTN was observant of the patient’s body language and studied her/him to see if he was in pain or seemed worried. At one point the patient began to move a little uneasily. The nurse observed this and gently took the patient’s hand and told him what was happening, which calmed the patient. (Participant 13)
To satisfy the patient’s need to be undisturbed during the intraoperative phase the OTN provided headphones. The patient could choose the type of music and rest comfortably: They showed respect for the patient and sometimes asked if she was OK. I thought it was good that the patient could choose what she wanted to listen to in the headphones during surgery. It is good that the patients do not have to hear all the noise from the machines and tools during surgery. (Participant 7)
To care for in a perioperative practice meant to preserve the patient’s dignity. By being compassionate, that is, touching the body with respect, listening to the patient’s voice, looking in the eyes and touching with soft hands, the OTN could alleviate the patient’s suffering in the operating theatre. Preserved dignity also meant to show respect for the patient’s desire for peace and quiet in a high-technology environment. The OTNs preserve the patients’ privacy. The students experienced how OTNs preserved the patients’ privacy part of the body by using warm blankets to protect the body from being exposed, cold and humiliated. The time parts of the body were uncovered was made as short as possible. Using warm blankets also made the patient relaxed: Because she would sleep with her genitals showing and have her legs in stirrups they also put a blanket over her crotch to cover her until the surgeon started working. She got more warm blankets over her body so she would not get cold and she appreciated it very much. The heat also caused her to relax a bit more. (Participant 19)
In order to preserve the patient’s privacy, the OTN asked the patient for permission to allow students to attend during the operation. If the patient was awake during the operation, he or she was informed about persons who suddenly entered the operating room: For every person who came into the room the patient received information about who it was and their function in the surgical team. (Participant 12)
The OTN had the courage to protect the patient’s privacy and prevent health professionals’ unprofessional behaviour during the patient’s surgery: Other health professionals talked about why the young woman wanted to do the operation and then brought up what the surgeon had said, and speculations and discussions started. Not foul or offensive, but a discussion had begun. The OTN averted it all by saying that it was sad that such a choice had to be made, but everyone has a reason why they do it. (Participant 10)
The OTN students understood that the OTNs cared for the patients when they preserved their privacy. They had an ethical responsibility to protect the patients’ privacy and save them from having their privacy violated when they were unable to participate in a discussion. The OTNs preserved the patient’s dignity by taking responsibility for his or her privacy and saving the body from being exposed during the surgery.
Downloaded from nej.sagepub.com at Stockholm University Library on November 14, 2015
Blomberg et al.
683
New understanding In accordance with Gadamer’s28 term ‘a spiral activity’, the present findings led to a new understanding of what OTN students perceive ‘preserved dignity’ to be when they are experiencing a perioperative practice (figure 1). The OTN students experienced preserved dignity by observing the OTNs’ caring acts and by interpreting and understanding what they saw. It has been understood that OTNs preserve a patient’s dignity by OTN and patient being present for each other by getting to know the patient and making themselves known as well as caring for the patient by being compassionate and preserving the patient’s privacy during the time they are together (see Figure 1).
Being present for each other OTNs getting to know the patient and making themselves known to the patient
Caring for the patient OTNs are compassionate OTNs preserve the patient’s privacy
Preserved dignity – an ethical and caring act OTNs care for the patient as a unique human being and are responsible during the time they spend together in the perioperative practice. The ethical caring acts contribute to the implementation of good and safe care.
Figure 1. The OTNs preserve the patient’s dignity in a perioperative practice. OTN: operating theatre nurse.
For the OTNs, the caring act being present for each other meant getting to know and making themselves known by meeting the patient face to face before putting on the mask. Making them known so that the patient could feel good was understood as an act of compassion. Compassion is a sympathetic consciousness of others’ distress with a desire to alleviate it. The caring act caring for the patient was understood as an act of compassion.33,34 It meant allowing the patient to express his or her fears and concerns and holding the patient’s hand in an embarrassing situation.
Downloaded from nej.sagepub.com at Stockholm University Library on November 14, 2015
684
Nursing Ethics 22(6)
To be compassionate and protect the patient’s privacy entailed listening to the patient’s body language and protecting the body from the glances of others when he or she had lost control over the own body. An OTN who comes close to the patient’s skin must be aware that the skin is the body’s limit of privacy, a limit that prevents the patient’s dignity from being humiliated.35 Every human being has his or her own privacy; his or her own sphere where nobody else is allowed without being invited.36 Dignity, the core of ethics, gives human beings the potential to be humiliated and hurt12,32 (see Figure 1).
Discussion This study describes that OTNs preserve the patient’s dignity by being present for each other, caring for, being compassionate and preserving the patient’s privacy. The results make us aware that OTN students learn by seeing, experiencing, interpreting and understanding what preserved dignity is in perioperative practice. Eriksson et al.37 hold that patients suffering in care are created by undignified care. In a study by Callaghan,38 the students identified that patients’ vulnerability, dignity and privacy in perioperative practice were important. The participants recognised that the OTNs protected the patient’s preferences and previously expressed values. Positive role modelling by the OTNs also encouraged students to immerse themselves in the environment and engage in teaching and learning. Gallagher39 is looking at role models in professionals’ practice to learn how best to act and argues that it is different from sharing experiences in the classroom. In this study, OTN students have the ability to perceive situations from an ethical standpoint and experience, identify and relate to ethical concepts and relationships in a perioperative practice. This experience is understood by Gallagher39 as a learning experience that will give the student an opportunity to develop ethical caring skills, skills that are highly complex and where the understanding of ethical theory is only part of the ethical competence. Gallagher39 also believes that students need to be prepared for the challenges and positions that the profession can bring and has developed a model for teaching of nursing ethics promoting ethical competence. The goals or aims of ethics education can be articulated by ethical ‘knowing’, ethical ‘seeing’ or perception, ethical ‘reflection’, ethical ‘doing’ and ethical ‘being’. Gallagher45 provides an overview of the current challenges to slow ethical caring that relates to patient experiences of neglect, abuse and indignity in care contexts. All OTN students took part in ethical theories and participated in seminars, where they had the opportunity to reflect on recent critical incidents or situations in perioperative practice. The findings, as well as previous research, show that human dignity is violated when unreflective routines prevail in the operating theatre.2 Rytterstro¨m et al.40 explain that rigid routines can, without knowing, cause suffering and humiliated patient dignity. The students described situations where the OTN was calm and introduced himself or herself to the patient. According to Baillie and Ilott,24 the health professionals should be courteous and introduce themselves using their first name when talking to the patient and explain what is going to happen. When encountering a patient in a high-technology environment, Kelvered et al.26 argue that it is important to give the patient confidence, share thoughts and enable the patient to be an individual. All human beings, regardless of race, gender and culture, should be treated equally and have the same right to healthcare.8 The OTN is present for the patient by seeing and listening to him or her, and a relationship develops between them. Le´vinas et al.14 argue that seeing the face of the other is to be invited to take responsibility for the other.16 Martinsen41 says that in ‘the fictional space’, which affects the patient and the nurse, the nurse is allowed to reflect on his or her responsibilities for the patient. It is also important to note that in a relationship, we can never fully understand another human being; it is always something that is alien. The result shows that the OTNs care for the patients by being compassionate when the patient was in an exposed situation. They care for the patients with warm and professional hands. According to Wiklund,34 compassion involves sharing the patient’s feelings, to be affected and to act to relieve the other’s suffering.
Downloaded from nej.sagepub.com at Stockholm University Library on November 14, 2015
Blomberg et al.
685
The compassionate act of just being together with the patient can be understood as an ethical act. The OTNs helped the patients so they did not need to feel alone in a high-technology environment,24 developed friendships despite the short meetings and took responsibility.42 Bull and FitzGerald1 showed that compassion, kindness, cheerfulness and recognition of the patient as a human being with individual needs were necessary in perioperative practice. Ethics include promises and OTN’s care for the patients well despite the prevailing idea that time is not sufficient.43 According to Bull and FitzGerald,44 the OTN works hard to balance between the real time and the surgeon’s time and actually makes better estimations of the time because he or she takes into account the human being. Gallagher45 draws attention to ‘fast ethics’, a trend towards speed and time-saving initiatives whereby quickness may be valued over doing things well and quantity is valued over quality. She suggested ‘slow ethics’ for healthcare practice to understand and reduce practice that compromises patient well-being and humiliates professional ethics. Slow ethics is described as listening and establishing a dialogue with patients, families and practitioners; engaging in an inter-disciplinary way to learn from recent and distant reports and research; articulating; aspiring and valuing care. In the operating theatre, nursing is a requirement for efficiency, but Arakelian et al.46 meant that the patient was the focus and efficiency was understood as maintaining quality of care and measuring benefits of care for the patient.
Methodological reflection The hermeneutical approach28 gave the opportunity to gain a new understanding of what constitutes preserved dignity in perioperative practice. Critical incident technique30 resulted in a diverse and multi-faceted picture of the caring act, preserved dignity. The hermeneutic text interpretation29 gave the unknown and known in perioperative practice a meaningful text and caring, as preserved dignity was given a language. The researchers’ professional pre-understanding made it possible to let the text speak. However, it was also an obstacle when we had to go beyond our professional pre-understanding and admit that we do not always see and think about what appears. There is always a question of how to collect and interpret data to gain new knowledge. Here, we chose to invite OTN students to write stories about their experiences of preserved dignity in perioperative practice. In one way, this could be considered as a detour around the patient’s own narrative of the subject. On the other hand, patients might find it hard being completely true and honest in their presentation of the perioperative practice, as they are in such a vulnerable situation and totally dependent on the goodwill of the health professionals. The study is based on a limited number of participants and represents perioperative practice in Norway and Sweden. The participating students provided many caring situations and recalled stories. This was a limitation that could be seen in the light of Ricoeur47 who explained that it is not the experiences themselves we are looking for, but the best interpretation of the common meaning. In that case, the number of participants is not of interest, but the understanding that can be lifted from the text narrated by the participants. The findings of this study could serve as a basis for future studies. In addition, we suggest that this result can be used for discussion in many international and national nursing and caring contexts and in future studies on interventions to promote an ethical and dignified climate.
Conclusion Findings from this study highlight OTN students’ experiences, interpretations and understandings of how OTNs preserve the dignity of the patients, the suffering human beings, in a perioperative practice. The students’ written stories show that OTNs protect patient dignity. Creating time to reflect on patient care is essential. These findings about preserved dignity could be a starting point for ethical discussions and reflections. Being allowed to observe and write down events, and then discuss dignity in groups continuously in the education, can lead to increased awareness and changed attitudes that are ethical in nature.
Downloaded from nej.sagepub.com at Stockholm University Library on November 14, 2015
686
Nursing Ethics 22(6)
Acknowledgements We would like to thank all OTN students from Sweden and Norway who took part and shared their stories, which made this clinical caring research possible. Conflict of interest No conflict of interest has been declared by the authors. Funding This research received no specific grant from any funding agency in the public, commercial or not for profit sectors. References 1. Bull RM and FitzGerald M. Nursing in a technological environment: nursing care in the operating room. Int J Nurs Pract 2006; 12: 3–7. 2. Lindwall L and von Post I. Habits in perioperative nursing culture. Nurs Ethics 2008; 15: 670–681. 3. Baillie L. Patient dignity in an acute hospital setting: a case study. Int J Nurs Stud 2009; 46: 22–37. 4. Eriksson K. Den Lidande Ma¨nniskan [The suffering human being]. 1st ed. Stockholm: Liber, 2001. 5. Rytterstro¨m P. Tradition Och Horisont: Va˚rdkulturens Betydelse Fo¨r Va˚rdens Praxis [Tradition and horizon. The importance of care culture for the care praxis]. Linko¨ping: Institutionen fo¨r samha¨lls-och va¨lfa¨rdsstudier, Linko¨pings universitet, 2011. 6. SFS 2006:1053. Fo¨rordningen Om a¨ndring Av Ho¨gskolefo¨rordningen [Regulation amending the Higher Education] (SFS 1993:100). 7. Eriksson K. Caring science in a new key. Nurs Sci Q 2002; 15: 61–65. 8. International Council of Nurses (ICN). Code of ethics for nurses, 2013, www.icn.ch/about-icn/code-of-ethics-for-nurses 9. Lindwall L, von Post I and Eriksson K. Caring perioperative culture: its ethos and ethic. J Adv Perioper Care 2007; 3: 27–34. ˚ bo Aka10. Eriksson K. Va˚rdvetenskap som akademisk disciplin [Caring science as an academic discipline]. Vasa: A demi, 2007. 11. Von Post I and Eriksson K. The ideal and practice concepts of professional nursing care. Int J Hum Caring 1999; 4: 14–22. 12. Edlund M, Lindwall L, von Post I, et al. Concept determination of human dignity. Nurs Ethics 2013; 8: 851–860. 13. Gallagher A. Dignity and respect for dignity – two key health professional values: implications for nursing practice. Nurs Ethics 2004; 11: 587–599. 14. Le´vinas E, Nemo P and Contassot MG. Etik Och Oa¨ndlighet: Samtal Med Philippe Nemo [Ethics and infinity]. Stockholm; Lund: Symposion, 1988. Pittsburgh: Duquesne University Press. ˚ , Lindholm L and Zetterlund JE. Theory of caritative caring. In: Alligood MR and Tomey AM (eds) 15. Lindstro¨m UA Nursing theorists and their work. 7th ed. Maryland Heights, MO: Mosby, 2009, pp. 190–221. ˚ and 16. Delmar C. Omsorgsetik i klinisk sykepleje – den gode, kloke og rigtige sygepleje. In: Alvsva˚g H, Bergland A Forland O (eds) Nodvendige Omveier. En Vitenskaplig Antologi Til Kari Martinsens 70 A˚rsdag. Oslo: Cappelen Damm, 2013, pp. 117–129. 17. Na˚den D, Rehnsfeldt A, Ra˚holm M, et al. Aspects of indignity in nursing home residences as experienced by family caregivers. Nurs Ethics 2013; 7: 748–761. 18. Heijkenskjo¨ld KB, Ekstedt M and Lindwall L. The patient’s dignity from the nurse’s perspective. Nurs Ethics 2010; 17: 313–324. 19. Vendlega˚rd C, Hu¨bner A and Lindwall L. Dignity as it emerges for nurses’ in surgery practice. Vard i Norden 2010; 30: 30–34 (in Norwegian).
Downloaded from nej.sagepub.com at Stockholm University Library on November 14, 2015
Blomberg et al.
687
20. Riley R, Manias E and Polglase A. Governing the surgical count through communication interactions: implications for patient safety. Qual Saf Health Care 2006; 15: 369–374. 21. Mitchell L and Flin R. Non-technical skills of the operating theatre scrub nurse: literature review. J Adv Nurs 2008; 63: 15–24. 22. Riley R and Manias E. Gatekeeping practices of nurses in operating rooms. Soc Sci Med 2009; 69: 215–222. 23. Bjo¨rn C and Bostro¨m EL. Theatre nurses’ understanding of their work: a phenomenographic study at a hospital theatre [An antohology of clinical caring science]. J Adv Perioper Care 2008; 3: 149–155. 24. Baillie L and Ilott L. Promoting the dignity of patients in perioperative practice. J Perioper Pract 2010; 20: 278–282. 25. Timmons S and Tanner J. Operating theatre nurses: emotional labour and the hostess role. Int J Nurs Pract 2005; 11: 85–91. ˚ . Operating theatre nurses experience of patient-related, intraoperative nur¨ hle´n J and Gustafsson BA 26. Kelvered M, O sing care. Scand J Caring Sci 2012; 26: 449–457. 27. Rudolfsson G and Flensner G. Suffering and suffering with the other – the perspective of perioperative nurse leaders. J Nurs Manag 2012; 20: 278–286. 28. Gadamer H. Truth and method. London: Continuum, 2004. 29. Lindwall L, von Post I and Eriksson K. Clinical research with a hermeneutical design and a element of application. Int J Qual Methods 2010; 9: 172–186. 30. Flanagan JC. The critical incident technique. Psychol Bull 1954; 51: 327–358. 31. Declaration of Helsinki. Ethical principles for medical research involving human subjects, 2013, http://www.wma. net/en/30publications/10policies/b3/ ˚ (eds) Gryning II. Klinisk Va˚rdvetenskap. A ˚ bo: A ˚ bo Akademi, 32. Eriksson K. Ethos. In: Eriksson K and Lindstro¨m UA 2003, pp. 21–33. 33. Compassion. http://www.merriam-webster.com/dictionary/compassion 34. Wiklund Gustin L and Bergbom I. Va˚rdvetenskapliga Begrepp i Teori Och Praktik [Caring science concepts in theory and practice]. 1st ed. Lund: Studentlitteratur, 2012. 35. Lindwall L and von Post I. Preserved and violated dignity in surgical practice – nurses’ experiences. Nurs Ethics 2013; 3: 335–346. 36. Shotton L and Seedhouse D. Practical dignity in caring. Nurs Ethics 1998; 5: 246–255. 37. Eriksson K, Peterson CI, Zetterlund JE, et al. The suffering human being. Chicago, IL: Nordic Studies Press, 2006. 38. Callaghan A. Student nurses’ perceptions of learning in a perioperative placement. J Adv Nurs 2011; 67: 854–864. 39. Gallagher A. The teaching of nursing ethics: content and method. Promoting ethical competence. In: Davis AJ, Tscudin V and de Raeve L (eds) Essential of teaching and learning in nursing ethics. Edinburgh: Elsevier, 2009, pp. 223–239. 40. Rytterstro¨m P, Unosson M and Arman M. The significance of routines in nursing practice. J Clin Nurs 2011; 20: 3513–3522. 41. Martinsen K. Løgstrup Og Sygepleien [Lo¨gstrup and nursing care]. Aarhus: Klim, 2012. 42. Rudolfsson G, Hallberg L, Ringsberg KC, et al. The nurse has time for me: the perioperative dialogue from the perspective of patients. J Adv Perioper Care 2003; 1: 77–84. 43. Karlsson M, Nystro¨m L and Bergbom I. To care for the patient: a theory based clinical application research. Int J Caring Sci 2012; 2: 129–136. 44. Bull RM and FitzGerald M. The invisible nurse – behind the scenes in an Australian OR. AORN J 2004; 79: 810–823. 45. Gallagher A. Slow ethics: A sustainable approach to ethical care practices? Clinical Ethics 2013; 8(4): 98–104. 46. Arakelian E, Gunningberg L and Larsson J. How operating room efficiency is understood in a surgical team: a qualitative study. Int J Qual Health Care 2011; 23: 100–106. 47. Ricoeur P. Interpretation theory: discourse and the surplus of meaning. 2nd ed. Fort Worth, TX: Texas Christian University Press, 1976.
Downloaded from nej.sagepub.com at Stockholm University Library on November 14, 2015
Student nurses’ experiences of preserved dignity in perioperative practice – Part I
Nursing Ethics 2015, Vol. 22(6) 676–687 ª The Author(s) 2014 Reprints and permission: sagepub.co.uk/journalsPermissions.nav 10.1177/0969733014542675 nej.sagepub.com
Ann-Catrin Blomberg Karlstad University, Sweden
Elin Willassen Oslo and Akershus University College of Applied Sciences, Norway
Ire´ne von Post
˚ bo Akademi, Finland A
Lillemor Lindwall Karlstad University, Sweden; Oslo and Akershus University College of Applied Sciences, Norway
Abstract Background: In recent years, operating theatre nurse students’ education focussed on ethical value issues and how the patient’s dignity is respected in the perioperative practice. Health professionals are frequently confronted with ethical issues that can impact on patient’s care during surgery. Objective: The objective of this study was to present what operating theatre nurse students experienced and interpreted as preserved dignity in perioperative practice. Research design: The study has a descriptive design with a hermeneutic approach. Data were collected using Flanagan’s critical incident technique. Participants and research context: Operating theatre nurse students from Sweden and Norway participated and collected data in 2011, after education in ethics and dignity. Data consisting of 47 written stories and the text were analysed with hermeneutical text interpretation. Ethical considerations: The study was conducted accordance with the Declaration of Helsinki and approved by a local University Ethics Research Committee. Findings: The findings revealed that students experienced that operating theatre nurses perserved patient’s dignity in perioperative practice by being present for each other and making themselves known to the patient. Operating theatre nurses caring for the patient by being compassionate and preserved the patient privacy. The new understanding that emerged was that the operating theatre nurse students understood that the operating theatre nurse wanted to care for the patient like a human being. Discussion: In the discussion, we have illuminated how professional ethics may be threatened by more pragmatic and utilitarian arguments contained in regulations and transplant act. Conclusion: Preserved dignity is an ethical and caring act. Ethical questions and how to preserve dignity in perioperative practice should be discussed more both in educations of healthcare professionals and in clinical practice.
Corresponding author: Ann-Catrin Blomberg, Department of Health Sciences, Karlstad University, SE-651 88 Karlstad, Sweden. Email: [email protected]
Downloaded from nej.sagepub.com at Stockholm University Library on November 14, 2015
Blomberg et al.
677
Keywords Caring science, hermeneutic, human dignity, operating theatre nurse, perioperative practice
Introduction This article presents operating theatre nurse (OTN) students’ experience of preserved human dignity, in the light of their experiences of the OTNs’ caring and ethical acts during their clinical practice education. OTN students’ education takes place in a perioperative practice described as a high-technology environment1 where the ethos is based on production.2 Patients who arrive in an operating theatre are vulnerable young or old human beings who need emergency or planned surgery and expect to be treated with respect and dignity.3 The patient, the suffering human being, is understood as an entity of body, soul and spirit.4 Patients who are to undergo surgery meet health professionals (physicians, OTNs and nurse anaesthetists) with different knowledge, competence, experiences and ethos. This study was conducted during the OTN students’ first clinical practice education, before habits of culture had become a part of them.5 The study seeks to answer what OTN students experience as caring acts aiming to preserve the patient’s dignity in a perioperative practice. The OTNs in Sweden and Norway have a specialist nursing education in operating theatre nursing. They have knowledge of medical technical equipment, surgical methodology, hygiene and asepsis in order to manage the responsibility of taking care of the patient in a high-technology environment.6 It takes courage and humility to be close to another human being in a caring situation.2,7 The caring acts are understood as ethical acts, based on caring knowledge, skills, experience, ethics and morals and are always conscious choices that the OTN is responsible for.7 In perioperative practice, nurses accept the safeguarding of the patient’s rights and their decisions and actions are determined by the code of ethics8 and the ability to preserve the patient’s dignity. The purpose of all caring is to alleviate suffering and serve life and health.7 Caring in perioperative practice includes showing respect and preserving for the patient’s dignity.9 Eriksson10 describes dignity as the deepest value in caring ethics. Dignity is manifested by attitudes, actions and attributes that are adapted to different situations. Health professionals who have an ethical attitude and language can preserve the patient’s dignity. Their professional caring ethos allows a patient to experience the feeling of being comfortable on the operating bed.11 According to Edlund et al.,12 there are two forms of dignity. The first form absolute dignity means that a patient has the right to be considered as a unique human being. The second form is relative dignity, which refers to an inner ethical behaviour and provides awareness that one’s own dignity, and others’, changes throughout life and is dependent on the culture in which people live. Gallagher13 explains that dignity can also be seen as a two-part professional value: Value to the other and to one self. Le´vinas et al.14 link dignity to humanity and responsibility for the other by meeting the other face to face, something the OTN is invited into by the patient in a vulnerable situation. Being there for the other is especially important in a perioperative practice where patients lose control of their body and meet unfamiliar faces in a high-technology environment.2 A dignified demeanour means that nurses are genuine in their demeanour. The will to be there for the patient comes from the heart.15 It is the OTNs’ duty to preserve patient dignity through their conduct, and to do well, to do right and to meet the patient with dignity. The OTNs observe and witness and hence become ethically responsible.16 Research on preserved dignity has been published in some studies, but they have primarily been conducted in other contexts, such as older people care,13,17 medical care18 and surgical care.19 It is less common to find studies on preserved dignity within the perioperative practice, in which research has focussed on promoting patient safety.20–22 Mitchell and Flin21 considered the importance of frequent communication
Downloaded from nej.sagepub.com at Stockholm University Library on November 14, 2015
678
Nursing Ethics 22(6)
between health professionals and the significance of this for operation results. According to Bjo¨rn and Bostro¨m,23 it is necessary for the OTNs to have control over the situation. Lindwall et al.9 show that many health professionals have focussed on increased productivity, which can mean that ethical values are not always taken into account. Baillie and Ilott24 described how health professionals promote patients’ dignity in perioperative practice by protecting the patients from others’ health professional’s behaviour. In studies by Timmons and Tanner25 and Kelvered et al.,26 the OTNs described their role as being responsible for the atmosphere in the operating theatre. Rudolfsson and Flensner27 suggested that the OTN is the one who ensures that the care does not cause suffering. On the basis of International Council of Nurses’s (ICN) ethical codes for nurses and the evidence from earlier studies about human dignity in care, the actual study emanates from promoting and persevering dignity. Ethical reflections are needed for healthcare practice and can help develop good perioperative practices. Therefore, this study may contribute to answer how OTN students, at the beginning of their clinical practice education, experience how the OTN preserves the patients’ dignity during the perioperative process. The aim of this study was to present what OTN students experienced and interpreted as preserved dignity in perioperative practice.
Methodology Design The study has a hermeneutical approach inspired by Gadamer’s28 philosophy of understanding and interpretation. Gadamer focussed on prejudgement, pre-understanding and fusion of horizons and emphasised that those who express themselves and understand are connected by a common human consciousness that makes understanding possible.
Sample and data collection The participants were 60 registered nurses (RNs) undertaking specialised OTN education (32 from Sweden and 28 from Norway). The participating students aged from 25 to 48 years and had different levels of professional nursing experience ranging from 1 to 16 years. All invited students accepted participation and completed the study. Before starting the study, all students participated in the same theoretical education in ethics and dignity. Data were collected by critical incident technique, a self-reporting technique that focuses on critical events that have affected the participants positively or negatively. Flanagan30 describes the critical incident technique as ‘The critical incident technique should be thought of as a flexible set of principles which must be modified and adapted to meet the specific situation at hand’ (p. 335). The students were asked to provide written critical incidents, which Gallagher39 argues can help the students to develop the ability to see the patient’s perspective. The following information was given to the students: Please describe one situation where OTNs preserved patient dignity, a critical incident from your clinical practice education reality. Critical incidents are descriptions of actions and ways of acting that you have experienced and that have been of importance to the caring situation which you have participated in. The critical incidents were described using the following steps: It all started like this and developed like this. Flanagan30 describes that the critical incident technique is seen as credible as the research subjects have experienced the incidents themselves. In this article, the data only covered 47 positive events. In total, 13 incidents were excluded because they did not focus on preserved dignity. In this study, part I presents the positive incidents and part II the negative incidents, related to the caring situation. The study was conducted during the autumn of 2011.
Downloaded from nej.sagepub.com at Stockholm University Library on November 14, 2015
Blomberg et al.
679
Ethical considerations The study was conducted in accordance with the Declaration of Helsinki,31 which is a set of ethical principles that protect research subjects’ anonymity, privacy and maintain public confidence. In this study, which is based on narratives, the privacy of informants, patients and staff has been protected by not mentioning names, dates of birth, type of surgery or hospital. The students were asked to provide informed consent and asked whether the material could be used for research purposes. The project was approved by a local University Research Ethics Committee.
Hermeneutic text interpretation The critical events were combined into a text that became a voice from reality. Hermeneutic text interpretation28,29 was selected, as it seeks to understand the substance of the text before declaring the speaker behind the text. Gadamer28 highlighted the meaning of language for the creation of a world in which reality can be revealed and interpreted. According to Gadamer,28 all people have an existential pre-understanding of life. However, professional pre-understanding should not be understood as only existential pre-understanding but rather as preunderstanding rising from the profession one investigates. The researchers’ professional preunderstanding is made up of a caring science encompassing OT nursing, medical knowledge and ethical values. The students’ pre-understanding derives from experiences of nursing as OTN students, clinical context experiences, ethical values and knowledge of caring and medical sciences. The profession can aid or veil seeing.32 It is a laborious process to push aside the veil, that is, to chase away the prejudices that block one’s vision, and see what actually appears in practice. Pushing the veil aside means that researchers try to go beyond the obvious and reflect on what they really saw and what they overlooked.29 The researchers are not free from tradition’s horizon of understanding.28 The interpretation of the text began with an examination of the text as the original source and its relevance to practice. The text was regarded as the original source since the events came from our time and from a context known to us. The students used caring language relevant within a perioperative practice. Integrating the text with the reader. In order to approach the text in an, as much as possible, unprejudiced way, the text was not read, compared or interpreted before data collection was completed. The text was read from beginning to end, because the last part can change everything. The first step began as an open reading during which questions emerged such as follows: Is this reality? The text answered: Yes it is reality. Professional pre-understanding made the text understandable. Fusion of horizons. The text was read carefully and was allowed to present itself in all its otherness.29 Professional pre-understanding had to be taken into account in relation to the context that was unfamiliar, and new questions emerged: Is it so or so? Gadamer stated that dialogue with a text leads to a fusion of horizons, in other words: The reality of the text becomes part of the reader. In the fusion of horizons, it became obvious that the text talked about preserved dignity. New questions to the text. The following question arose when the researchers transcended the horizon of the text, as well as their own horizon: What does the text have to say about how OTN students experienced preserved dignity in a perioperative practice? Movements back and forth throughout the text took place in order to discover answers to the question. The answers were significant expressions and quotations with common and distinguishing qualities.
Downloaded from nej.sagepub.com at Stockholm University Library on November 14, 2015
680
Nursing Ethics 22(6)
Summarising the main themes and subthemes. The text was carefully read through to search for common features in all significant expressions. The common feature was formed into two main themes, after which distinctive qualities were sought, which resulted in four subthemes. Each subtheme has received its design using quotes from the text. The new understanding. The entire text was read again to reconfirm the themes and to search for a new understanding by moving back and forth between the parts and the whole. This process of understanding involved abstraction of the main themes and subthemes to form a new understanding, a coherent whole (Figure 1), which was deemed valid and free from contradictions.
Results The results revealed that OTN students understood that OTNs want to preserve patient dignity in a perioperative practice through caring acts such as OTN and patient being present for each other and OTN caring for the patient.
OTN and patient being present for each other The main theme consists of two subthemes: The OTNs getting to know the patient and making themselves known to the patient. The OTN getting to know the patient. The students understood that the OTNs wanted to know more about the patient before the first meeting, and therefore, they collected information from the medical records. When they met the patient, they listened to his or her story about their life, body, problems and needs: . . . they first read about the patient in the medical record, then go and see the patient at the day surgery department. They greet the patient, ask a bit about previous surgeries, if she has problems with her hips or has implanted material in the body. (Participant 1)
When patients came from other cultures, it was valuable to know about them before the first meeting. OTNs needed to have knowledge about the patient’s culture in order to understand the patient’s situation and language, so they could explain what happened during the time they spent together: . . . the OTN understands the situation because she read the journal and found that the patient came from another culture, where abuse is not unusual. The OTN explains that she understands and will take care of the patient, in the best way. (Participant 5)
In order to preserve the patient’s dignity, the OTN took time to get to know the patient and learned about his or her culture before surgery. Making themselves known to the patient. The students understood making themselves known to the patient as an act aiming to protect the patient’s dignity. The OTNs welcomed the patient and introduced themselves with name and profession. They removed their face masks before greeting the patients because they considered it worthwhile to meet each other face to face: . . . the nurses in the operating theatre waited until the patient arrived before putting on their masks so that he would not be frightened and so that the first thing he saw were their faces. (Participant 28)
Downloaded from nej.sagepub.com at Stockholm University Library on November 14, 2015
Blomberg et al.
681
By being a known person, the OTN became a present person who took the patient’s feelings seriously, someone who wanted to alleviate the patient’s suffering: I felt that the patient’s nervousness disappeared through the care . . . It felt like the patient appreciated the presence when she was in an uncomfortable situation. (Participant 6)
The OTN wanted to be there for the patient during the time the patient was awake and slept. She allowed the patient’s voice to be heard and listened to: The OTN was present with the patient while the patient was awake. She lingered a moment, so that the patient had the opportunity to ask if there was anything else she wondered about. (Participant 18)
During the ongoing preparations, the patient and the OTN talked to each other about everyday things. When the OTN allowed himself or herself to be known to the patient, a relationship and trust developed between them: . . . my supervisor and I began to wash and dress the patient. We continued to talk about ‘everyday things’ with him and the conversation flowed in a fun, healthy way. (Participant 4)
The OTN wanted to know the child and also the parents, who had the chance to have any ambiguities clarified. By being present, the OTN could focus on the child and take care of the parents: The OTN had focus on the baby. They talked to Teddy and Teddy had electrodes glued to the same parts of the body as the boy. The mother had been informed and had the opportunity to ask if something was unclear . . . (Participant 27)
The OTN students understood being present for each other before surgery as a caring act. The OTN learned from the patient and promised to be there during the whole time. They chose ethical acts and preserved the patient’s dignity. A relationship would develop between them and they would trust each other and be able to plan the time together.
OTNs care for the patient This main theme consists of two subthemes: The OTNs are compassionate and the OTNs preserve the patient’s privacy. The OTNs are compassionate. The students regarded the OTNs as being compassionate when they talked to the patient with a respectful and friendly voice. The patients were given the opportunity to talk about their worries and fears. The OTNs’ hands were soft and caring and their eyes and smiles conveyed that they were compassionate: . . . during the whole situation, I felt a warm feeling of satisfaction. It really felt like the OTN was dedicated to making the whole thing a good experience for the patient. (Participant 2) The woman was allowed to express her concern and fear and was met with respect. The nurses used touch to provide security. Their glances and smiles conveyed that they cared. (Participant 17)
The compassionate OTN preserved the patient’s dignity by devoting time to the patient and holding the patient’s hand when he or she was in a situation of dependence. Facing a vulnerable patient in an exposed situation required courage from the OTN:
Downloaded from nej.sagepub.com at Stockholm University Library on November 14, 2015
682
Nursing Ethics 22(6)
. . . the patient appreciated the presence and that someone took the time to hold her hand while she was in an embarrassing situation. (Participant 14)
Being compassionate entailed observing the patient’s body language to notice whether the patient was in pain during surgery. At the same time, it also meant answering questions honestly: The OTN was observant of the patient’s body language and studied her/him to see if he was in pain or seemed worried. At one point the patient began to move a little uneasily. The nurse observed this and gently took the patient’s hand and told him what was happening, which calmed the patient. (Participant 13)
To satisfy the patient’s need to be undisturbed during the intraoperative phase the OTN provided headphones. The patient could choose the type of music and rest comfortably: They showed respect for the patient and sometimes asked if she was OK. I thought it was good that the patient could choose what she wanted to listen to in the headphones during surgery. It is good that the patients do not have to hear all the noise from the machines and tools during surgery. (Participant 7)
To care for in a perioperative practice meant to preserve the patient’s dignity. By being compassionate, that is, touching the body with respect, listening to the patient’s voice, looking in the eyes and touching with soft hands, the OTN could alleviate the patient’s suffering in the operating theatre. Preserved dignity also meant to show respect for the patient’s desire for peace and quiet in a high-technology environment. The OTNs preserve the patients’ privacy. The students experienced how OTNs preserved the patients’ privacy part of the body by using warm blankets to protect the body from being exposed, cold and humiliated. The time parts of the body were uncovered was made as short as possible. Using warm blankets also made the patient relaxed: Because she would sleep with her genitals showing and have her legs in stirrups they also put a blanket over her crotch to cover her until the surgeon started working. She got more warm blankets over her body so she would not get cold and she appreciated it very much. The heat also caused her to relax a bit more. (Participant 19)
In order to preserve the patient’s privacy, the OTN asked the patient for permission to allow students to attend during the operation. If the patient was awake during the operation, he or she was informed about persons who suddenly entered the operating room: For every person who came into the room the patient received information about who it was and their function in the surgical team. (Participant 12)
The OTN had the courage to protect the patient’s privacy and prevent health professionals’ unprofessional behaviour during the patient’s surgery: Other health professionals talked about why the young woman wanted to do the operation and then brought up what the surgeon had said, and speculations and discussions started. Not foul or offensive, but a discussion had begun. The OTN averted it all by saying that it was sad that such a choice had to be made, but everyone has a reason why they do it. (Participant 10)
The OTN students understood that the OTNs cared for the patients when they preserved their privacy. They had an ethical responsibility to protect the patients’ privacy and save them from having their privacy violated when they were unable to participate in a discussion. The OTNs preserved the patient’s dignity by taking responsibility for his or her privacy and saving the body from being exposed during the surgery.
Downloaded from nej.sagepub.com at Stockholm University Library on November 14, 2015
Blomberg et al.
683
New understanding In accordance with Gadamer’s28 term ‘a spiral activity’, the present findings led to a new understanding of what OTN students perceive ‘preserved dignity’ to be when they are experiencing a perioperative practice (figure 1). The OTN students experienced preserved dignity by observing the OTNs’ caring acts and by interpreting and understanding what they saw. It has been understood that OTNs preserve a patient’s dignity by OTN and patient being present for each other by getting to know the patient and making themselves known as well as caring for the patient by being compassionate and preserving the patient’s privacy during the time they are together (see Figure 1).
Being present for each other OTNs getting to know the patient and making themselves known to the patient
Caring for the patient OTNs are compassionate OTNs preserve the patient’s privacy
Preserved dignity – an ethical and caring act OTNs care for the patient as a unique human being and are responsible during the time they spend together in the perioperative practice. The ethical caring acts contribute to the implementation of good and safe care.
Figure 1. The OTNs preserve the patient’s dignity in a perioperative practice. OTN: operating theatre nurse.
For the OTNs, the caring act being present for each other meant getting to know and making themselves known by meeting the patient face to face before putting on the mask. Making them known so that the patient could feel good was understood as an act of compassion. Compassion is a sympathetic consciousness of others’ distress with a desire to alleviate it. The caring act caring for the patient was understood as an act of compassion.33,34 It meant allowing the patient to express his or her fears and concerns and holding the patient’s hand in an embarrassing situation.
Downloaded from nej.sagepub.com at Stockholm University Library on November 14, 2015
684
Nursing Ethics 22(6)
To be compassionate and protect the patient’s privacy entailed listening to the patient’s body language and protecting the body from the glances of others when he or she had lost control over the own body. An OTN who comes close to the patient’s skin must be aware that the skin is the body’s limit of privacy, a limit that prevents the patient’s dignity from being humiliated.35 Every human being has his or her own privacy; his or her own sphere where nobody else is allowed without being invited.36 Dignity, the core of ethics, gives human beings the potential to be humiliated and hurt12,32 (see Figure 1).
Discussion This study describes that OTNs preserve the patient’s dignity by being present for each other, caring for, being compassionate and preserving the patient’s privacy. The results make us aware that OTN students learn by seeing, experiencing, interpreting and understanding what preserved dignity is in perioperative practice. Eriksson et al.37 hold that patients suffering in care are created by undignified care. In a study by Callaghan,38 the students identified that patients’ vulnerability, dignity and privacy in perioperative practice were important. The participants recognised that the OTNs protected the patient’s preferences and previously expressed values. Positive role modelling by the OTNs also encouraged students to immerse themselves in the environment and engage in teaching and learning. Gallagher39 is looking at role models in professionals’ practice to learn how best to act and argues that it is different from sharing experiences in the classroom. In this study, OTN students have the ability to perceive situations from an ethical standpoint and experience, identify and relate to ethical concepts and relationships in a perioperative practice. This experience is understood by Gallagher39 as a learning experience that will give the student an opportunity to develop ethical caring skills, skills that are highly complex and where the understanding of ethical theory is only part of the ethical competence. Gallagher39 also believes that students need to be prepared for the challenges and positions that the profession can bring and has developed a model for teaching of nursing ethics promoting ethical competence. The goals or aims of ethics education can be articulated by ethical ‘knowing’, ethical ‘seeing’ or perception, ethical ‘reflection’, ethical ‘doing’ and ethical ‘being’. Gallagher45 provides an overview of the current challenges to slow ethical caring that relates to patient experiences of neglect, abuse and indignity in care contexts. All OTN students took part in ethical theories and participated in seminars, where they had the opportunity to reflect on recent critical incidents or situations in perioperative practice. The findings, as well as previous research, show that human dignity is violated when unreflective routines prevail in the operating theatre.2 Rytterstro¨m et al.40 explain that rigid routines can, without knowing, cause suffering and humiliated patient dignity. The students described situations where the OTN was calm and introduced himself or herself to the patient. According to Baillie and Ilott,24 the health professionals should be courteous and introduce themselves using their first name when talking to the patient and explain what is going to happen. When encountering a patient in a high-technology environment, Kelvered et al.26 argue that it is important to give the patient confidence, share thoughts and enable the patient to be an individual. All human beings, regardless of race, gender and culture, should be treated equally and have the same right to healthcare.8 The OTN is present for the patient by seeing and listening to him or her, and a relationship develops between them. Le´vinas et al.14 argue that seeing the face of the other is to be invited to take responsibility for the other.16 Martinsen41 says that in ‘the fictional space’, which affects the patient and the nurse, the nurse is allowed to reflect on his or her responsibilities for the patient. It is also important to note that in a relationship, we can never fully understand another human being; it is always something that is alien. The result shows that the OTNs care for the patients by being compassionate when the patient was in an exposed situation. They care for the patients with warm and professional hands. According to Wiklund,34 compassion involves sharing the patient’s feelings, to be affected and to act to relieve the other’s suffering.
Downloaded from nej.sagepub.com at Stockholm University Library on November 14, 2015
Blomberg et al.
685
The compassionate act of just being together with the patient can be understood as an ethical act. The OTNs helped the patients so they did not need to feel alone in a high-technology environment,24 developed friendships despite the short meetings and took responsibility.42 Bull and FitzGerald1 showed that compassion, kindness, cheerfulness and recognition of the patient as a human being with individual needs were necessary in perioperative practice. Ethics include promises and OTN’s care for the patients well despite the prevailing idea that time is not sufficient.43 According to Bull and FitzGerald,44 the OTN works hard to balance between the real time and the surgeon’s time and actually makes better estimations of the time because he or she takes into account the human being. Gallagher45 draws attention to ‘fast ethics’, a trend towards speed and time-saving initiatives whereby quickness may be valued over doing things well and quantity is valued over quality. She suggested ‘slow ethics’ for healthcare practice to understand and reduce practice that compromises patient well-being and humiliates professional ethics. Slow ethics is described as listening and establishing a dialogue with patients, families and practitioners; engaging in an inter-disciplinary way to learn from recent and distant reports and research; articulating; aspiring and valuing care. In the operating theatre, nursing is a requirement for efficiency, but Arakelian et al.46 meant that the patient was the focus and efficiency was understood as maintaining quality of care and measuring benefits of care for the patient.
Methodological reflection The hermeneutical approach28 gave the opportunity to gain a new understanding of what constitutes preserved dignity in perioperative practice. Critical incident technique30 resulted in a diverse and multi-faceted picture of the caring act, preserved dignity. The hermeneutic text interpretation29 gave the unknown and known in perioperative practice a meaningful text and caring, as preserved dignity was given a language. The researchers’ professional pre-understanding made it possible to let the text speak. However, it was also an obstacle when we had to go beyond our professional pre-understanding and admit that we do not always see and think about what appears. There is always a question of how to collect and interpret data to gain new knowledge. Here, we chose to invite OTN students to write stories about their experiences of preserved dignity in perioperative practice. In one way, this could be considered as a detour around the patient’s own narrative of the subject. On the other hand, patients might find it hard being completely true and honest in their presentation of the perioperative practice, as they are in such a vulnerable situation and totally dependent on the goodwill of the health professionals. The study is based on a limited number of participants and represents perioperative practice in Norway and Sweden. The participating students provided many caring situations and recalled stories. This was a limitation that could be seen in the light of Ricoeur47 who explained that it is not the experiences themselves we are looking for, but the best interpretation of the common meaning. In that case, the number of participants is not of interest, but the understanding that can be lifted from the text narrated by the participants. The findings of this study could serve as a basis for future studies. In addition, we suggest that this result can be used for discussion in many international and national nursing and caring contexts and in future studies on interventions to promote an ethical and dignified climate.
Conclusion Findings from this study highlight OTN students’ experiences, interpretations and understandings of how OTNs preserve the dignity of the patients, the suffering human beings, in a perioperative practice. The students’ written stories show that OTNs protect patient dignity. Creating time to reflect on patient care is essential. These findings about preserved dignity could be a starting point for ethical discussions and reflections. Being allowed to observe and write down events, and then discuss dignity in groups continuously in the education, can lead to increased awareness and changed attitudes that are ethical in nature.
Downloaded from nej.sagepub.com at Stockholm University Library on November 14, 2015
686
Nursing Ethics 22(6)
Acknowledgements We would like to thank all OTN students from Sweden and Norway who took part and shared their stories, which made this clinical caring research possible. Conflict of interest No conflict of interest has been declared by the authors. Funding This research received no specific grant from any funding agency in the public, commercial or not for profit sectors. References 1. Bull RM and FitzGerald M. Nursing in a technological environment: nursing care in the operating room. Int J Nurs Pract 2006; 12: 3–7. 2. Lindwall L and von Post I. Habits in perioperative nursing culture. Nurs Ethics 2008; 15: 670–681. 3. Baillie L. Patient dignity in an acute hospital setting: a case study. Int J Nurs Stud 2009; 46: 22–37. 4. Eriksson K. Den Lidande Ma¨nniskan [The suffering human being]. 1st ed. Stockholm: Liber, 2001. 5. Rytterstro¨m P. Tradition Och Horisont: Va˚rdkulturens Betydelse Fo¨r Va˚rdens Praxis [Tradition and horizon. The importance of care culture for the care praxis]. Linko¨ping: Institutionen fo¨r samha¨lls-och va¨lfa¨rdsstudier, Linko¨pings universitet, 2011. 6. SFS 2006:1053. Fo¨rordningen Om a¨ndring Av Ho¨gskolefo¨rordningen [Regulation amending the Higher Education] (SFS 1993:100). 7. Eriksson K. Caring science in a new key. Nurs Sci Q 2002; 15: 61–65. 8. International Council of Nurses (ICN). Code of ethics for nurses, 2013, www.icn.ch/about-icn/code-of-ethics-for-nurses 9. Lindwall L, von Post I and Eriksson K. Caring perioperative culture: its ethos and ethic. J Adv Perioper Care 2007; 3: 27–34. ˚ bo Aka10. Eriksson K. Va˚rdvetenskap som akademisk disciplin [Caring science as an academic discipline]. Vasa: A demi, 2007. 11. Von Post I and Eriksson K. The ideal and practice concepts of professional nursing care. Int J Hum Caring 1999; 4: 14–22. 12. Edlund M, Lindwall L, von Post I, et al. Concept determination of human dignity. Nurs Ethics 2013; 8: 851–860. 13. Gallagher A. Dignity and respect for dignity – two key health professional values: implications for nursing practice. Nurs Ethics 2004; 11: 587–599. 14. Le´vinas E, Nemo P and Contassot MG. Etik Och Oa¨ndlighet: Samtal Med Philippe Nemo [Ethics and infinity]. Stockholm; Lund: Symposion, 1988. Pittsburgh: Duquesne University Press. ˚ , Lindholm L and Zetterlund JE. Theory of caritative caring. In: Alligood MR and Tomey AM (eds) 15. Lindstro¨m UA Nursing theorists and their work. 7th ed. Maryland Heights, MO: Mosby, 2009, pp. 190–221. ˚ and 16. Delmar C. Omsorgsetik i klinisk sykepleje – den gode, kloke og rigtige sygepleje. In: Alvsva˚g H, Bergland A Forland O (eds) Nodvendige Omveier. En Vitenskaplig Antologi Til Kari Martinsens 70 A˚rsdag. Oslo: Cappelen Damm, 2013, pp. 117–129. 17. Na˚den D, Rehnsfeldt A, Ra˚holm M, et al. Aspects of indignity in nursing home residences as experienced by family caregivers. Nurs Ethics 2013; 7: 748–761. 18. Heijkenskjo¨ld KB, Ekstedt M and Lindwall L. The patient’s dignity from the nurse’s perspective. Nurs Ethics 2010; 17: 313–324. 19. Vendlega˚rd C, Hu¨bner A and Lindwall L. Dignity as it emerges for nurses’ in surgery practice. Vard i Norden 2010; 30: 30–34 (in Norwegian).
Downloaded from nej.sagepub.com at Stockholm University Library on November 14, 2015
Blomberg et al.
687
20. Riley R, Manias E and Polglase A. Governing the surgical count through communication interactions: implications for patient safety. Qual Saf Health Care 2006; 15: 369–374. 21. Mitchell L and Flin R. Non-technical skills of the operating theatre scrub nurse: literature review. J Adv Nurs 2008; 63: 15–24. 22. Riley R and Manias E. Gatekeeping practices of nurses in operating rooms. Soc Sci Med 2009; 69: 215–222. 23. Bjo¨rn C and Bostro¨m EL. Theatre nurses’ understanding of their work: a phenomenographic study at a hospital theatre [An antohology of clinical caring science]. J Adv Perioper Care 2008; 3: 149–155. 24. Baillie L and Ilott L. Promoting the dignity of patients in perioperative practice. J Perioper Pract 2010; 20: 278–282. 25. Timmons S and Tanner J. Operating theatre nurses: emotional labour and the hostess role. Int J Nurs Pract 2005; 11: 85–91. ˚ . Operating theatre nurses experience of patient-related, intraoperative nur¨ hle´n J and Gustafsson BA 26. Kelvered M, O sing care. Scand J Caring Sci 2012; 26: 449–457. 27. Rudolfsson G and Flensner G. Suffering and suffering with the other – the perspective of perioperative nurse leaders. J Nurs Manag 2012; 20: 278–286. 28. Gadamer H. Truth and method. London: Continuum, 2004. 29. Lindwall L, von Post I and Eriksson K. Clinical research with a hermeneutical design and a element of application. Int J Qual Methods 2010; 9: 172–186. 30. Flanagan JC. The critical incident technique. Psychol Bull 1954; 51: 327–358. 31. Declaration of Helsinki. Ethical principles for medical research involving human subjects, 2013, http://www.wma. net/en/30publications/10policies/b3/ ˚ (eds) Gryning II. Klinisk Va˚rdvetenskap. A ˚ bo: A ˚ bo Akademi, 32. Eriksson K. Ethos. In: Eriksson K and Lindstro¨m UA 2003, pp. 21–33. 33. Compassion. http://www.merriam-webster.com/dictionary/compassion 34. Wiklund Gustin L and Bergbom I. Va˚rdvetenskapliga Begrepp i Teori Och Praktik [Caring science concepts in theory and practice]. 1st ed. Lund: Studentlitteratur, 2012. 35. Lindwall L and von Post I. Preserved and violated dignity in surgical practice – nurses’ experiences. Nurs Ethics 2013; 3: 335–346. 36. Shotton L and Seedhouse D. Practical dignity in caring. Nurs Ethics 1998; 5: 246–255. 37. Eriksson K, Peterson CI, Zetterlund JE, et al. The suffering human being. Chicago, IL: Nordic Studies Press, 2006. 38. Callaghan A. Student nurses’ perceptions of learning in a perioperative placement. J Adv Nurs 2011; 67: 854–864. 39. Gallagher A. The teaching of nursing ethics: content and method. Promoting ethical competence. In: Davis AJ, Tscudin V and de Raeve L (eds) Essential of teaching and learning in nursing ethics. Edinburgh: Elsevier, 2009, pp. 223–239. 40. Rytterstro¨m P, Unosson M and Arman M. The significance of routines in nursing practice. J Clin Nurs 2011; 20: 3513–3522. 41. Martinsen K. Løgstrup Og Sygepleien [Lo¨gstrup and nursing care]. Aarhus: Klim, 2012. 42. Rudolfsson G, Hallberg L, Ringsberg KC, et al. The nurse has time for me: the perioperative dialogue from the perspective of patients. J Adv Perioper Care 2003; 1: 77–84. 43. Karlsson M, Nystro¨m L and Bergbom I. To care for the patient: a theory based clinical application research. Int J Caring Sci 2012; 2: 129–136. 44. Bull RM and FitzGerald M. The invisible nurse – behind the scenes in an Australian OR. AORN J 2004; 79: 810–823. 45. Gallagher A. Slow ethics: A sustainable approach to ethical care practices? Clinical Ethics 2013; 8(4): 98–104. 46. Arakelian E, Gunningberg L and Larsson J. How operating room efficiency is understood in a surgical team: a qualitative study. Int J Qual Health Care 2011; 23: 100–106. 47. Ricoeur P. Interpretation theory: discourse and the surplus of meaning. 2nd ed. Fort Worth, TX: Texas Christian University Press, 1976.
Downloaded from nej.sagepub.com at Stockholm University Library on November 14, 2015
