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Clinical Decision-making Processes in Perioperative Nursing
JULY 1999, VOL 70, NO 1 Parker Minick Kee 8
Clinical Decision-making Processes in Perioperative Nursing
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lthough perioperative nurses are required by the nature of the environment to amve at clinical decisions quickly, the processes by which these clinical decisions are made is not fully understood. Perioperative practice models are not well documented, and the essence of perioperative nursing is not well identified. As a result, the ways in which perioperative nurses influence patient care delivery and patient outcomes is not known.
and one that nurses use to arrive at clinical decisions in variety of settings.' In addition, several studies have found a caring relationship associated with intuitive recognition and intervention.' Very little research has been conducted about the ways in which perioperative nurses make clinical decisions.' No studies were found that linked perioperative nursing practice to patient outcomes, yet few of us would question the contributions that expert perioperative nurses make to positive patient outcomes. As perioperative nursing practice is not well PURPOSE The purpose of this qualitative study was to documented, administrators who are unfamiliar with reveal the processes used by how perioperative nurses contribute to quality care suggest that expert perioperative nurses as they make clinical decisions. As the A B S T R A C T unlicensed assistive personnel processes of expert clinical deciThe purpose of this phenom- (UAP) may be substituted for sion making are more fully under- enological study was to reveal nurses to save money. This stood, this knowledge can be used the processes Of clinical decision research project provides an initial to assist the novice perioperative making by expert PeriOperfJtiVe step in understanding the decinurse in the quest towards excel- nurses. Six nurses with a mini- sion-making processes of perioplence. The goal of this research mum Of five years experience erative nurses and, thus, their conwas to answer the following ques- who considered themselves to tributions to patient care. tion: What are the processes used be experts in OR flUrsing were by expert perioperative nurses in asked to describe perioperative ASSUMPTIOWS clinical decision making? situations in which they had Assumptions explicit in this made a difference in patient research are that the perioperative R M E W OF LITERATURE outcomes. In every situation nurse is a necessary, vital member Several research studies have described, an intricate pattern Of of the surgical team who conbeen conducted regarding clinical concern was present and OSSOCi- tributes to the achievement of posdecision making of critical care ated with further assessments. itive patient outcomes. The perinurses.' These scholars have inter- The pattern was labeled Seeing operative nurse must possess the viewed a total of more than 350 the big picture: Engendered ability to make clinical decisions nurses and noted a relationship through caring. This study pro- quickly and accurately so that between expert decision making vides initial documentation to quality patient care occurs in the and intuitive knowledge. More SuppOrt how RNs make critical OR. Some situations require deciand more nursing literature sup- contributions to the quality Of sions critical for the preservation ports the idea of intuitive h o w l - perioperative patient care. AORN of life. More often, however, situedge as a valid way of knowing J 70 (July 1999) 45-62. ations require everyday decisions CHERYL B. PARKER, R N ; PTLENE M I N I C K , R N : CAROLYN C . KEE, RN
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that involve preventing serious patient problems. When problems are prevented, the knowledge required for this prevention is taken for granted and becomes invisible, yet patient outcomes are positively influenced. The invisible nature of problem prevention might be the reason why there is so little research linking the contributions of penoperative nurses to patient outcomes. The processes by which split-second clinical decisions are made is of critical importance in understanding how perioperative nurses make a difference. Perioperative nurses provide care during rapidly changing situations in a highly technical environment. Complex nursing judgments are required continually? SIGNIFICANCE OF THE STUDY TO THE PROFESSION
The present health care environment demands that nurses validate their influence on patient care. An understanding of the processes involved in clinical decision making is one of the first steps in relating nursing care to patient outcomes. In addition, an understanding of these processes contributes not only to nursing science, but also will influence nursing education and ultimately contribute to the improvement of patient care.
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cation. The processes of moving from novice to expert can be facilitated when clinical decision-making strategies are better understood. Delineating the knowledge embedded in the practices of perioperative nursing is the challenge for the nursing profession.’ This proposed study is a pivotal step in documenting the clinical nursing judgment that occurs in the OR. PHILOSOPHICAL FRAMEWORK
Phenomenology was chosen as the framework to guide this research because of its usefulness in uncovering the taken-for-granted knowledge found in practice.* It focuses on everyday experiences and the meaning found within those experiences. Clinical decision making was conceptualized to be embedded in the everyday activities of the perioperative nurse. In addition, staff nurses were conceptualized to be the most knowledgeable of clinical practices and the judgments required in the complex technological environment of the OR. RESEARCH METHODS AND PARTICIPANT SELECTION
Nurses who worked a minimum of five years and considered themselves to be expert circulating nurses in the OR were sought. There were no restricSIGNIFICANCE OF THE STUDY tions relative to education, age, gender, race, or socioeconomic status. Participants were recruited TO PERIOPERATIVE NURSING Documenting how clinical decision making during late 1996 and early 1997 at monthly meetings occurs in perioperative nursing will help validate of a local AORN chapter. A general announcement perioperative nursing practices and provide direction was made during the business portion of the meeting for the education of perioperative nurses. The impor- about the opportunity to participate. In addition, tance of expert nursing practice in the OR can be dis- information was provided in the chapter’s monthly counted easily, particularly if the role has not been newsletter during these same months to recruit nursclearly articulated and the contributions have not es who were not able to attend the meetings. Participants also were asked to recommend other been documented. As the health care arena of the 1990s is more fre- perioperative nurses whom they perceived as practicquently driven by economic concerns than by quality ing as experts so that nurses who were not AORN concerns, validation of perioperative nursing practice members could be included in the study. A total of is essential. Many health care managers are mandat- eight perioperative nurses working in hospitals in a ed by administrators to reduce budgets. An easy tar- large southern urban and suburban area were recruitget is the budgetary allotment for nursing personnel. ed for this study. Two participants withdrew from the The role of RN circulator has been scrutinized, and study before the interview due to scheduling difficulmany institutions are moving toward substituting ties; therefore, the final sample size was six. UAP for this traditional nursing Economic conPROTCCnON siderations must not be allowed to replace the quality Approval for this investigation was obtained care that patients deserve to have when undergoing a from the institutional review board at the sponsoring surgical procedure. Additionally, knowledge of decision-making university for the protection of human subjects. strategies can help guide perioperative nursing edu- Written informed consent was obtained from each 46 AORN JOURNAL
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Table 1 INTERVIEW GUIDE
You will be asked to describe a clinical situation, either preoperatively or intraoperatively, in which you intervened on the patient's behalf and affected the patient's outcome. Recording this information will assist in an accurate description of your feelings and intentions during this intervention. Feel free to make notes before the interview, and bring these notes with you. The following questions may help you identify clinical situations that you may want to discuss in the interview. Did you have an "early warning signal" in a situation? An early warning signal is when you have a 'sixth sense' about the patient without supporting data. It may or may not turn out to be a correct feeling. Was there o situation in which there was a need to consult with another nurse or a physician? Was there a situation in which you believe your intervention really made a difference in patient outcome, either directly or indirectly (by helping other staff members)? The following are areas to include when identifying a clinical situation for the interview. The context of the situation (ie, regular schedule, emergency, staff resources). A description of what happened.
Why you chose this situation (ie, why this situation made an impact on you). What your concerns were at the time. What you were thinking about as it was taking place. What you were feeling during and after the situation. What, if anything, you found most demanding about the situation. What, if anything, you found most satisfying about the situation.
rizing participant stones with the goal of understanding the interviews as a whole and including the context. In the second level of analysis, key paragraphs, phrases, and words were extracted from the text to exemplify the message of the participant. During the third level of analysis, key phrases identified by the investigators as important were compared across interviews. The key phrases were grouped together according to content and became categories. Frequently, the investigators agreed on the meaning in the data. When there were differences in interpretation, checking the original text, which had a full description of the situation, helped investigators reach a consensus. At this point, the investigators sought related research findings in the literature to support or refute notions found in the texts. The fourth level of analysis involved identifying similar and contradictory categories within texts and across texts and comparing them again to the literature to identify related research findings. During the fifth level of analysis, the entire data set was examined for common patterns constitutive of clinical decision making. Level six involved review of the interpretation from an independent researcher and
participant, and the interviews were held in a convenient, quiet room conducive to maintaining confidentiality. THE INTERVIEW
Participants were asked to describe any perioperative clinical situation in which they intervened on a patient's behalf and affected the patient's outcome by doing so. They were asked to describe the situations in detail, to note if they had a sense of something about to happen, and if they believed that their interventions made a difference. The interview guide used is shown in Table 1. DATA COLLECTION AND ANALYSIS
After the interviews were transcribed verbatim, data were loaded into a software program for data management. This program was used to categorize the data and later to sort and manage the data. An analysis of each interview was done by the principle investigator and a phenomenological researcher according to the procedure outlined by other researchers? The first level of analysis consisted of summa48
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key study participants. The independent nurse researcher, who was skilled in interpretative research, was asked to review the interpretation and evaluate whether the themes seemed appropriate and whether sufficient data was presented to represent the themes. Two participants were available and willing to review the findings; these participants were asked to evaluate whether the interpretations were true for them and if the examples were exemplary of perioperative nursing. The participants were the final authority regarding the interpretation of the findings. The multiple steps of analysis conducted with other scholars and key participants helped ensure that data were not overinterpreted or underinterpreted. These analytic procedures yielded patterns in which themes, and, in turn, subthemes, were embedded. FINDINGS AND IllCrWPRElATlON
12 years, with a mean of slightly more than five years. The time employed on the current unit ranged from two years to 23 years, with a mean of nearly 11 years. A variety of surgical services were represented. Two of the participants did not specialize in a particular service but floated wherever needed. One of the participants specialized in outpatient orthopedic surgery, one specialized in pediatric neurosurgery, one specialized in urology, and one specialized in general/vascular surgery. Operating room units of employment. Five different hospitals were represented by the participants. Three participants were employed by public institutions, and three were employed by private hospitals. Four participants were employed in inpatient OR settings, and two participants were employed in outpatient ORs. Five of the participants worked the day shift, and one participant worked the night shift.
The participants related rich detailed clinical situations that exemplified the complexity of the surgical environment. Within the situations, elaborate patterns of caring and commitment were intertwined with knowledge and ethical decisions by perioperative nurses. In the following sections, characteristics of participants are presented first, followed by the pattern and themes identified in the data. Examples from the data are used to illustrate the context so the reader can evaluate the interpretation. In addition, each of the patterns and themes are discussed in light of the relevant literature.
1IYCIIRPRETATW)N
Data interpretation yielded one overriding pattern with three themes subsumed under this pattern. The first theme had three subthemes; the second theme had two subthemes; and the third theme had none. The ovemding pattern, implied or explicit in every interview, contributing to the clinical decisionmaking process among these expert nurses was identified as “Seeing the big picture: Engendered through caring.” Within each nurse’s practice were multiple decisions, and within each decision, certain characteristics were identified and categorized into themes. The three themes identified from analysis of the interviews as requisite for expert clinical decision making included connecting with patients, advocating for patients, and embodied knowing. Each of these themes will be presented with data to illustrate the interpretation; relevant literature will be used to discuss the findings. A list of the overriding pattern with the underlying themes and subthemes is provided in Table 2.
CIIARACTERISTICSOF PARnClPAMs
A sample of six female RNs who were employed in hospitals in a large southern metropolitan area participated in the study. Five of the participants were active members of AORN, and one participant was not a member of the organization. Ages ranged from 29 years to 58 years, with a mean of 39 years. Level of education. Three participants in this study held baccalaureates in nursing. Two of the participating nurses were diploma graduates, one of whom was currently enrolled in a baccalaureate program in nursing, and one held an associate degree in nursing. Experience of participants. The total years of OR nursing experience of the participants in this study ranged from 6.5 to 23 years, with a mean of 12.25 years. Three participants had worked on other units before working in the OR. Nursing experience other than that in the OR ranged from two years to
THE WlTERN
Without exception, in every patient situation nurses talked about “seeing the big picture,” when notions of concern for the patient and for the future of the patient as a person were clearly evident. As the concern was about more than the immediate circumstances, the examples were labeled “Seeing the big 50
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picture: Engendered through caring.” Many participants used the phrase “seeing the big picture” as they described the importance of thinking beyond the care provided in the perioperative area. In addition, each patient care situation reported was filled with a concern for the patient’s well-being. Kim described an instance in which she was scrubbed for a trauma procedure. The surgical team was expecting a patient with a ruptured spleen and instead found that the patient had almost transected his aorta. In spite of the urgency of the situation and the brief time spent with the patient while he was awake, she demonstrated an awareness for the patient as a person as she prepared for the procedure.
aware of the importance of responding to the patient and treating him as a person. As she was preparing the setup for his physical needs, she also was aware of his psychological needs, and she implemented actions to help him feel safe and cared for. Kim continued to describe the situation and how she noticed the patient was experiencing back pain, which suggested to her that the patient’s dropping blood pressure might be caused by a problem in the chest rather than the initial assessment of a ruptured spleen. “He was still conscious and talking when we moved him from the stretcher to the table. I remember him really groaning when he was moved. He said it was his back.” With the patient’s history of an automobile accident, Kim knew from previous experience that back pain suggested a possible transected aorta. She rapidly thought beyond the assessment of a ruptured spleen provided by the trauma team. Kim saw the “big picture” and moved from an abdominal setup to a chest/vascular setup quickly, so she was instrumental in saving the patient’s life. In spite of the fact that Kim was faced with an urgent situation in which the patient’s blood pressure was dropping, she was able to notice him as a person, realize that he had back pain, incorporate his history with his pain, and respond. Caring allowed Kim to correlate the patient’s symptoms with his history and grasp the totality of the situation. One study documented the recurring theme of expert nurses’ ability to see the “big picture.” According to these scholars, the expert nurse can see beyond the current situation and understand something about what a patient and his or her family members might encounter in their future.’’ To understand what an illness or injury means for someone and his or her family members, the nurse must come to know the patient in a personal way. “Seeing the big picture” suggests that there is an element of human awareness and care for the individual. This phenomenon has been described as “making the connection.”“ When nurses described episodes of “seeing the big picture,” the situations were filled with concern for the patient as a person. Although concern was associated with episodes of “seeing the big picture,’’ these patient-care descriptions included little language about the technology in the environment. The OR requires a myriad of technology for even the most routine procedures. Even though the nurses were in the midst of an environment filled with technology, their primary conversation was about the patients-who they were and what they
I try to [talk to the patient] even when I’m scrubbed, and of course in that situation we were in a hurry and you try to set up . . . hut then . . . you think about the psychological component also, maybe not consciously at that moment, but you’re still doing it. You know,you try to be as quiet as possible so when they are putting him to sleep and while he’s awake you don’t disturb him any more than . . . he already is. I tried to speak to him, even i f it is [only] to say “Hi.” I remember my coworker . . . was talking to him, saying, “This is Kim” and I turned around and said “Hi.” I feel like this is important with any patient, that you tell them who’s in the room, and you try to keep the noise levels down. Increasing noise increases stress, and that affects the way he responds to the anesthetic . . .
In the midst of a tense trauma situation, Kim was
Table 2 mll€RNSAND lHEMES
Pattern: Seeing the big picture: Engendered through caring Theme: Making a connection Subtheme: Touch Subtheme: Perioperative intelview Subtheme: Humanizing care Theme: Embodied knowing Subtheme: Knowing through similar experiences Subtheme: Knowing through personal experiences Theme: Comprehensive patient advocacy 52
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running around not paying attention to you . . . just having someone with you, holding you, kind of helps.” Susan believed that touch was an important aspect of connecting with the patient. Ann also believed that touch was important in connecting with patients. Even when she was scrubbed and physical contact with the patient was not possible, Ann attended to the emotional aspects of the patient through touch.
needed. The distinct lack of discussion about the technology suggests that the technical aspects of the situation were of little concern. Use of the equipment became routine and fell into the background. Through familiarity, technology became unimportant as a topic, and the person for whom the nurses cared was central. This type of human care response in the midst of constant technological challenge is one way in which these perioperative nurses demonstrated that “seeing the big picture” is truly derived from and engendered through caring.” The technology involved was mentioned only in passing as nurses talked about patient situations. Patients, not technology, were the focus of the stories conveyed by nurses in this study. Many of the clinical decisions described showed an allencompassing view of the situation and transcended the task-focused mind-set that is a necessity for the novice nurse.
. . . we had a lady that we were doing a mastectomy on, and she was scared to death. You could see it. . . . I was scrubbed. I couldn’t hold her hand. All I could do was stand by her side and smile at her. . . . When it came close to time for induction, I motioned for [the physician] to come over. He came next to me, and I said “Please hold her hand” , . . and you could just see the relief on her face. That human touchit’s so important.
TllE FIRST THEME: MAKlNG A CONNECTION
The first theme identified within the overriding pattern of “seeing the big picture” was labeled “making a connection.” The three ways in which making a connection was manifested in these data were through touch, the preoperative interview, and humanizing care. Touch. One way that the nurses connected with patients was through touch. For instance, Susan used touch to let the patient know that the nurse was physically and emotionally available. To Susan, touch was comforting.
Ann noticed the subtle changes in the patient’s face that said she was frightened and then saw the change that occurred when the physician held her hand. Because she cared and intervened, she created a human connection for this patient in the midst of a frightening situation. Both Susan and Ann exemplify caring. By connecting with patients, they used touch to humanize the technological world of the OR. The preoperative interview. Another method nurses used to connect with their patients was by getting to know the patient during the brief preoperative interview. Jean described her care of children and how she makes a connection in this limited time period.
One thing I do like to do with my patients is hold their hand or just rest my hand on their arm . . . let them know I’m there when they go to sleep-because that, to me, is one of the most Comforting things that can happen while you’re going to sleep under anesthesia. That’s what somebody did for me when I had surgery, and I’ ve never forgotten it.
You hold them, talk to them, and ask them questions. Just age appropriate . . . You kind of make a connection then so the child doesn’t have a strange person just coming in, picking them up, and taking them to surgery. . . . You get to know them, and then you talk to them as they are going to sleep.
Susan’s personal experience reinforced to her the importance of human touch and the positive effects that touch can have. She described how holding someone’s hand or touching them on the arm allowed them to know that you are there for them. To provide touch, attention must be focused on the patient and not on other activity in the room. Susan also believed that providing touch conveyed a sense of empathy to the patient. She said “I sympathize with the fear of going to sleep when everybody is
She recognized the fear that a child might have with a stranger and used the brief preoperative interview time to establish rapport. Then she used the information gained in the preoperative interview to comfort the child. Jean also included what she had learned about 53
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the child during the perioperative interview to comfort the family members who were waiting beyond the closed doors of the OR.
duced a sense of empathy and urgency for her as she responded to the crisis. The literature supports the idea that making a connection with the patient plays a critical role in the nurse-patient interaction, helps decrease the stress response, and enhances positive patient outcomes. Scholars have described a phenomenon called “knowing the patient.”14 In the process of “seeing the big picture,” the nurses in this study demonstrated that there was a connection and an element of knowing the patient even in perioperative settings where time was limited and patients were quickly anesthetized. Through touch, the preoperative interview, and the ability to humanize care, these perioperative nurses were still able to make a connection with their patients. The literature also supports the concept that caring is the force behind making connections. Caring allows the nurse to identify problems that might not otherwise be recognized and to intervene. By coming to know about the patient as a person, the nurse is able to understand possible problems and possible solutions. As a result, nurses are able to support and assist patients through problems.ls Meaningful rapport and human connection can be made in the face of limited time and does make a positive impact on the patient.16 The nurses in this study provided vivid exemplars about the intricate pattern of care and concern in the perioperative arena.
We call the parents every hour or two hours just to give them a verbal “things are going OK’ . . .you kind of personalize it. . . “Johnny went to sleep holding his teddy bear,” and that’s a big comfort to the family. Jean included the family members in her perioperative patient care. Through her communication, she provided support to the parents even though she was not physically with them. Jean let the family members know that Johnny was in a safe and caring environment. Researchers described how nurses can reassure patients and family members by creating a caring atmosphere even though the environment is highly technological and initially frightening.” The connection Jean established during the preoperative interview comforted both the family members and the child initially and again later during the surgery. Humanizing care. Another way in which the nurses in this study demonstrated making a connection with limited time was by humanizing patient care. The participants saw the patient as a person in his or her role as a father, mother, or child. Susan exemplified this type of connection as she described her thoughts during a crisis situation in which a major vessel had been lacerated in the process of a trocar insertion for a laparoscopic tubal ligation. As she reacted quickly to provide the needed supplies and help anesthesia personnel with obtaining blood and volume expanders, her thoughts were about the patient.
THE SECOND THEME EMBODIED KNOWING
The second theme derived from the data analysis was “embodied knowing.” Stories were told that included a technological knowing so skillfully practiced that it seemed almost second nature to the nurses. When the nurse participants described situations in which they were performing technological tasks but were focused on more complex patient care issues, the knowledge was labeled “embodied knowing,’’ a term used by other scholars for this kind of knowledge.” Two types of embodied knowing described by the participants were categorized into the subthemes of “knowing through similar experiences” and “knowing through personal experience.” Knowing through simikr experiences. Susan’s story, described previously, regarded an incident in which a major artery was lacerated by the insertion of a trocar for a routine laparoscopic tubal ligation. It is important to note that Susan was a perioperative nurse working in an outpatient department. Outpatient surgery does not provide experience with
Gosh, I thought, “Don’t let this patient die.” I just felt for the patient’s life . . . here was a young girl coming to get her tubes tied and then something like this happened and I was just praying that we wouldn’t have to give bad news to the family. As it turned out, [fluid resuscitation was successful]. She even got her tubes tied in the process , . . I can identify with the patient’sfeelings. I’ve been [a patient], too, many times myself. Susan recognized this patient as a mother and as a wife. Even though she did not know this patient personally, the “personhood” Susan recognized pro54
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thing he checked. I was scrubbed at the time and [the circulating nurse] wasprepping. I was watching what the anesthetist was doing and how he kept looking up. He still had not mentioned that she hadflat-lined at that time, and when he finally did say “I don’t think it’s the EKG;I think she’sflat-lining, and I don’tfeel a pulse,’’ we realized that it was a full blown code. . . . Even though the D & C was considered such a simple procedure, we had a patient in a very critical condition, and it was a matter of us reacting to it immediately. . . . I am very happy I had another nurse who was also very experienced in the room with me. It all went rather smoothly.
major arterial bleeding. Her past experiences with vascular surgery helped her respond to this situation quickly and efficiently. Even though that past experience was more than 10 years ago, she described the way in which the experience helped her.
Well, back years and years ago [at a general hospital] we used to do a lot of on-call ruptured aortic aneurysms-which is a similar situation to t h i d u t a ruptured aortic aneurysm is more controlled because you know what the problem is. You know where the bleeding is probably coming from, yet having that experience helped. IfI had been just totally outpatient surgery oriented and an arterial laceration occurred, I would not have had a clue as to what other instruments were needebsuch as the vascular instruments and vascular sutures. Having been in the situation where I’ve done vascular cases in the past, I knew the importance of certain clamps and certain special suture and all. . . . It’s still fresh . . . well, not fresh in my mind, but it’s still back there. And it came forward when this situation occurred. So I remembered deBakey clamps, Cooley clamps, anything else that they might have needed.
Nancy went on to describe how the arrest was managed quickly and effectively, with the patient making a complete recovery. Nancy was aware of the importance of attentiveness during induction and, because of her attentiveness, she was able to pick up cues from the situation and act quickly. If I’d had my back turned to the anesthetist, doing something else, or talking to someone in the roorn-rzot seeing how [the anesthetist] was acting or seeing how worried he was getting at what was going on . . . it could have been longer before I picked up that the patient was really in trouble, and it was not just faulty equipment.
The expert responses exemplified here come from real, concrete situations. Knowledge derived from textbooks cannot replace actual lived experiences in developing expert practice. Another nurse, Nancy, described an incident in which a patient with no prior cardiac history had a cardiac arrest when being placed into stirrups for a dilatation and curettage (D & C) procedure. Nancy attributed her ability to respond quickly to the many times she had practiced how to intervene when a patient arrested. Her previous education and training prepared her to make a quick response to an unexpected event.
The successful recovery of this patient included the skilled performance of the entire team. Sequencing and delegating various tasks were required for a quick response. Nancy abandoned her role as scrub person, contaminated her sterile attire, and immediately refocused her priorities to respond to the unexpected arrest.
I immediately grabbed the bed control to get the foot of the bed back up so that we could get her legs down from lithotomy and start compressions. Because of the high lithotomy position of her legs, we could not get to her chest, so we had to get her legs down as quickly as possible. Then [the circulating] ran to get the crash cart, and I got into position to do compressions.
I had a patient who came in for a very simple D & C , and she was a very obese patient with no cardiac history whatsoever, and we all assumed this was going to be a very short case and would be done in no time. As soon as we put the patient up in the lithotomy position to prep herpshe flat-lined on her EKG, and the anesthetist in the room at the time-his immediate reaction was possibly that some of the leads had come loose, and that was the first
Nancy did not hesitate to break scrub and assist with the code. Her response to the situation was 55
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almost simultaneous with the announcement from the anesthetist that the patient was in cardiac arrest. Nancy also recognized the abilities of other team members and was able to coordinate tasks appropriately. “Almost immediately another anesthetist arrived and took over compressions. From that point on, I helped prepare and pass medications from the crash cart.” Understanding the skills of colleagues and being able to direct others in an emergent situation is characteristic of nursing expertise.‘* Nancy changed roles quickly as she and other team members responded to the situation. She contributed effectively to the team effort.
patient was necessary. Paradigm cases such as this reinforce the importance of the skills of the expert nurse. Jean continued describing how daily routines do not challenge the limits of her skills, yet, when the unexpected occurs, her expertise becomes important to the patient.
Just this past week, someone said, “I could do this; this is easy.” There are easy parts of being a nurse, but then . . . when things become abnormal is when what I’ve learned comes into play, and it’s important for that patient. The expert perioperative nurse makes decisions based on the ability to recognize the abnormal and react quickly to the unexpected. Jean knew that the tumor was located on the left side because of her previous patient care experiences with x-rays. Knowing through similar experiences allowed her to advocate for the child with the resident. Intervening with the resident about positioning the child on the wrong side became a paradigm case for Jean, and she uses this story when orienting new nurses.
I felt I had the adrenaline rush, but I still felt I was in control. It’s almost like you’re not even truly there . . . you’re just working on your education and your instincts and everything you’ve been taught over years and years and years of experience. . . . I was able to react and give my part to it. I felt like I was part of the solution. Even though she stated that she had never before had a patient arrest in the OR, Nancy contributed to the patient’s successful outcome because of similar experiences on other nursing units. Another nurse, Jean, described a situation that exemplified the theme of “embodied knowing” and the subtheme of “knowing through similar experiences.” Jean discovered that the information on a patient’s consent form and the OR schedule was inconsistent. The resident was prepping the patient for a brain tumor on the right side when the x-rays indicated that the tumor was actually on the left. Jean had gained expertise in reading x-rays from working in neurosurgery and was able to advocate for the patient.
I share this experience with [orientees], and they realize how important checking and double-checking eveiything is. You can’t just rely on someone else’s word. People are human, and they make mistakes. So, we are all there to help each other. Sharing this story with new perioperative nurses emphasizes the importance of attention to detail. Jean used this example from her clinical practice to teach new orientees the importance of checking and rechecking the smallest detail.I9 The clinical story conveyed the importance of questioning and persistent questioning. Providing examples to convey complex skills to less experienced nurses is characteristic of expert nursing.” Knowing through personal experiences. Participants who had personal experiences as patients discussed how being patients themselves influenced their nursing practices. Experiencing nursing care from the patient’s perspective was a powerful leaming situation. Nancy described how she felt.
[The resident] pretty much had positioned the patient and had him in the skull pins. He had positioned the child to do a right side . . . and I was reviewing the x-rays with the orientee when I realized that the tumor was on the left side of the head. The resident was arguing with me, “No, no, this is the right side, this is the right side.” I dragged him over to the x-ray, and I said, “Well you tell me what side the tumor is on. ”
[Being a patient is] a veryfiightening experience. . . , It’s very different to be on the other side of the bed. . . . It really makes you look at
Jean recognized the inconsistency, acted quickly, and argued with the resident that repositioning the 56
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things a little direrently. You reevaluate how you’re taking care of the patient and what differences you can make. After nurses became patients themselves, they described how they changed some of their nursing practices. As discussed previously, Susan began to incorporate the practice of holding the patient’s hand during induction because of her own experience. Susan stated that
patient, and there was no one to move the patient’s feet. The patient was having surgery unrelated to his feet, but Ann was concerned about possible skin breakdown because of his diabetes and the potential for injury.
. . . especially with a diabetic patient . , . you definitely don’t want to drag the feet because that sets them up for postoperative necrosis of the skin. . . . The minute I saw his feet were left on the bed, I went over and picked his feet up and put them on the stretcher. . . . It’s little instances like those that you intervene all the time. . . . If you’re going to be a good patient advocate, there are so many incidents where you are protecting the patient . . . taking charge of the patient’s safety is your responsibility and maintaining the patient’s dignity and maintaining an environment that is conducive for that patient to not only do well, but heal.
[having your hand held during induction] to me is one of the most comforting things that can happen while you’re going to sleep under anesthesia. That’s what somebody did to me when I had surqery, and I’ve never forgotten it. Both of these participants emphasized the effect that their own personal experiences had on their current nursing practices. Both Susan and Nancy indicated they tried to take time from the numerous tasks required of them in the OR to connect with patients on a person-to-person level. Although these nurses may have learned to individualize care in nursing school, they attributed learning the importance of caring from their personal experiences as patients. THE THIRD THEME: COMPREHENSIVE PATIENT I\DVOCACY
The third theme identified by the participants was that of a type of advocacy for the patient that led to clinical decisions and interventions. Certainly, the importance of patient advocacy is ingrained in each new orientee to the OR. Traditionally, advocacy in the OR includes protecting the patient when the patient cannot do so, providing a safe surgical environment, and using a “surgical conscience” to make decisions. The expert nurse participants in this study advocated for patients in these customary ways but also in another way. Nurse participants described situations in which they accepted responsibility for education of the patient and family members regarding surgery by planning interventions that involved the “big picture” beyond the doors of the OR. These practices were labeled “comprehensive advocacy” because the activities went beyond those required of the perioperative nurse. For example, Ann discussed a situation in which a diabetic patient was being moved from a bed to a stretcher. She described her reaction when she saw that only two people were attempting to move this
Ann considered the patient and his welfare beyond the doors of the OR. She was interested in more than simply the surgical aspects of the patient. Ann understood that injury to the patient’s feet during a transfer could occur and become a major problem. She took personal responsibility to ensure that this patient would be protected from injury during his perioperative experience and immediately intervened when his safety was threatened. Comprehensive advocacy involved truly seeing the big picture beyond the doors of the OR and was linked to a caring attitude. In another example, Ann discussed her role when she discovered during the perioperative interview that the patient could not speak English.
There was a Spanish-speaking patient one day that we were taking back to surgery and . . . she couldn’t understand any of the preop questions. She had a son in there who was interpreting for her, and she would answer [him] and he would give me the answer. . . . The look on her face told you that she was totally scared. . . . So, realizing that this person would not have any way of communicating in the postoperative recovery phase of her care or up on the floor, in the preoperative area we determined certain signs for all the various things that could be a potential problem. . . . So it was a continuum of care from the minute she 58
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made explicit. Storytelling of nurse-patient scenarios involves much more than entertainment for the listener.” In addition to traditional nursing advocacy activities, descriptions of a more comprehensive kind of advocacy with mention of specific patient situations may help improve nursing practice. Further, expert perioperative nurses can use their exemplars to teach through sharing knowledge with peers. Articulating what expert perioperative nurses do and how they do it can be difficult. Exemplars create concrete pictures and reinforce other methods of teaching. These stories convey the “big picture.” They document who we are and the contribution we make to patient outcomes. We need to continue to study, learn, and design our educational programs by observing nursing practice. Additional research conducted with other populations of perioperative nurses will help document nursing practice patterns and eventually provide a pool of accumulated data that clearly links nursing care to patient outcomes. Other research questions that might be helpful include the following. Do different types of nursing models and administrative cultures influence patient outcomes? What type of skill mix provides optimal patient outcomes? What type of skill mix produces the optimal economic outcomes when patient complications are considered? Do perioperative nurse-physician communication patterns influence patient outcomes? Answering these research questions would contribute to data documenting expert perioperative nursing practice and support the need for expert perioperative nurses. The perioperative nurse participants in this study demonstrated an ability to connect with patients and to respond to patient needs in the midst of the highly technological, stressful environment of the OR. These nurses developed this ability only because they were able to transcend task-focused practice. Each of the participants had years of OR experience and considered themselves expert practitioners. Without prior experiences, their ability to see the big picture and thus be able to incorporate caring into highly stressful situations could have been limited. This study begins to reveal the decision-making processes used by expert nurses in the perioperative area and provides a beginning step in documenting the quality of clinical nursing judgment that occurs in the
entered the hospital into the preoperative area to the time she left the hospital two days later. . . . I don’t know where I developed the time to actually plan this woman’s care because she was just the next patient.
In this situation, Ann felt a personal responsibility to intervene in spite of time constraints so that the patient not only would go into surgery with less anxiety but also would be able to have a way to have some autonomy in making her feelings and needs known postoperatively. This nurse recognized a need and took responsibility to advocate in a way that would meet this patient’s needs. AM was able to use hand signals and pictures to extend the voice of her patient and alleviate some of the concerns of this patient and her family members. This expert practice was labeled “comprehensive advocacy.” LIMITATIONS OF THE STUDY
The findings of this study were limited to female Caucasian nurses practicing in an urban area of the southeastern United States. In addition, the sample was small, and data were derived only from experienced nurses. IMPLICATIONS
These data suggest the need for nurses with extensive expertise in perioperative nursing to be readily available in all areas where surgery is performed. Developing nursing expertise in the OR requires extensive experience. Experience in other areas of nursing can facilitate the process of gaining expertise in the OR. Expert nursing skills are not always apparent during routine perioperative care of the patient but can become crucial when the unexpected occurs. Positive patient outcomes depend on the ability of the perioperative nurse to integrate all nursing knowledge, make rapid decisions, and constantly advocate for the patient. These data also suggest that we change our approach to nursing education. First, if nurses need to connect with patients on a person-to-person level to assess and care for them expertly, then students are apt to develop expertise more efficiently if the implications of connecting with patients are described in an explicit way. These data also suggest that nurses and nursing students would benefit if personal patient care experiences were related so that the taken-for-granted knowledge of clinical practice could be examined and caring practices could be 61
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OR. The ability to manage difficult technological situations while simultaneously exhibiting care and concern for patients was associated with the clinical decision-making skills of the expert perioperative nurse.
Ptlene Minick, RN, PhD, is an associate professor, Virginia Commonwealth University. School of Nursing, Richmond.
Despite necessarily brief patient encounters, the ability to make connections was demonstrated. The stories of these perioperative nurses exemplify the critical need for expert care in the midst of the highly technological and demanding environment of the OR. A
Carolyn C . Kee, RN, PhD, is an associate professor. Georgia State University, Atlanta.
Cheryl B. Parker, RN, MSN, is a nurse clinician in the OR, Emory HealthCarelCrawford Long Hospital, Atlanta. NOTES 1. P E Benner, From Novice to Expert: Excellence and Power in Clinical Nursing Practice (Menlo Park, Calif: Addison Wesley Publishing Co, Inc, 1984); P Benner, C A Tanner, C A Chesla, Expertise in Nursing Practice: Caring, Clinical Judgment, and Ethics (New York: Springer Publishing Co, 1996); P Minick, “The power of human caring: Early recognition of patient problems,” Journal of Scholarly Inquiry for Nursing Practice 9 (Winter 1995) 303-317; C A Tanner et al, “The phenomenology of knowing the patient,” IMAGE: Journal of Nursing Scholarship 25 (Winter 1993) 273-280. 2. D W Lener, “Nursing intuition: The deep connection,” in A Global Agenda for Caring, ed D A Gaut (New York: National League for Nursing Press, 1993) 223-240 L Rew, “Intuition in decision-making,’’ IMAGE: Journal of Nursing Scholarship 20 (Fall 1988) 150-154. 3. P E Benner, J Wrubel, The Primacy of Caring: Stress and Coping in Health and Illness (Menlo Park, Calif: Addison Wesley Publishing Co, Inc, 1989); P Minick, “The power of human caring: Early recognition of patient problems,” Journal of Scholarly Inquiryfor Nursing Practice 9 (Winter 1995) 303-314; Tanner et al, ‘‘ The phenomenology of knowing the patient,” 273-280. 4. V D Wagner, C C Kee, D P Gray, ‘‘ A historical decline of educa-
This study was partially funded by the AORN Foundation Degree Completion Grant.
tional perioperative clinical experiences,” AORN Journal 62 (November 1995) 771-782. 5. C A Abbott, “Intraoperative nursing activities performed by surgical technologists,”AORN Journal 60 (September 1994) 382-392. 6. K S Ponder, “The RN circulator,” AORN Journal 60 (September 1994) 459-462. 7. Wagner, Kee, Gray, “A historical decline of educational perioperative clinical experiences,” 771-782. 8. I von Post, “Exploring ethical dilemmas in perioperative nursing practice through critical incidents,” Nursing Ethics 3 (September 1996) 236-249; E C Parsons, C C Kee, P Gray, “Perioperative nurse caring behaviors. Perceptions of surgical patients,” AORN Journal 57 (May 1993) 1106-1114. 9. N L Diekelmann, D Allen, “A hermeneutic analysis of the NLN criteria for the appraisal of baccalaureate programs,” in The NLN Criteria for Appraisal of Baccalaureate Programs: A Critical Hermeneutic Analysis, ed N Diekelmann, D Allen, C Tanner (New York National League for Nursing Press, 1989). 10. Benner, Tanner, Chesla, Expertise in Nursing Practice: Caring, Clinical Judgment, and Ethics. 11. Minick, “The power of human caring: Early recognition of patient problems,” 303-3 17. 12. R C Locsin, “Machine technologies and caring in nursing,” 62 AORN JOURNAL
IMAGE: Journal of Nursing Scholarship 27 (Fall 1995) 201-203. 13. C A Tanner et al, “The phenomenology of knowing the patient,” 273-80. 14. Benner, Wrubel, The Primacy of Caring: Stress and Coping in Health and Illness. 15. R McCorkle, “Effects of touch on seriously ill patients,” Nursing Research 23 (MarcWApril 1974) 125-132. 16. Benner, Tanner, Chesla, Expertise in Nursing Practice: Caring, Clinical Judgment, and Ethics; Parsons, Kee, Gray, “Perioperative nurse caring behaviors. Perceptions of surgical patients,” 1106-1114. 17. Benner, Wrubel, The Primacy of Caring: Stress and Coping in Health and Illness. 18. Benner, Tanner, Chesla, Expertise in Nursing Practice: Caring, Clinical Judgment, and Ethics. 19. Ibid. 20. Ibid. 2 1. Parsons, Kee, Gray, “Perioperative nurse caring behaviors,” 1106-1114. S U G G E S T E D READING Clement, J M. “Touch: Research findings and use in preoperative care.”AORN Journal 45 (June 1987) 1429-1439. Sandelowski, M. “The problem of rigor in qualitative research.” Advances in Nursing Science 8 (April 1986) 27-37.
Clinical Decision-making Processes in Perioperative Nursing
A
lthough perioperative nurses are required by the nature of the environment to amve at clinical decisions quickly, the processes by which these clinical decisions are made is not fully understood. Perioperative practice models are not well documented, and the essence of perioperative nursing is not well identified. As a result, the ways in which perioperative nurses influence patient care delivery and patient outcomes is not known.
and one that nurses use to arrive at clinical decisions in variety of settings.' In addition, several studies have found a caring relationship associated with intuitive recognition and intervention.' Very little research has been conducted about the ways in which perioperative nurses make clinical decisions.' No studies were found that linked perioperative nursing practice to patient outcomes, yet few of us would question the contributions that expert perioperative nurses make to positive patient outcomes. As perioperative nursing practice is not well PURPOSE The purpose of this qualitative study was to documented, administrators who are unfamiliar with reveal the processes used by how perioperative nurses contribute to quality care suggest that expert perioperative nurses as they make clinical decisions. As the A B S T R A C T unlicensed assistive personnel processes of expert clinical deciThe purpose of this phenom- (UAP) may be substituted for sion making are more fully under- enological study was to reveal nurses to save money. This stood, this knowledge can be used the processes Of clinical decision research project provides an initial to assist the novice perioperative making by expert PeriOperfJtiVe step in understanding the decinurse in the quest towards excel- nurses. Six nurses with a mini- sion-making processes of perioplence. The goal of this research mum Of five years experience erative nurses and, thus, their conwas to answer the following ques- who considered themselves to tributions to patient care. tion: What are the processes used be experts in OR flUrsing were by expert perioperative nurses in asked to describe perioperative ASSUMPTIOWS clinical decision making? situations in which they had Assumptions explicit in this made a difference in patient research are that the perioperative R M E W OF LITERATURE outcomes. In every situation nurse is a necessary, vital member Several research studies have described, an intricate pattern Of of the surgical team who conbeen conducted regarding clinical concern was present and OSSOCi- tributes to the achievement of posdecision making of critical care ated with further assessments. itive patient outcomes. The perinurses.' These scholars have inter- The pattern was labeled Seeing operative nurse must possess the viewed a total of more than 350 the big picture: Engendered ability to make clinical decisions nurses and noted a relationship through caring. This study pro- quickly and accurately so that between expert decision making vides initial documentation to quality patient care occurs in the and intuitive knowledge. More SuppOrt how RNs make critical OR. Some situations require deciand more nursing literature sup- contributions to the quality Of sions critical for the preservation ports the idea of intuitive h o w l - perioperative patient care. AORN of life. More often, however, situedge as a valid way of knowing J 70 (July 1999) 45-62. ations require everyday decisions CHERYL B. PARKER, R N ; PTLENE M I N I C K , R N : CAROLYN C . KEE, RN
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that involve preventing serious patient problems. When problems are prevented, the knowledge required for this prevention is taken for granted and becomes invisible, yet patient outcomes are positively influenced. The invisible nature of problem prevention might be the reason why there is so little research linking the contributions of penoperative nurses to patient outcomes. The processes by which split-second clinical decisions are made is of critical importance in understanding how perioperative nurses make a difference. Perioperative nurses provide care during rapidly changing situations in a highly technical environment. Complex nursing judgments are required continually? SIGNIFICANCE OF THE STUDY TO THE PROFESSION
The present health care environment demands that nurses validate their influence on patient care. An understanding of the processes involved in clinical decision making is one of the first steps in relating nursing care to patient outcomes. In addition, an understanding of these processes contributes not only to nursing science, but also will influence nursing education and ultimately contribute to the improvement of patient care.
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cation. The processes of moving from novice to expert can be facilitated when clinical decision-making strategies are better understood. Delineating the knowledge embedded in the practices of perioperative nursing is the challenge for the nursing profession.’ This proposed study is a pivotal step in documenting the clinical nursing judgment that occurs in the OR. PHILOSOPHICAL FRAMEWORK
Phenomenology was chosen as the framework to guide this research because of its usefulness in uncovering the taken-for-granted knowledge found in practice.* It focuses on everyday experiences and the meaning found within those experiences. Clinical decision making was conceptualized to be embedded in the everyday activities of the perioperative nurse. In addition, staff nurses were conceptualized to be the most knowledgeable of clinical practices and the judgments required in the complex technological environment of the OR. RESEARCH METHODS AND PARTICIPANT SELECTION
Nurses who worked a minimum of five years and considered themselves to be expert circulating nurses in the OR were sought. There were no restricSIGNIFICANCE OF THE STUDY tions relative to education, age, gender, race, or socioeconomic status. Participants were recruited TO PERIOPERATIVE NURSING Documenting how clinical decision making during late 1996 and early 1997 at monthly meetings occurs in perioperative nursing will help validate of a local AORN chapter. A general announcement perioperative nursing practices and provide direction was made during the business portion of the meeting for the education of perioperative nurses. The impor- about the opportunity to participate. In addition, tance of expert nursing practice in the OR can be dis- information was provided in the chapter’s monthly counted easily, particularly if the role has not been newsletter during these same months to recruit nursclearly articulated and the contributions have not es who were not able to attend the meetings. Participants also were asked to recommend other been documented. As the health care arena of the 1990s is more fre- perioperative nurses whom they perceived as practicquently driven by economic concerns than by quality ing as experts so that nurses who were not AORN concerns, validation of perioperative nursing practice members could be included in the study. A total of is essential. Many health care managers are mandat- eight perioperative nurses working in hospitals in a ed by administrators to reduce budgets. An easy tar- large southern urban and suburban area were recruitget is the budgetary allotment for nursing personnel. ed for this study. Two participants withdrew from the The role of RN circulator has been scrutinized, and study before the interview due to scheduling difficulmany institutions are moving toward substituting ties; therefore, the final sample size was six. UAP for this traditional nursing Economic conPROTCCnON siderations must not be allowed to replace the quality Approval for this investigation was obtained care that patients deserve to have when undergoing a from the institutional review board at the sponsoring surgical procedure. Additionally, knowledge of decision-making university for the protection of human subjects. strategies can help guide perioperative nursing edu- Written informed consent was obtained from each 46 AORN JOURNAL
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Table 1 INTERVIEW GUIDE
You will be asked to describe a clinical situation, either preoperatively or intraoperatively, in which you intervened on the patient's behalf and affected the patient's outcome. Recording this information will assist in an accurate description of your feelings and intentions during this intervention. Feel free to make notes before the interview, and bring these notes with you. The following questions may help you identify clinical situations that you may want to discuss in the interview. Did you have an "early warning signal" in a situation? An early warning signal is when you have a 'sixth sense' about the patient without supporting data. It may or may not turn out to be a correct feeling. Was there o situation in which there was a need to consult with another nurse or a physician? Was there a situation in which you believe your intervention really made a difference in patient outcome, either directly or indirectly (by helping other staff members)? The following are areas to include when identifying a clinical situation for the interview. The context of the situation (ie, regular schedule, emergency, staff resources). A description of what happened.
Why you chose this situation (ie, why this situation made an impact on you). What your concerns were at the time. What you were thinking about as it was taking place. What you were feeling during and after the situation. What, if anything, you found most demanding about the situation. What, if anything, you found most satisfying about the situation.
rizing participant stones with the goal of understanding the interviews as a whole and including the context. In the second level of analysis, key paragraphs, phrases, and words were extracted from the text to exemplify the message of the participant. During the third level of analysis, key phrases identified by the investigators as important were compared across interviews. The key phrases were grouped together according to content and became categories. Frequently, the investigators agreed on the meaning in the data. When there were differences in interpretation, checking the original text, which had a full description of the situation, helped investigators reach a consensus. At this point, the investigators sought related research findings in the literature to support or refute notions found in the texts. The fourth level of analysis involved identifying similar and contradictory categories within texts and across texts and comparing them again to the literature to identify related research findings. During the fifth level of analysis, the entire data set was examined for common patterns constitutive of clinical decision making. Level six involved review of the interpretation from an independent researcher and
participant, and the interviews were held in a convenient, quiet room conducive to maintaining confidentiality. THE INTERVIEW
Participants were asked to describe any perioperative clinical situation in which they intervened on a patient's behalf and affected the patient's outcome by doing so. They were asked to describe the situations in detail, to note if they had a sense of something about to happen, and if they believed that their interventions made a difference. The interview guide used is shown in Table 1. DATA COLLECTION AND ANALYSIS
After the interviews were transcribed verbatim, data were loaded into a software program for data management. This program was used to categorize the data and later to sort and manage the data. An analysis of each interview was done by the principle investigator and a phenomenological researcher according to the procedure outlined by other researchers? The first level of analysis consisted of summa48
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key study participants. The independent nurse researcher, who was skilled in interpretative research, was asked to review the interpretation and evaluate whether the themes seemed appropriate and whether sufficient data was presented to represent the themes. Two participants were available and willing to review the findings; these participants were asked to evaluate whether the interpretations were true for them and if the examples were exemplary of perioperative nursing. The participants were the final authority regarding the interpretation of the findings. The multiple steps of analysis conducted with other scholars and key participants helped ensure that data were not overinterpreted or underinterpreted. These analytic procedures yielded patterns in which themes, and, in turn, subthemes, were embedded. FINDINGS AND IllCrWPRElATlON
12 years, with a mean of slightly more than five years. The time employed on the current unit ranged from two years to 23 years, with a mean of nearly 11 years. A variety of surgical services were represented. Two of the participants did not specialize in a particular service but floated wherever needed. One of the participants specialized in outpatient orthopedic surgery, one specialized in pediatric neurosurgery, one specialized in urology, and one specialized in general/vascular surgery. Operating room units of employment. Five different hospitals were represented by the participants. Three participants were employed by public institutions, and three were employed by private hospitals. Four participants were employed in inpatient OR settings, and two participants were employed in outpatient ORs. Five of the participants worked the day shift, and one participant worked the night shift.
The participants related rich detailed clinical situations that exemplified the complexity of the surgical environment. Within the situations, elaborate patterns of caring and commitment were intertwined with knowledge and ethical decisions by perioperative nurses. In the following sections, characteristics of participants are presented first, followed by the pattern and themes identified in the data. Examples from the data are used to illustrate the context so the reader can evaluate the interpretation. In addition, each of the patterns and themes are discussed in light of the relevant literature.
1IYCIIRPRETATW)N
Data interpretation yielded one overriding pattern with three themes subsumed under this pattern. The first theme had three subthemes; the second theme had two subthemes; and the third theme had none. The ovemding pattern, implied or explicit in every interview, contributing to the clinical decisionmaking process among these expert nurses was identified as “Seeing the big picture: Engendered through caring.” Within each nurse’s practice were multiple decisions, and within each decision, certain characteristics were identified and categorized into themes. The three themes identified from analysis of the interviews as requisite for expert clinical decision making included connecting with patients, advocating for patients, and embodied knowing. Each of these themes will be presented with data to illustrate the interpretation; relevant literature will be used to discuss the findings. A list of the overriding pattern with the underlying themes and subthemes is provided in Table 2.
CIIARACTERISTICSOF PARnClPAMs
A sample of six female RNs who were employed in hospitals in a large southern metropolitan area participated in the study. Five of the participants were active members of AORN, and one participant was not a member of the organization. Ages ranged from 29 years to 58 years, with a mean of 39 years. Level of education. Three participants in this study held baccalaureates in nursing. Two of the participating nurses were diploma graduates, one of whom was currently enrolled in a baccalaureate program in nursing, and one held an associate degree in nursing. Experience of participants. The total years of OR nursing experience of the participants in this study ranged from 6.5 to 23 years, with a mean of 12.25 years. Three participants had worked on other units before working in the OR. Nursing experience other than that in the OR ranged from two years to
THE WlTERN
Without exception, in every patient situation nurses talked about “seeing the big picture,” when notions of concern for the patient and for the future of the patient as a person were clearly evident. As the concern was about more than the immediate circumstances, the examples were labeled “Seeing the big 50
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picture: Engendered through caring.” Many participants used the phrase “seeing the big picture” as they described the importance of thinking beyond the care provided in the perioperative area. In addition, each patient care situation reported was filled with a concern for the patient’s well-being. Kim described an instance in which she was scrubbed for a trauma procedure. The surgical team was expecting a patient with a ruptured spleen and instead found that the patient had almost transected his aorta. In spite of the urgency of the situation and the brief time spent with the patient while he was awake, she demonstrated an awareness for the patient as a person as she prepared for the procedure.
aware of the importance of responding to the patient and treating him as a person. As she was preparing the setup for his physical needs, she also was aware of his psychological needs, and she implemented actions to help him feel safe and cared for. Kim continued to describe the situation and how she noticed the patient was experiencing back pain, which suggested to her that the patient’s dropping blood pressure might be caused by a problem in the chest rather than the initial assessment of a ruptured spleen. “He was still conscious and talking when we moved him from the stretcher to the table. I remember him really groaning when he was moved. He said it was his back.” With the patient’s history of an automobile accident, Kim knew from previous experience that back pain suggested a possible transected aorta. She rapidly thought beyond the assessment of a ruptured spleen provided by the trauma team. Kim saw the “big picture” and moved from an abdominal setup to a chest/vascular setup quickly, so she was instrumental in saving the patient’s life. In spite of the fact that Kim was faced with an urgent situation in which the patient’s blood pressure was dropping, she was able to notice him as a person, realize that he had back pain, incorporate his history with his pain, and respond. Caring allowed Kim to correlate the patient’s symptoms with his history and grasp the totality of the situation. One study documented the recurring theme of expert nurses’ ability to see the “big picture.” According to these scholars, the expert nurse can see beyond the current situation and understand something about what a patient and his or her family members might encounter in their future.’’ To understand what an illness or injury means for someone and his or her family members, the nurse must come to know the patient in a personal way. “Seeing the big picture” suggests that there is an element of human awareness and care for the individual. This phenomenon has been described as “making the connection.”“ When nurses described episodes of “seeing the big picture,” the situations were filled with concern for the patient as a person. Although concern was associated with episodes of “seeing the big picture,’’ these patient-care descriptions included little language about the technology in the environment. The OR requires a myriad of technology for even the most routine procedures. Even though the nurses were in the midst of an environment filled with technology, their primary conversation was about the patients-who they were and what they
I try to [talk to the patient] even when I’m scrubbed, and of course in that situation we were in a hurry and you try to set up . . . hut then . . . you think about the psychological component also, maybe not consciously at that moment, but you’re still doing it. You know,you try to be as quiet as possible so when they are putting him to sleep and while he’s awake you don’t disturb him any more than . . . he already is. I tried to speak to him, even i f it is [only] to say “Hi.” I remember my coworker . . . was talking to him, saying, “This is Kim” and I turned around and said “Hi.” I feel like this is important with any patient, that you tell them who’s in the room, and you try to keep the noise levels down. Increasing noise increases stress, and that affects the way he responds to the anesthetic . . .
In the midst of a tense trauma situation, Kim was
Table 2 mll€RNSAND lHEMES
Pattern: Seeing the big picture: Engendered through caring Theme: Making a connection Subtheme: Touch Subtheme: Perioperative intelview Subtheme: Humanizing care Theme: Embodied knowing Subtheme: Knowing through similar experiences Subtheme: Knowing through personal experiences Theme: Comprehensive patient advocacy 52
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running around not paying attention to you . . . just having someone with you, holding you, kind of helps.” Susan believed that touch was an important aspect of connecting with the patient. Ann also believed that touch was important in connecting with patients. Even when she was scrubbed and physical contact with the patient was not possible, Ann attended to the emotional aspects of the patient through touch.
needed. The distinct lack of discussion about the technology suggests that the technical aspects of the situation were of little concern. Use of the equipment became routine and fell into the background. Through familiarity, technology became unimportant as a topic, and the person for whom the nurses cared was central. This type of human care response in the midst of constant technological challenge is one way in which these perioperative nurses demonstrated that “seeing the big picture” is truly derived from and engendered through caring.” The technology involved was mentioned only in passing as nurses talked about patient situations. Patients, not technology, were the focus of the stories conveyed by nurses in this study. Many of the clinical decisions described showed an allencompassing view of the situation and transcended the task-focused mind-set that is a necessity for the novice nurse.
. . . we had a lady that we were doing a mastectomy on, and she was scared to death. You could see it. . . . I was scrubbed. I couldn’t hold her hand. All I could do was stand by her side and smile at her. . . . When it came close to time for induction, I motioned for [the physician] to come over. He came next to me, and I said “Please hold her hand” , . . and you could just see the relief on her face. That human touchit’s so important.
TllE FIRST THEME: MAKlNG A CONNECTION
The first theme identified within the overriding pattern of “seeing the big picture” was labeled “making a connection.” The three ways in which making a connection was manifested in these data were through touch, the preoperative interview, and humanizing care. Touch. One way that the nurses connected with patients was through touch. For instance, Susan used touch to let the patient know that the nurse was physically and emotionally available. To Susan, touch was comforting.
Ann noticed the subtle changes in the patient’s face that said she was frightened and then saw the change that occurred when the physician held her hand. Because she cared and intervened, she created a human connection for this patient in the midst of a frightening situation. Both Susan and Ann exemplify caring. By connecting with patients, they used touch to humanize the technological world of the OR. The preoperative interview. Another method nurses used to connect with their patients was by getting to know the patient during the brief preoperative interview. Jean described her care of children and how she makes a connection in this limited time period.
One thing I do like to do with my patients is hold their hand or just rest my hand on their arm . . . let them know I’m there when they go to sleep-because that, to me, is one of the most Comforting things that can happen while you’re going to sleep under anesthesia. That’s what somebody did for me when I had surgery, and I’ ve never forgotten it.
You hold them, talk to them, and ask them questions. Just age appropriate . . . You kind of make a connection then so the child doesn’t have a strange person just coming in, picking them up, and taking them to surgery. . . . You get to know them, and then you talk to them as they are going to sleep.
Susan’s personal experience reinforced to her the importance of human touch and the positive effects that touch can have. She described how holding someone’s hand or touching them on the arm allowed them to know that you are there for them. To provide touch, attention must be focused on the patient and not on other activity in the room. Susan also believed that providing touch conveyed a sense of empathy to the patient. She said “I sympathize with the fear of going to sleep when everybody is
She recognized the fear that a child might have with a stranger and used the brief preoperative interview time to establish rapport. Then she used the information gained in the preoperative interview to comfort the child. Jean also included what she had learned about 53
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the child during the perioperative interview to comfort the family members who were waiting beyond the closed doors of the OR.
duced a sense of empathy and urgency for her as she responded to the crisis. The literature supports the idea that making a connection with the patient plays a critical role in the nurse-patient interaction, helps decrease the stress response, and enhances positive patient outcomes. Scholars have described a phenomenon called “knowing the patient.”14 In the process of “seeing the big picture,” the nurses in this study demonstrated that there was a connection and an element of knowing the patient even in perioperative settings where time was limited and patients were quickly anesthetized. Through touch, the preoperative interview, and the ability to humanize care, these perioperative nurses were still able to make a connection with their patients. The literature also supports the concept that caring is the force behind making connections. Caring allows the nurse to identify problems that might not otherwise be recognized and to intervene. By coming to know about the patient as a person, the nurse is able to understand possible problems and possible solutions. As a result, nurses are able to support and assist patients through problems.ls Meaningful rapport and human connection can be made in the face of limited time and does make a positive impact on the patient.16 The nurses in this study provided vivid exemplars about the intricate pattern of care and concern in the perioperative arena.
We call the parents every hour or two hours just to give them a verbal “things are going OK’ . . .you kind of personalize it. . . “Johnny went to sleep holding his teddy bear,” and that’s a big comfort to the family. Jean included the family members in her perioperative patient care. Through her communication, she provided support to the parents even though she was not physically with them. Jean let the family members know that Johnny was in a safe and caring environment. Researchers described how nurses can reassure patients and family members by creating a caring atmosphere even though the environment is highly technological and initially frightening.” The connection Jean established during the preoperative interview comforted both the family members and the child initially and again later during the surgery. Humanizing care. Another way in which the nurses in this study demonstrated making a connection with limited time was by humanizing patient care. The participants saw the patient as a person in his or her role as a father, mother, or child. Susan exemplified this type of connection as she described her thoughts during a crisis situation in which a major vessel had been lacerated in the process of a trocar insertion for a laparoscopic tubal ligation. As she reacted quickly to provide the needed supplies and help anesthesia personnel with obtaining blood and volume expanders, her thoughts were about the patient.
THE SECOND THEME EMBODIED KNOWING
The second theme derived from the data analysis was “embodied knowing.” Stories were told that included a technological knowing so skillfully practiced that it seemed almost second nature to the nurses. When the nurse participants described situations in which they were performing technological tasks but were focused on more complex patient care issues, the knowledge was labeled “embodied knowing,’’ a term used by other scholars for this kind of knowledge.” Two types of embodied knowing described by the participants were categorized into the subthemes of “knowing through similar experiences” and “knowing through personal experience.” Knowing through simikr experiences. Susan’s story, described previously, regarded an incident in which a major artery was lacerated by the insertion of a trocar for a routine laparoscopic tubal ligation. It is important to note that Susan was a perioperative nurse working in an outpatient department. Outpatient surgery does not provide experience with
Gosh, I thought, “Don’t let this patient die.” I just felt for the patient’s life . . . here was a young girl coming to get her tubes tied and then something like this happened and I was just praying that we wouldn’t have to give bad news to the family. As it turned out, [fluid resuscitation was successful]. She even got her tubes tied in the process , . . I can identify with the patient’sfeelings. I’ve been [a patient], too, many times myself. Susan recognized this patient as a mother and as a wife. Even though she did not know this patient personally, the “personhood” Susan recognized pro54
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thing he checked. I was scrubbed at the time and [the circulating nurse] wasprepping. I was watching what the anesthetist was doing and how he kept looking up. He still had not mentioned that she hadflat-lined at that time, and when he finally did say “I don’t think it’s the EKG;I think she’sflat-lining, and I don’tfeel a pulse,’’ we realized that it was a full blown code. . . . Even though the D & C was considered such a simple procedure, we had a patient in a very critical condition, and it was a matter of us reacting to it immediately. . . . I am very happy I had another nurse who was also very experienced in the room with me. It all went rather smoothly.
major arterial bleeding. Her past experiences with vascular surgery helped her respond to this situation quickly and efficiently. Even though that past experience was more than 10 years ago, she described the way in which the experience helped her.
Well, back years and years ago [at a general hospital] we used to do a lot of on-call ruptured aortic aneurysms-which is a similar situation to t h i d u t a ruptured aortic aneurysm is more controlled because you know what the problem is. You know where the bleeding is probably coming from, yet having that experience helped. IfI had been just totally outpatient surgery oriented and an arterial laceration occurred, I would not have had a clue as to what other instruments were needebsuch as the vascular instruments and vascular sutures. Having been in the situation where I’ve done vascular cases in the past, I knew the importance of certain clamps and certain special suture and all. . . . It’s still fresh . . . well, not fresh in my mind, but it’s still back there. And it came forward when this situation occurred. So I remembered deBakey clamps, Cooley clamps, anything else that they might have needed.
Nancy went on to describe how the arrest was managed quickly and effectively, with the patient making a complete recovery. Nancy was aware of the importance of attentiveness during induction and, because of her attentiveness, she was able to pick up cues from the situation and act quickly. If I’d had my back turned to the anesthetist, doing something else, or talking to someone in the roorn-rzot seeing how [the anesthetist] was acting or seeing how worried he was getting at what was going on . . . it could have been longer before I picked up that the patient was really in trouble, and it was not just faulty equipment.
The expert responses exemplified here come from real, concrete situations. Knowledge derived from textbooks cannot replace actual lived experiences in developing expert practice. Another nurse, Nancy, described an incident in which a patient with no prior cardiac history had a cardiac arrest when being placed into stirrups for a dilatation and curettage (D & C) procedure. Nancy attributed her ability to respond quickly to the many times she had practiced how to intervene when a patient arrested. Her previous education and training prepared her to make a quick response to an unexpected event.
The successful recovery of this patient included the skilled performance of the entire team. Sequencing and delegating various tasks were required for a quick response. Nancy abandoned her role as scrub person, contaminated her sterile attire, and immediately refocused her priorities to respond to the unexpected arrest.
I immediately grabbed the bed control to get the foot of the bed back up so that we could get her legs down from lithotomy and start compressions. Because of the high lithotomy position of her legs, we could not get to her chest, so we had to get her legs down as quickly as possible. Then [the circulating] ran to get the crash cart, and I got into position to do compressions.
I had a patient who came in for a very simple D & C , and she was a very obese patient with no cardiac history whatsoever, and we all assumed this was going to be a very short case and would be done in no time. As soon as we put the patient up in the lithotomy position to prep herpshe flat-lined on her EKG, and the anesthetist in the room at the time-his immediate reaction was possibly that some of the leads had come loose, and that was the first
Nancy did not hesitate to break scrub and assist with the code. Her response to the situation was 55
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almost simultaneous with the announcement from the anesthetist that the patient was in cardiac arrest. Nancy also recognized the abilities of other team members and was able to coordinate tasks appropriately. “Almost immediately another anesthetist arrived and took over compressions. From that point on, I helped prepare and pass medications from the crash cart.” Understanding the skills of colleagues and being able to direct others in an emergent situation is characteristic of nursing expertise.‘* Nancy changed roles quickly as she and other team members responded to the situation. She contributed effectively to the team effort.
patient was necessary. Paradigm cases such as this reinforce the importance of the skills of the expert nurse. Jean continued describing how daily routines do not challenge the limits of her skills, yet, when the unexpected occurs, her expertise becomes important to the patient.
Just this past week, someone said, “I could do this; this is easy.” There are easy parts of being a nurse, but then . . . when things become abnormal is when what I’ve learned comes into play, and it’s important for that patient. The expert perioperative nurse makes decisions based on the ability to recognize the abnormal and react quickly to the unexpected. Jean knew that the tumor was located on the left side because of her previous patient care experiences with x-rays. Knowing through similar experiences allowed her to advocate for the child with the resident. Intervening with the resident about positioning the child on the wrong side became a paradigm case for Jean, and she uses this story when orienting new nurses.
I felt I had the adrenaline rush, but I still felt I was in control. It’s almost like you’re not even truly there . . . you’re just working on your education and your instincts and everything you’ve been taught over years and years and years of experience. . . . I was able to react and give my part to it. I felt like I was part of the solution. Even though she stated that she had never before had a patient arrest in the OR, Nancy contributed to the patient’s successful outcome because of similar experiences on other nursing units. Another nurse, Jean, described a situation that exemplified the theme of “embodied knowing” and the subtheme of “knowing through similar experiences.” Jean discovered that the information on a patient’s consent form and the OR schedule was inconsistent. The resident was prepping the patient for a brain tumor on the right side when the x-rays indicated that the tumor was actually on the left. Jean had gained expertise in reading x-rays from working in neurosurgery and was able to advocate for the patient.
I share this experience with [orientees], and they realize how important checking and double-checking eveiything is. You can’t just rely on someone else’s word. People are human, and they make mistakes. So, we are all there to help each other. Sharing this story with new perioperative nurses emphasizes the importance of attention to detail. Jean used this example from her clinical practice to teach new orientees the importance of checking and rechecking the smallest detail.I9 The clinical story conveyed the importance of questioning and persistent questioning. Providing examples to convey complex skills to less experienced nurses is characteristic of expert nursing.” Knowing through personal experiences. Participants who had personal experiences as patients discussed how being patients themselves influenced their nursing practices. Experiencing nursing care from the patient’s perspective was a powerful leaming situation. Nancy described how she felt.
[The resident] pretty much had positioned the patient and had him in the skull pins. He had positioned the child to do a right side . . . and I was reviewing the x-rays with the orientee when I realized that the tumor was on the left side of the head. The resident was arguing with me, “No, no, this is the right side, this is the right side.” I dragged him over to the x-ray, and I said, “Well you tell me what side the tumor is on. ”
[Being a patient is] a veryfiightening experience. . . , It’s very different to be on the other side of the bed. . . . It really makes you look at
Jean recognized the inconsistency, acted quickly, and argued with the resident that repositioning the 56
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things a little direrently. You reevaluate how you’re taking care of the patient and what differences you can make. After nurses became patients themselves, they described how they changed some of their nursing practices. As discussed previously, Susan began to incorporate the practice of holding the patient’s hand during induction because of her own experience. Susan stated that
patient, and there was no one to move the patient’s feet. The patient was having surgery unrelated to his feet, but Ann was concerned about possible skin breakdown because of his diabetes and the potential for injury.
. . . especially with a diabetic patient . , . you definitely don’t want to drag the feet because that sets them up for postoperative necrosis of the skin. . . . The minute I saw his feet were left on the bed, I went over and picked his feet up and put them on the stretcher. . . . It’s little instances like those that you intervene all the time. . . . If you’re going to be a good patient advocate, there are so many incidents where you are protecting the patient . . . taking charge of the patient’s safety is your responsibility and maintaining the patient’s dignity and maintaining an environment that is conducive for that patient to not only do well, but heal.
[having your hand held during induction] to me is one of the most comforting things that can happen while you’re going to sleep under anesthesia. That’s what somebody did to me when I had surqery, and I’ve never forgotten it. Both of these participants emphasized the effect that their own personal experiences had on their current nursing practices. Both Susan and Nancy indicated they tried to take time from the numerous tasks required of them in the OR to connect with patients on a person-to-person level. Although these nurses may have learned to individualize care in nursing school, they attributed learning the importance of caring from their personal experiences as patients. THE THIRD THEME: COMPREHENSIVE PATIENT I\DVOCACY
The third theme identified by the participants was that of a type of advocacy for the patient that led to clinical decisions and interventions. Certainly, the importance of patient advocacy is ingrained in each new orientee to the OR. Traditionally, advocacy in the OR includes protecting the patient when the patient cannot do so, providing a safe surgical environment, and using a “surgical conscience” to make decisions. The expert nurse participants in this study advocated for patients in these customary ways but also in another way. Nurse participants described situations in which they accepted responsibility for education of the patient and family members regarding surgery by planning interventions that involved the “big picture” beyond the doors of the OR. These practices were labeled “comprehensive advocacy” because the activities went beyond those required of the perioperative nurse. For example, Ann discussed a situation in which a diabetic patient was being moved from a bed to a stretcher. She described her reaction when she saw that only two people were attempting to move this
Ann considered the patient and his welfare beyond the doors of the OR. She was interested in more than simply the surgical aspects of the patient. Ann understood that injury to the patient’s feet during a transfer could occur and become a major problem. She took personal responsibility to ensure that this patient would be protected from injury during his perioperative experience and immediately intervened when his safety was threatened. Comprehensive advocacy involved truly seeing the big picture beyond the doors of the OR and was linked to a caring attitude. In another example, Ann discussed her role when she discovered during the perioperative interview that the patient could not speak English.
There was a Spanish-speaking patient one day that we were taking back to surgery and . . . she couldn’t understand any of the preop questions. She had a son in there who was interpreting for her, and she would answer [him] and he would give me the answer. . . . The look on her face told you that she was totally scared. . . . So, realizing that this person would not have any way of communicating in the postoperative recovery phase of her care or up on the floor, in the preoperative area we determined certain signs for all the various things that could be a potential problem. . . . So it was a continuum of care from the minute she 58
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made explicit. Storytelling of nurse-patient scenarios involves much more than entertainment for the listener.” In addition to traditional nursing advocacy activities, descriptions of a more comprehensive kind of advocacy with mention of specific patient situations may help improve nursing practice. Further, expert perioperative nurses can use their exemplars to teach through sharing knowledge with peers. Articulating what expert perioperative nurses do and how they do it can be difficult. Exemplars create concrete pictures and reinforce other methods of teaching. These stories convey the “big picture.” They document who we are and the contribution we make to patient outcomes. We need to continue to study, learn, and design our educational programs by observing nursing practice. Additional research conducted with other populations of perioperative nurses will help document nursing practice patterns and eventually provide a pool of accumulated data that clearly links nursing care to patient outcomes. Other research questions that might be helpful include the following. Do different types of nursing models and administrative cultures influence patient outcomes? What type of skill mix provides optimal patient outcomes? What type of skill mix produces the optimal economic outcomes when patient complications are considered? Do perioperative nurse-physician communication patterns influence patient outcomes? Answering these research questions would contribute to data documenting expert perioperative nursing practice and support the need for expert perioperative nurses. The perioperative nurse participants in this study demonstrated an ability to connect with patients and to respond to patient needs in the midst of the highly technological, stressful environment of the OR. These nurses developed this ability only because they were able to transcend task-focused practice. Each of the participants had years of OR experience and considered themselves expert practitioners. Without prior experiences, their ability to see the big picture and thus be able to incorporate caring into highly stressful situations could have been limited. This study begins to reveal the decision-making processes used by expert nurses in the perioperative area and provides a beginning step in documenting the quality of clinical nursing judgment that occurs in the
entered the hospital into the preoperative area to the time she left the hospital two days later. . . . I don’t know where I developed the time to actually plan this woman’s care because she was just the next patient.
In this situation, Ann felt a personal responsibility to intervene in spite of time constraints so that the patient not only would go into surgery with less anxiety but also would be able to have a way to have some autonomy in making her feelings and needs known postoperatively. This nurse recognized a need and took responsibility to advocate in a way that would meet this patient’s needs. AM was able to use hand signals and pictures to extend the voice of her patient and alleviate some of the concerns of this patient and her family members. This expert practice was labeled “comprehensive advocacy.” LIMITATIONS OF THE STUDY
The findings of this study were limited to female Caucasian nurses practicing in an urban area of the southeastern United States. In addition, the sample was small, and data were derived only from experienced nurses. IMPLICATIONS
These data suggest the need for nurses with extensive expertise in perioperative nursing to be readily available in all areas where surgery is performed. Developing nursing expertise in the OR requires extensive experience. Experience in other areas of nursing can facilitate the process of gaining expertise in the OR. Expert nursing skills are not always apparent during routine perioperative care of the patient but can become crucial when the unexpected occurs. Positive patient outcomes depend on the ability of the perioperative nurse to integrate all nursing knowledge, make rapid decisions, and constantly advocate for the patient. These data also suggest that we change our approach to nursing education. First, if nurses need to connect with patients on a person-to-person level to assess and care for them expertly, then students are apt to develop expertise more efficiently if the implications of connecting with patients are described in an explicit way. These data also suggest that nurses and nursing students would benefit if personal patient care experiences were related so that the taken-for-granted knowledge of clinical practice could be examined and caring practices could be 61
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OR. The ability to manage difficult technological situations while simultaneously exhibiting care and concern for patients was associated with the clinical decision-making skills of the expert perioperative nurse.
Ptlene Minick, RN, PhD, is an associate professor, Virginia Commonwealth University. School of Nursing, Richmond.
Despite necessarily brief patient encounters, the ability to make connections was demonstrated. The stories of these perioperative nurses exemplify the critical need for expert care in the midst of the highly technological and demanding environment of the OR. A
Carolyn C . Kee, RN, PhD, is an associate professor. Georgia State University, Atlanta.
Cheryl B. Parker, RN, MSN, is a nurse clinician in the OR, Emory HealthCarelCrawford Long Hospital, Atlanta. NOTES 1. P E Benner, From Novice to Expert: Excellence and Power in Clinical Nursing Practice (Menlo Park, Calif: Addison Wesley Publishing Co, Inc, 1984); P Benner, C A Tanner, C A Chesla, Expertise in Nursing Practice: Caring, Clinical Judgment, and Ethics (New York: Springer Publishing Co, 1996); P Minick, “The power of human caring: Early recognition of patient problems,” Journal of Scholarly Inquiry for Nursing Practice 9 (Winter 1995) 303-317; C A Tanner et al, “The phenomenology of knowing the patient,” IMAGE: Journal of Nursing Scholarship 25 (Winter 1993) 273-280. 2. D W Lener, “Nursing intuition: The deep connection,” in A Global Agenda for Caring, ed D A Gaut (New York: National League for Nursing Press, 1993) 223-240 L Rew, “Intuition in decision-making,’’ IMAGE: Journal of Nursing Scholarship 20 (Fall 1988) 150-154. 3. P E Benner, J Wrubel, The Primacy of Caring: Stress and Coping in Health and Illness (Menlo Park, Calif: Addison Wesley Publishing Co, Inc, 1989); P Minick, “The power of human caring: Early recognition of patient problems,” Journal of Scholarly Inquiryfor Nursing Practice 9 (Winter 1995) 303-314; Tanner et al, ‘‘ The phenomenology of knowing the patient,” 273-280. 4. V D Wagner, C C Kee, D P Gray, ‘‘ A historical decline of educa-
This study was partially funded by the AORN Foundation Degree Completion Grant.
tional perioperative clinical experiences,” AORN Journal 62 (November 1995) 771-782. 5. C A Abbott, “Intraoperative nursing activities performed by surgical technologists,”AORN Journal 60 (September 1994) 382-392. 6. K S Ponder, “The RN circulator,” AORN Journal 60 (September 1994) 459-462. 7. Wagner, Kee, Gray, “A historical decline of educational perioperative clinical experiences,” 771-782. 8. I von Post, “Exploring ethical dilemmas in perioperative nursing practice through critical incidents,” Nursing Ethics 3 (September 1996) 236-249; E C Parsons, C C Kee, P Gray, “Perioperative nurse caring behaviors. Perceptions of surgical patients,” AORN Journal 57 (May 1993) 1106-1114. 9. N L Diekelmann, D Allen, “A hermeneutic analysis of the NLN criteria for the appraisal of baccalaureate programs,” in The NLN Criteria for Appraisal of Baccalaureate Programs: A Critical Hermeneutic Analysis, ed N Diekelmann, D Allen, C Tanner (New York National League for Nursing Press, 1989). 10. Benner, Tanner, Chesla, Expertise in Nursing Practice: Caring, Clinical Judgment, and Ethics. 11. Minick, “The power of human caring: Early recognition of patient problems,” 303-3 17. 12. R C Locsin, “Machine technologies and caring in nursing,” 62 AORN JOURNAL
IMAGE: Journal of Nursing Scholarship 27 (Fall 1995) 201-203. 13. C A Tanner et al, “The phenomenology of knowing the patient,” 273-80. 14. Benner, Wrubel, The Primacy of Caring: Stress and Coping in Health and Illness. 15. R McCorkle, “Effects of touch on seriously ill patients,” Nursing Research 23 (MarcWApril 1974) 125-132. 16. Benner, Tanner, Chesla, Expertise in Nursing Practice: Caring, Clinical Judgment, and Ethics; Parsons, Kee, Gray, “Perioperative nurse caring behaviors. Perceptions of surgical patients,” 1106-1114. 17. Benner, Wrubel, The Primacy of Caring: Stress and Coping in Health and Illness. 18. Benner, Tanner, Chesla, Expertise in Nursing Practice: Caring, Clinical Judgment, and Ethics. 19. Ibid. 20. Ibid. 2 1. Parsons, Kee, Gray, “Perioperative nurse caring behaviors,” 1106-1114. S U G G E S T E D READING Clement, J M. “Touch: Research findings and use in preoperative care.”AORN Journal 45 (June 1987) 1429-1439. Sandelowski, M. “The problem of rigor in qualitative research.” Advances in Nursing Science 8 (April 1986) 27-37.