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Exploratory study of nursing in an operating department: preliminary findings on the role of the nurse
Exploratory study of nursing in an operating department: preliminary findings on the role of the nurse Helen E. McGarvey, Mary G. A. Chambers, Jennifer R. R Boore This study was exploratory and describes how nursing was viewed and practised by nurses who worked in an operating department. It also highlighted factors that might influence the role performance of operating department nurses. The research involved interviews with a sample of 6 nurses working in an operating department, observation of 32 hours of nursing work over 6 operating sessions, in addition to the analysis of various documents, including the nursing care plans of 22 patients. Data were triangulated and analysed by constant comparison.
Dr Helen E. McGarvey RGN, RNT, PGCTHE, DPhil, Research Officer, School of Health SciencesNursing; Professor Mary G. A. Chambers RN, RNT, DPhil, Cert Behavioural Psychotherapy, Professor of Mental Health Nursing, School of Health SciencesNursing; Professor Jennifer R.P. Boore RGN, RM, RNT, PhD, Professor of Nursing, School of Health Sciences Nursing, University of Ulster, Cromore Road, Coleraine, Northern Ireland, BT52 lSA, UK. Tel.: +44 (0) 1265 324362/324286
Findings indicated that nurses had difficulty in articulating exactly what it was that operating department nursing entailed, but rather viewed their role in terms of the functions they performed. Observations indicated that the nursing role was primarily orientated toward the physical rather than the psychological aspects of care-giving. Furthermore, it appeared that the medical profession, nursing philosophy/leadership and the characteristics of patients all influenced the manner in which nurses enacted their role. These findings suggest that further research into the role of the nurse within the operating department environment is warranted. Key factors from this study were developed into a framework suitable for guiding future study of the nursing role in this environment. © 1999 Harcourt Publishers Ltd
Introduction Operating department nursing has been under much scrutiny recently, with financial restrictions on health service spending and developments in the nursing role. However, there is a dearth of research exploring the role of operating department nurses within the context of UK healthcare. This paper reports preliminary research findings on how operating department nursing was described and practised by one particular group of nurses and elucidates a theoretical framework suitable for guiding further research.
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Literature review
Manuscript accepted
Operating department nursing emerged as a distinct specialty at the end of the nineteenth
century (Clemons 1976) and since then has evolved largely in response to medical advancements and developments in surgical technology. As a result, it is now a role which is reported to be complex and, consequently, some believe that this has made it difficult to define (Carrington 1991; West 1993). This is certainly the case in the UK literature, where definitions of operating department nursing are difficult to locate and a clear, all-embracing definition of what operating department nursing entails is notably absent. In contrast, US nurses have made greater strides toward defining the scope of their practice. The Association of Operating Room Nurses (AORN) have defined and clarified their role on a number of occasions (AORN 1969, 1978, 1985, 1993) resulting in usage of the term
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'perioperative nursing' (AORN 1993). This change in terminology reflects the fact that the practice setting of the nurses has shifted from its geographical boundary inside the operating room to a more temporal orientation represented by the division of pre-operative, intra-operative and post-operative nursing. Furthermore, definitions of the role emphasize the nature of perioperative nursing as: ® a science and caring art; ® the creative application of knowledge, skills and interpersonal competencies to provide high-quality, individualized patient care; • the recognition of life-sustaining needs, but also the physiological, psychological, sociocultural and spiritual dimensions of human responses caused by the prospect or performance of an invasive procedure. Inherent in this revised framework for care is the move from nursing-centred activity to patient-centred activity, in addition to a transition from the medical model of illness to a health-wellness model as a basis for nursing. While similar definitions in the UK literature are somewhat elusive, the term 'perioperative" has been adopted for use, first informally (e.g. Frost 1982; Mazza 1985; Brigden 1988; Armitage 1991; McGee 1991) and then on a national level by the National Association of Theatre Nurses in its Strategy for Nursing in the Operating Department (NATN 1991). However, examination of the literature suggests that the term has been interpreted with a high degree of ambiguity and, until such time as clarification emerges, some prefer to retain the term 'operating department nursing' (McGarvey 1998).
Research into operating department nursing Given the difficulty in ascertaining a comprehensive definition of operating department nursing, it was not surprising to discover that a dearth of research exists into the role of nurses in providing care for patients in this particular environment. One of the first studies was carried out in the USA by Grundemann (1970) to determine the functions that operating room nurses were actually performing. She revealed that:
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® patient care activities in the operating room were a higher priority in the minds of nurses, but a combination of activities took higher precedence in their reported actions; • half of the nurses wanted their roles to change, and nearly one-third wanted more involvement with patients. However, since Grundemann did not actually observe nursing practice, her findings must be considered with some caution. Further US research was carried out by Hanson and Nelson (1985) as part of a larger project investigating operating room staffing patterns and costs. They suggested that nurses spent a larger amount of time performing technical functions (55.3%) than they did on assessment and evaluation (14.3%), overseeing and supervision (4.5%) or patient preparation (25.9%). In keeping with the finding of Grundemann (1970), this would suggest that operating department nursing is indeed a strongly technically and procedurally orientated occupation. Additional support for this view was provided in the small amount of UK research available. Roberts (1989) indicated from a questionnaire given to 200 nurses throughout England and Scotland (response rate 73.5%) that the area of care least liked by nurses involved direct communication and care of conscious patients in anaesthetics and recovery (55%). Most nurses preferred to work in the scrub role (61.9%). Johnson (1991a,b) examined the amount of nonnursing activity undertaken by nurses working in the operating department and indicated that nonnursing duties came third, preceded by scrubbing and circulating, respectively. Pre-operative care tasks came fourth. West (1992) conducted a Scottish study which investigated the use of the nursing process in four hospital settings, one of which was the operating theatre. She raised a number of important issues, namely that: • nursing care in more intensive settings tended to be routinized to help staff combat the constantly changing environment and to help to ensure patient well-being by standardizing treatments; • patients were perceived in terms of the physical rather than the psychological care they required;
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• nurses viewed their roles differently, depending on the environment within which they worked. In the context of inside the operating theatre, pre-operative visits and post-operative evaluations were marginal to the immediate tasks relating to the actual process of surgery. Fisher and Peterson (1993) suggested that one of the key factors influencing the role of nurses in the operating department was the medical profession. They collected data over a five-month period using in-depth interviews and participant observation in a private US hospital. Their study revealed some interesting findings in relation to the triadic relationship between doctor, nurse and patient. They suggested that surgeons had ultimate responsibility in the operating room and while nurses did not agree with this, they were powerless to change the situation. Consequently, in an attempt to maintain professional distance in a relationship over which they had no control, staff viewed patients as procedures, rather than as individuals. Ultimately, patient safety and dignity were jeopardized. The small amount of literature available thus indicates that not only do nurses spend a limited amount of time focusing on patient-related activities, but there would also appear to be various contextual influences on the role which they perform. As yet, no study has explored these issues more fully within the bounds of the UK health care system.
Design and methods Design A qualitative approach using ethnographic methods was adopted. This was specifically chosen because Hammersley (1990) suggested that, as an open-ended strategy, it involves the study of people's behaviour in their everyday setting. In the context of this study, this was important for two reasons. Firstly, operating department nursing is a practical discipline and it was felt necessary to explore nursing practice as it actually occurred in its natural environment. Secondly, as little guidance was available prior to the commencement of the research about which concepts to study, this approach would give enough freedom to pursue lines of inquiry as and when they arose.
Methods The three methods of investigation used are characteristic of exploratory research (Lincoln & Guba 1985). These were: • observation of nurses' behaviour as they carried out their daily role; • interview with nurses; • document analysis of nursing careplans and other documents relevant to operating department nursing.
Observational work
Aim of the study Research-based information is necessary as a basis for sound understanding, evaluation and development of any nursing specialty such as operating department nursing. Given the relative lack of previous research in this area, it was felt appropriate to conduct an exploratory study into operating department nursing first before an in-depth study could be carried out. This would then suggest whether further study was indicated. The aim of this exploratory study was therefore to: • describe how operating department nursing was viewed and practised by operating department nurses; and • highlight possible factors which might be influential in the performance of operating department nursing and which might direct and inform future study.
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According to Robson (1993), the directness of watching what people do and listening to what they say is fimdamentally important to real world research. He commented that 'direct observation in the field permits a lack of artificiality which is all too rare with other techniques' (p. 191). Similarly, the impact of observation as a key strategy for data collection has been extolled by many others (Schatzman & Strauss 1973; Hammersley & Atkinson 1983; Bodgan & Taylor 1984; Adler & Adler 1994). The researcher needed the observational strategy to give her opportunity to interact with nursing staff so that issues relating to practice could be discussed as they arose. With reference to Gold's typology (Gold 1958) and the work of Chambers (1994), a modified, interactive version of the observer role was adopted. This allowed the researcher the freedom to collect observational data, yet allowed her to mingle and converse with staff.
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Observational work was conducted over the period of 6 operating lists, totalling 32 hours of fieldwork. These sessions were selected to represent a cross-section of the working week and involved 23 staff: 14 nurses, 6 doctors and 3 technical/support staff. Key words and phrases were recorded in a small notebook which was kept in the researcher's theatre tunic. These notes were elaborated as soon as possible and were written up into a full set of fieldnotes at the end of each day.
° operating list and daily allocation records for each observation session; o the nursing care plan documents in use within this operating department; ® nursing entries on the care plan of each patient who had surgery during the study (n=22). Document review ran concurrently with other methods of data collection.
Access and ethical considerations Interviews Robson (1993) commented that an interview is a kind of conversation which has a specific purpose that of collecting information. A less structured interview format is most suitable when little is known about a subject (Brink 1989; Oppenheim 1992; May 1993; Robson 1993). The aim is to try to understand how ordinary individuals think and feel about the particular topic. For each of the 6 operating lists selected, one key member of staff was identified and interviewed. This nurse was the main provider of nursing care for patients during the operations on that particular list. Grades of nurses were therefore D (n=2), E (n=3) and F (n=l). In total, 5.5 hours of interview data were collected from these 6 nurses. Interviews were tape-recorded with the consent of participants and transcribed by the researcher. Immediately following the interview, reflexive notes were added to the completed report. This allowed the researcher to assess critically her performance during the interview and to keep a check on possible biases. -
Document analysis Document analysis is an unobtrusive method of research that has frequently been used by researchers as a supplement to observation and interviewing (Hammersley & Atkinson 1983; Field & Morse 1985; May 1993). It can provide insight into the understanding of a setting or group and is particularly useful in elucidating the personal values and beliefs, aspirations and intentions of the group or its individual members specific to a particular time-period. Analysis of care plans and other associated nursing records and documents was considered to be an integral and important part of this research. The following documents were reviewed:
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Once ethical approval for the study was granted, access to the site was secured through the appropriate line manager. A series of meetings were held to ensure that consent was given at all levels of the organization. Finally, individual nurses were approached and their approval for participation in the study was given. Ethical principles of informed consent and confidentiality were upheld throughout the study.
Ensuring accurate data Ensuring the accuracy of data is an important aspect of research. Qualitative researchers tend to review a study in terms of its authenticity and trustworthiness. Lincoln and Guba (1985) talked of assessing a study in terms of its credibility, transferability, dependability and confirmability. Typical procedures to ensure trustworthy data, as outlined by Powers and Knapp (1990), were carried out in this study. These included: ® detailed record keeping; • analytical notes accounting for personal actions and subjective thoughts and impressions of the researcher; • multiple approaches to verification of data, e.g. respondent, peer and expert review checks during various stages of the data collection and analysis; • simultaneous collection and analysis of data to examine their adequacy and to correc~ inaccuracies and imbalances. Furthermore, triangulation within method and across methods was used to ensure that data were accurate and free from bias (Denzin 1989).
Analysis of the data The process of data analysis is essentially a synthetic one in which the constructions that
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have emerged and been shaped by inquirer-source interaction are reconstructed into meaningful wholes (Lincoln & Guba 1985). Data analysis imposes order on the large volume of data that have been collected, so conclusions can be drawn and disseminated (Polit & Hungler 1995). In a naturalistic study, the analysis is cyclical and involves the constant interplay between theory, concepts and data (Woods & Catanzano 1987). Firstly, an initial analysis took place daily as the data were being collected. Once the data collection was completed, a more complete analysis took place. This summative analysis then allowed the data to be viewed in the context of the full study. Three phases of data analysis were identified: open coding, axial coding and constant comparison (Strauss 1987; Strauss & Corbin 1990). Initially, data were read and re-read, allowing the researcher to become 'immersed in' the data (Strauss 1987). Codes were allocated to words, phrases and sections of the data and simultaneously these codes were written on the transcript and on a separate index card (open coding). A meeting was then held with an experienced researcher and these codes were discussed. Codes were then compared and grouped. This process of grouping codes into categories is termed axial coding (Strauss & Corbin 1990). As this process developed, comparisons were also made between the concepts within each category and across the categories. Memos were written exploring the links between concepts and becoming increasingly more involved as the analysis progressed. Links were tested using further data to support or refute them. When two or more examples of a linkage were found, the proposition linking them could be accepted. This strategy was similar to that used by Fisher and Peterson (1993). Consistency in the themes generated in the data was verified within each method of collection, and also across the three methods used. This reflected the strategy of triangulation mentioned earlier.
Results and discussion These findings must be considered with recognition of the limitations of a small exploratory study. But they merit consideration since they are thought-provoking and contribute
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to further investigation and understanding of operating department nursing.
Beliefs about operating department nursing Defining role The literature review indicated that a comprehensive UK definition of operating department nursing was lacking. That this was reinforced in the study was therefore not a surprising finding. All of the nurses in the interview sample said that they had difficulty in expressing a clear and concise definition of what operating department nursing entailed. One nurse said nursing was difficult to define because it was done routinely every day and she did not give it much thought, it was an 'automatic role'. Another said it was difficult to define because the activities that nurses did were so varied. However, despite the difficulty in defining their role, there was agreement between nurses that, whatever it was, it was complex and specialized.
Components of operating department nursing Nurses in the study tended to view their role in a pragmatic fashion and, as a result, had no difficulty in describing the various activities that they did. This was consistent with functions outlined in the literature (Warren 1983; Groah 1983; Kneedler & Dodge 1991). The components of nursing in the operating department were related to three spheres of activity: patient, medical and technical elements.
(a) Patient-related elements Part of the nursing role in the operating department was carried out directly in relation to the patient. Such activities included: • • • • •
maintaining safety; monitoring; acting as advocate; protecting the patient's dignity; giving information, comfort and support.
While nurses in the study verbally embraced these functions under the broad notion of 'caring', observations revealed that they were not always easy to carry out in practice. For the most part, the activities nurses performed were
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connected with the physical requirements of surgery, for example, attaching monitors and positioning the patient for surgery. There was little interacting on a psychological basis with patients even when patients showed signs of anxiety or information deficit.
(b) Medically and technically related elements Nurses had a strong role in relation to medical assistance and technical preparation. Both the opinions and actions of nurses reinforced the point that assisting doctors was a key element of the nursing role within the operating department. Typical activities observed included setting out equipment and drugs for doctors and tidying up after doctors, for instance, picking up operating gowns from the floor where medical staff had dropped them. Of the interview sample, two nurses had undertaken the intravenous (IV) additives course. These extended roles were readily accepted by these nurses and viewed as helping the doctors out when they were busy, thereby increasing the rate of patient throughput. However, both nurses only undertook cannulation of patients when under observation by the anaesthetist on duty and did not engage in this role independently. McKee and Lessof (1992) have questioned whether taking on such activities contributes to nursing care. Evidence here would suggest that these roles, in the case of these two nurses, might serve to reinforce the authority which anesthetists had to supervise nurses and little else. The general trend within this unit was that medico-technical activities were popular amongst nurses. Half of the nurses in the interview sample said they preferred the scrub role to the anaesthetic role because of a preference for working with instrumentation. Two could not differentiate between role preferences, and one nurse preferred the anaesthetic role to the scrub role. This was a similar finding to that reported by Roberts (1989).
The nurse-patient relationship The nurse-patient relationship has been purported in the literature to be the central tenet of nursing (Henderson 1966; Altschul 1972; Wright 1989; Ersser 1998). However, this study
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a. During interviews, nurses had emphasized the importance of their relationships with patients, therefore it was expected that their actions would reflect this. This was not the case observed in their practice. b. Nurses said that intensity of interaction with patients depended on the time available. Data revealed even when the preoperative time stretched up to 40 minutes, nurses did not engage in interpersonal nursing with patients. Many opportunities for interactions were not seized. In fact, it appeared from observations made in this study that the longer a nurse spent with a patient, the less she interacted. Interestingly, interpersonal communication with patients did not feature highly in the past education of these particular nurses. Teaching and learning was reported to focus more on procedural and technical aspects of their role.
Medical influence on nurse-patient interaction
Caring for patients
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highlighted that, although the nurse-patient relationship was recognized by nurses as being of great importance, it was not a central feature of operating department nursing. For example, two nurses believed that patients were important because otherwise nurses would not have a job. One nurse spoke of meeting patients' needs with regards to 'drips and drugs', others gave a more enlightened image of activities like 'caring', 'comforting', 'reassuring', 'being there', and 'acting as advocate'. In practice, the actual relationship which nurses had with conscious patients was brief. This was not unanticipated, given the transitory nature of each individual patient's passage through the operating department. The time nurses spent with conscious patients prior to their anaesthetic ranged from 5 to 40 minutes (with an average of 12 minutes). The length of time that a nurse spent in the anaesthetic room with a preoperative patient appeared to have no bearing on the depth of that relationship. This was a surprising outcome for two reasons:
Another factor that affected the degree to which nurses interacted with patients seemed to be related to which anaesthetist was present. One anaesthetist adopted a particularly technical approach to his work and did not speak to patients much except to give them rather abrupt
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commands, such as 'move your hand', 'don't move', or "look the other way'. When working with this doctor, nurses did not talk to the patient either, even when they were not actually engaged in medical tasks. The available time they spent watching him as he worked and listening to him as he explained to them in medical language what he was doing. These findings gave support to the research of Fisher and Peterson (1993) who remarked on the highly influential position of the medical staff in affecting the quality of nursing care given to patients.
Barriers to communication: the disempowerment of patients Within the context of the nurse-patient relationship, various other barriers to interaction were apparent. Nurses said that they preferred to wear facemasks to protect themselves from patient secretions. In fact, the wearing of masks was observed to inhibit the interactions between nurses and patients. Masks decreased the audibility of nurses. Patients were frequently observed to indicate that they had not heard what nurses had said to them. Fox (1992) asserted that the actual wearing of the facemask as part of operating department uniform was concerned with power rather than cleanliness. He stated that masks were an indicator of the authority to perform surgery and was therefore a sign of role legitimacy, rather than a means of infection control. Staff in this department suggested that continual mask wearing was the result of tradition. It was not seen as a barrier to communication, but rather as a barrier to protect nurses from patients, for instance if blood or body fluids should spurt from a patient. In effect, it was observed to reinforce the disempowement of patients by constituting a barrier to communication between patients and nurses. Nurses generally did not introduce themselves to patients and did not wear name badges, therefore it was left to patients to assume that females were nurses and males were doctors. This was apparent when one patient asked an operating department assistant if he was going to be doing the operation and another patient asked the female anaesthetist how long she had been a nurse only for her to reply indignantly, 'Oh I'm not a nurse, I'm the doctor!'. Again, this indicated how some staff had the ability to disempower patients by keeping their identities hidden.
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The fact that patients had been asked to remove their glasses, hearing aids and false teeth before coming to the operating department was a clear inhibitor to communication. Similarly, the fact that patients were placed in the horizontal position immediately upon entering the anaesthetic room meant that they could not interact with nurses face-to-face. Instead, nurses assumed a superior position looking down over patients. Various patients indicated that they could not see without their glasses, could not hear without their hearing aids, and held tissues up to their mouth apologizing for not having their teeth in. The possibility of removing these prostheses in the anaesthetic room immediately prior to the induction of anaesthesia had not been considered by nursing staff, even though such ritualistic preparation of patients for surgery has received harsh criticism (Walsh & Ford 1989). Changing the pre-operative routine would firstly have meant a break with tradition. Secondly, it would have increased the responsibility of nursing staff to ensure that loss or damage did not occur while the patient was in surgery. Adherence to such practices has been indicative in the past of methods by which staff cope with the intense role demands placed upon them (Menzies 1970; Chapman 1983; Bailey 1985).
Perceptions about patients 'Good' patients Nurses indicated that there were certain patients they considered to be 'good'. For example, 'good' patients made a quick recovery, did not get upset in the anaesthetic room, or ask too many questions. That was not to say that patients who did not conform to treatment expectations were 'bad', but rather gave an indication that "good' patients were those who did not make any great demands on nursing time or skill. Findings in relation to patients who are perceived as popular or unpopular are not new (Stockwell 1972). However, it was interesting to note that in the operating department nurses also have a tendency to make value judgements about patients. In Stockwell's study, it was discovered that least nursing attention was directed at those who were neither popular or unpopular. Patient popularity was not gauged the same way in this study. Instead, it emerged that nurses were more likely to interact with patients who were 'safe', i.e. those patients who were having routine
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surgery, did not have cancer, and were not openly anxious. Nurses also reacted more intensely to those patients who themselves initiated the interactions, rather than those who were quieter. The inherent danger in this practice was the risk that quieter patients w h o were perhaps internally more anxious and feeling more vulnerable, were those at w h o m nurses did not direct nursing action.
focused on ensuring the physical safety of the patient rather than having any intended psychological impact. Therefore, the emergent nursing philosophy was medical and technical, governed and influenced by the needs of the medical profession within the situational restraints presented b y a complex environment. Nurses practised without any clear nursing leadership.
Patient vulnerability
The nursing process
Not all patients recognized the consultant surgeon or anaesthetist who was to perform their anaesthetic or surgery. One patient asked a nurse 'was that Mr X?' [the consultant surgeon], after he had exposed her breasts without consent, briefly p r o d d e d her and then disappeared. Consequently, patients placed implicit trust that all individuals who examined them were appropriately qualified and had legitimate access to the environment. Moreover, it was also apparent that not all patients were aware of who was actually going to be doing their surgery. Patients asked, 'What is the surgeon's name?' indicating that they were unaware as to who was going to be performing their surgery. The fact that patients were physically and emotionally exposed to a considerable n u m b e r of nameless people indicated not only the trust which patients placed in operating department staff, but also the vulnerability they were experiencing in the patient role. Yet, this did not seem to be of particular concern to nurses, despite the stress they placed on their role as a key cater for patients.
Nursing care in the operating department was guided by the nursing process, using a framework which was outlined on the patient documentation. This comprised a preoperative checklist that did not embrace any recognizable model of nursing. References to care-planning revealed that nurses did not view care to be any better as a result of using documentation their way. Given the inadequacies and ambiguities in the documentation, this was not surprising. Nurses stated that they had always performed the particular actions a n y w a y regardless having to record them. Therefore, nursing care was automatic rather than individualistic. Some of the entries were ticked as a matter of routine, rather than forming part of a more comprehensive nursing assessment. For instance, the entry on skin condition and pressure sores was frequently ticked without a nurse asking or examining them.
Care philosophy In the initial stages of this study, it was difficult to gauge the extent of the nursing philosophy in this site because while nurses said the focus of their day was the patients, their actions were not commensurate with this. This presented a confusing paradox because the majority of activities in which nurses engaged were connected to functions other than direct patient care activities. As was seen earlier, the nurse-patient relationship was short and superficial and so in itself could not be described as close, meaningful or therapeutic. There was no clear philosophy of nursing within the unit. Patient-related activities that were carried out
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Preoperative visiting Preoperative visiting was seen as an important part of the nursing role. However, it was intensely problematic in practice. All nurses commented on how difficult it was to fit preoperative visits into the routine of the working day. No pre-operative visits were carried out during the observational work as staff reported that they were too busy. Observations concurred with this. However, it was evident that m u c h effort was spent cleaning and tidying inside the operating department, thus suggesting that insufficient time was perhaps an excuse for not engaging in nurse-patient interaction. In the absence of pre-operative visits, it was difficult to gauge h o w nurses did manage to assess patients' needs with any degree of accuracy. No obvious patient assessment was carried out in the anaesthetic room prior to the induction of anaesthesia since nurses did not
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spend any significant time interacting with patients. Consequently, nursing actions that were carried out were done in accordance with the checklist rather than a nursing process philosophy.
Role performance
Development of a theoretical framework As well as describing how operating department nursing was viewed and practised by nurses, the exploratory work was carried out with the purpose of highlighting possible factors that might be influential in the performance of operating department nursing and that might direct and inform future study. From the data obtained in this study and from the limited amount of literature available, a theoretical framework was developed to represent the role performance of operating department nurses. The framework, illustrated in Figure 1, was generated from three key interrelated themes: nurses themselves; the context within which they work; and the resultant performance of their role. A number of concepts inherent within the overall framework also emerged as a result of the exploratory work. These provided tangible concepts that were instrumental in guiding the main phase of the research (McGarvey 1998), and are represented in Table 1. Given the lack of previous research into operating department nursing, this framework Table 1
Context
•
IL N u d e s
Fig. 1 Theoretical f r a m e w o r k f o r role per f o r m a n c e o f o p e r a t i n g d e p a r t m e n t nurses.
represents work at an early stage of development. Nevertheless, it provides a logical first step and structure upon which to develop further research into the role performance of operating department nurses within the context of modern health care.
Conclusions There were several issues that emerged in relation to nursing in the operating department as a result of this exploratory study. Firstly, nurses viewed operating department nursing in terms of the functions they performed. However, they had difficulty in articulating exactly what it was that nursing in the operating department entailed. Operating department nursing was seen as being complex, but nurses could give no
Key dimensions o f o p e r a t i n g d e p a r t m e n t nursing
Characteristics of nurses
Context
Role performance
• Personal characteristics
• Physical c o n t e x t
• Socialization into role
• Expectations and beliefs a b o u t t h e i r role
• Atmosphere
• N u r s e - p a t i e n t relationships
• Beliefs a b o u t patients
• O r gani zat i onal structure
• Nursing process
• Reasons f o r choosing this w o r k
• D o c t o r - n u r s e relationships
• Pre-operative visiting
• Personal-occupational conflicts
• Relationships w i t h wards
• Named nursing
• Educational p r e p a r a t i o n
• Support staff
• Non-nursing duties
• Ethos f o r care
• M o n i t o r i n g per f orm a n c e
• Role stability
• Accountability
• Technology
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further comprehensive or theoretical elaboration on that. Furthermore, nurses practised nursing in different ways. Half of the sample preferred to work with technology and medical staff than to spend time in the anaesthetic room with patients. Only one nurse out of the six had a clear preference for working in the anaesthetic room. For the most part, nurse-patient relationships were brief and focused on the routine physical care of patients rather than on identifying and dealing with any psychological needs they might have had. This was commensurate with the literature. Previous education of nurses tended to support this medical and technical focus of behaviour. Furthermore, it was evident that the manner in which nurses practised their role in this particular site was influenced by the context within which they worked. Inherent in the concept of context were factors such as: the effect of the medical profession, the absence of a nursing philosophy or leadership and mechanisms available for providing nursing care, and the characteristics of individual patients.
Limitations of the study It is accepted that this study was small in size and exploratory in nature. Consequently no generalizations can be made from the findings reported here. In addition, the qualitative focus of the study means that the study is more concerned with theory generation than testing. Attempts to ensure trustworthy data were made; however, relying on h u m a n involvement in this type of study means that bias must always be considered as a limitation. It is also accepted that the theoretical framework that emerged from this preliminary work now requires rigorous testing before it can be further endorsed as contributing to a theory of operating department nursing. Nevertheless, in the relative absence of other research into nursing in the operating department within the UK, this study has provided a tangible starting point from which more in-depth research can be undertaken. This study and that which followed it (McGarvey 1998) have provided key concepts and possible relationships relating to nursing within the operating department. Exploring, testing and validating such relationships in more depth and by quantitative means is the basis for the future practice of operating department nurses.
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Recommendations for further research It is suggested that further research into the role of nurses in operating departments is therefore crucial to the development of an efficient and effective service. Firstly, it is necessary to examine what exactly is the contribution of operating department nurses to patient care in the perioperative period. As yet, this has to be evaluated critically. This study suggested that nursing activity concentrates mainly on the physical aspects of care. Indeed, this is an important element in an environment where patient safety is critical. However, as Martin (1996) has indicated, it may be that nurses working in the operating department can also make a contribution to care in terms of improved patient outcomes by using psychological interventions, like decreasing post-operative pain through information given during pre-operative visits. Such interventions require deeper investigation. Secondly, research is needed to examine, in a more penetrating way, the factors that influence and inhibit the enactment of sound nursing practice. It emerged in this study that various factors affected the way nurses performed their role. Further examination of these issues could enlighten the future practice of nurses so that therapeutic practices could not only be identified, but also facilitated. There is no doubt that the experience of patients undergoing surgery is a difficult one, fraught with both tension and emotion. The challenge for nurses, particularly those working in the treatment intensive arena of the operating department, is to address how this experience might best be managed to yield positive outcomes,
Acknowledgements The author would like to acknowledge the following sources of funding: National Association of Theatre Nurses; Association of Operating Room Nurses; Northern Board Nurses Research Forum.
References Adler P A, Adler P A 1994 Observational Techniques. In: Denzin N K, Lincoln Y S (eds) Handbook of Qualitative Research. London: Sage
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Altschul A 1972 Patient-Nurse Interaction: A Study of Interaction Patterns in Acute Psychiatric Wards. Edinburgh: Churchill Livingstone Armitage S 1991 Perioperative care of the ear, nose and throat patient. British Journal of Theatre Nursing 1(4):16-17 Association of Operating Room Nurses 1969 Definition and objective for clinical practice of professional operating room nursing. AORN Journal 10:43-47, Nov Association of Operating Room Nurses 1978 Operating room nursing: perioperative role. AORN Journal 27(6):1156-1175 Association of Operating Room Nurses 1985 A model for perioperative nursing practice. AORN Journal 41(1):188-193 Association of Operating Room Nurses 1993 Project 2000 final report: a work plan for the future. AORN Journal 57(1):54-77 Bailey R D 1985 Coping with Stress in Caring. Oxford: Blackwell Scientific Bogdan R, Taylor S 1984 Introduction to Qualitative Research Methods, 2rid edn. New York: John Wiley and Sons Brigden R J 1988 Operating Theatre Technique 5th edn. Edinburgh: Churchill Livingstone Brink P J 1989 Exploratory Designs. In: Brink P J, Wood M J (eds) Advanced Design in Nursing Research. London: Sage Carrington A C 1991 Theatre nursing as a profession. British Journal of Theatre Nursing 1(1):5-7, 26 Chambers M G A 1994 Learning Psychiatric Skills: The Contribution of the Ward Environment. University of Ulster, Coleraine: Unpublished DPhil thesis Chapman G 1983 Ritual and rational action in hospitals. Journal of Advanced Nursing 1:13-20 Clemons B 1976 Lister's day in America. AORN Journal 24(1):43-51 Denzin N K 1989 The Research Act, 3rd edn New York: McGraw Hill Ersser S 1998 A search for the therapeutic dimensions of nurse-patient interaction. In: McMahon R, Pearson A (eds) Nursing as Therapy, 2nd edn Cheltenham: Stanley Thornes Publishers Field P A, Morse J M 1985 Nursing Research: The Application of Qualitative Approaches. London: Croom Helm Fisher B J, Peterson C 1993 She won't be dancing much anyway: a study of surgeons, surgical nurses and elderly patients. Qualitative Health Research 3(2):165-183 Fox N J 1992 The Social Meaning of Surgery. Buckingham: Open University Press Frost A 1982 The role of the theatre nurse within the surgical team. British Journal of Theatre Nursing 19(7):25-26, 28 Gold R L 1958 Roles in sociological field observation. Social Forces 26(3):217-223 Groah L 1983 Operating Room Nursing. Reston, Virginia: Reston Publishing Grundemann B J 1970 Analysis of the role of the professional staff nurse in the operating room. Nursing Research 19(4):349-353 Hammersely M 1990 Reading Ethnographic Research. London: Longman
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Hammersely M, Atkinson P 1983 Ethnography: Principles in Practice. London: Routledge Hanson R L, Nelson A H 1985 OR personnel functions: testing of observability. AORN Journal 42 (3):376-387 Henderson V 1966 The Nature of Nursing. London: MacMillan Johnson G 1991a Non-nursing duties in theatre. Part 1. British Journal of Theatre Nursing I (3):24-25 Johnson G 1991b Non-nursing duties in theatre. Part 2. British Journal of Theatre Nursing 1(4):20-22 Kneedler J A, Dodge G H 1991 Perioperative Patient Care, 2nd edn. Boston: Jones and Bartlett Lincoln Y S, Guba E G 1985 Naturalistic Inquiry. London: Sage Martin D 1996 Pre-operative visits to reduce patient anxiety: a study. Nursing Standard 10(23):33-38 May T 1993 Social Research. Milton Keynes: Open University Press Mazza J 1985 The perioperative role of the OR nurse. NATNews March, pp 13-16 McGarvey H E 1998 Nursing in the operating department: investigating the role of the nurse. University of Ulster, Unpublished DPhil thesis McGee P 1991 Perioperative nursing: a review of the literature. British Journal of Theatre Nursing 1(7):12-17 McKee M, Lessof L 1992 Nurse and doctor: whose task is it anyway? In: Robinson J, Gray A, Elkin R (eds) Policy Issues in Nursing. Milton Keynes: Open University Press Menzies I E P 1970 The Functioning of Social Systems as a Defence Against Anxiety. London: Tavistock Institute for Human Relations National Association of Theatre Nurses 1991 A Strategy for Nursing in the Operating Department. Harrogate: NATN Oppenheim A N 1992 Questionnaire Design, Interviewing and Attitude Measurement. London: Pinter Publishers Polit D F, Hungler B P 1995 Nursing Research: Principles and Methods (5th edn) Philadelphia: J B Lippincott Powers B A, Knapp T R 1990 A Dictionary of Nursing Theory and Research. London: Sage Roberts S 1989 Going, going, gone? Nursing Times 85(40):61-65 Robson C 1993 Real World Research. Oxford: Blackwell Schatzman L, Strauss A 1973 Field Research. Englewood Cliffs, New Jersey: Prentice Hall Stockwell F 1972 The Unpopular Patient. London: Royal College of Nursing Strauss A L 1987 Qualitative Analysis for Social Scientists. Cambridge: Cambridge University Press Strauss A L, Corbin J 1990 Basics of Qualitative Research. London: Sage Walsh M, Ford P 1989 Nursing Rituals, Research and Rational Actions. Oxford: Heinemann Warren M 1983 Operating Theatre Nursing. London: Harper and Row West B J M 1993 Caring: the essence of theatre nursing. British Journal of Theatre Nursing 3(9):16-22 West B J M 1992 Nurses' perceptions of patients in the nursing process: a study of 2 cardiothoracic units. Unpublished PhD thesis, University of Edinburgh Woods N F, Catanzano M 1988 Nursing Research: Theory and Practice. St Louis: C V Mosby Wright S G 1989 My Patient-My Nurse: Primary Nursing in Practice. London: Scutari
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Dr Helen E. McGarvey RGN, RNT, PGCTHE, DPhil, Research Officer, School of Health SciencesNursing; Professor Mary G. A. Chambers RN, RNT, DPhil, Cert Behavioural Psychotherapy, Professor of Mental Health Nursing, School of Health SciencesNursing; Professor Jennifer R.P. Boore RGN, RM, RNT, PhD, Professor of Nursing, School of Health Sciences Nursing, University of Ulster, Cromore Road, Coleraine, Northern Ireland, BT52 lSA, UK. Tel.: +44 (0) 1265 324362/324286
Findings indicated that nurses had difficulty in articulating exactly what it was that operating department nursing entailed, but rather viewed their role in terms of the functions they performed. Observations indicated that the nursing role was primarily orientated toward the physical rather than the psychological aspects of care-giving. Furthermore, it appeared that the medical profession, nursing philosophy/leadership and the characteristics of patients all influenced the manner in which nurses enacted their role. These findings suggest that further research into the role of the nurse within the operating department environment is warranted. Key factors from this study were developed into a framework suitable for guiding future study of the nursing role in this environment. © 1999 Harcourt Publishers Ltd
Introduction Operating department nursing has been under much scrutiny recently, with financial restrictions on health service spending and developments in the nursing role. However, there is a dearth of research exploring the role of operating department nurses within the context of UK healthcare. This paper reports preliminary research findings on how operating department nursing was described and practised by one particular group of nurses and elucidates a theoretical framework suitable for guiding further research.
(Requests for offprints to HEMcG)
Literature review
Manuscript accepted
Operating department nursing emerged as a distinct specialty at the end of the nineteenth
century (Clemons 1976) and since then has evolved largely in response to medical advancements and developments in surgical technology. As a result, it is now a role which is reported to be complex and, consequently, some believe that this has made it difficult to define (Carrington 1991; West 1993). This is certainly the case in the UK literature, where definitions of operating department nursing are difficult to locate and a clear, all-embracing definition of what operating department nursing entails is notably absent. In contrast, US nurses have made greater strides toward defining the scope of their practice. The Association of Operating Room Nurses (AORN) have defined and clarified their role on a number of occasions (AORN 1969, 1978, 1985, 1993) resulting in usage of the term
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'perioperative nursing' (AORN 1993). This change in terminology reflects the fact that the practice setting of the nurses has shifted from its geographical boundary inside the operating room to a more temporal orientation represented by the division of pre-operative, intra-operative and post-operative nursing. Furthermore, definitions of the role emphasize the nature of perioperative nursing as: ® a science and caring art; ® the creative application of knowledge, skills and interpersonal competencies to provide high-quality, individualized patient care; • the recognition of life-sustaining needs, but also the physiological, psychological, sociocultural and spiritual dimensions of human responses caused by the prospect or performance of an invasive procedure. Inherent in this revised framework for care is the move from nursing-centred activity to patient-centred activity, in addition to a transition from the medical model of illness to a health-wellness model as a basis for nursing. While similar definitions in the UK literature are somewhat elusive, the term 'perioperative" has been adopted for use, first informally (e.g. Frost 1982; Mazza 1985; Brigden 1988; Armitage 1991; McGee 1991) and then on a national level by the National Association of Theatre Nurses in its Strategy for Nursing in the Operating Department (NATN 1991). However, examination of the literature suggests that the term has been interpreted with a high degree of ambiguity and, until such time as clarification emerges, some prefer to retain the term 'operating department nursing' (McGarvey 1998).
Research into operating department nursing Given the difficulty in ascertaining a comprehensive definition of operating department nursing, it was not surprising to discover that a dearth of research exists into the role of nurses in providing care for patients in this particular environment. One of the first studies was carried out in the USA by Grundemann (1970) to determine the functions that operating room nurses were actually performing. She revealed that:
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® patient care activities in the operating room were a higher priority in the minds of nurses, but a combination of activities took higher precedence in their reported actions; • half of the nurses wanted their roles to change, and nearly one-third wanted more involvement with patients. However, since Grundemann did not actually observe nursing practice, her findings must be considered with some caution. Further US research was carried out by Hanson and Nelson (1985) as part of a larger project investigating operating room staffing patterns and costs. They suggested that nurses spent a larger amount of time performing technical functions (55.3%) than they did on assessment and evaluation (14.3%), overseeing and supervision (4.5%) or patient preparation (25.9%). In keeping with the finding of Grundemann (1970), this would suggest that operating department nursing is indeed a strongly technically and procedurally orientated occupation. Additional support for this view was provided in the small amount of UK research available. Roberts (1989) indicated from a questionnaire given to 200 nurses throughout England and Scotland (response rate 73.5%) that the area of care least liked by nurses involved direct communication and care of conscious patients in anaesthetics and recovery (55%). Most nurses preferred to work in the scrub role (61.9%). Johnson (1991a,b) examined the amount of nonnursing activity undertaken by nurses working in the operating department and indicated that nonnursing duties came third, preceded by scrubbing and circulating, respectively. Pre-operative care tasks came fourth. West (1992) conducted a Scottish study which investigated the use of the nursing process in four hospital settings, one of which was the operating theatre. She raised a number of important issues, namely that: • nursing care in more intensive settings tended to be routinized to help staff combat the constantly changing environment and to help to ensure patient well-being by standardizing treatments; • patients were perceived in terms of the physical rather than the psychological care they required;
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• nurses viewed their roles differently, depending on the environment within which they worked. In the context of inside the operating theatre, pre-operative visits and post-operative evaluations were marginal to the immediate tasks relating to the actual process of surgery. Fisher and Peterson (1993) suggested that one of the key factors influencing the role of nurses in the operating department was the medical profession. They collected data over a five-month period using in-depth interviews and participant observation in a private US hospital. Their study revealed some interesting findings in relation to the triadic relationship between doctor, nurse and patient. They suggested that surgeons had ultimate responsibility in the operating room and while nurses did not agree with this, they were powerless to change the situation. Consequently, in an attempt to maintain professional distance in a relationship over which they had no control, staff viewed patients as procedures, rather than as individuals. Ultimately, patient safety and dignity were jeopardized. The small amount of literature available thus indicates that not only do nurses spend a limited amount of time focusing on patient-related activities, but there would also appear to be various contextual influences on the role which they perform. As yet, no study has explored these issues more fully within the bounds of the UK health care system.
Design and methods Design A qualitative approach using ethnographic methods was adopted. This was specifically chosen because Hammersley (1990) suggested that, as an open-ended strategy, it involves the study of people's behaviour in their everyday setting. In the context of this study, this was important for two reasons. Firstly, operating department nursing is a practical discipline and it was felt necessary to explore nursing practice as it actually occurred in its natural environment. Secondly, as little guidance was available prior to the commencement of the research about which concepts to study, this approach would give enough freedom to pursue lines of inquiry as and when they arose.
Methods The three methods of investigation used are characteristic of exploratory research (Lincoln & Guba 1985). These were: • observation of nurses' behaviour as they carried out their daily role; • interview with nurses; • document analysis of nursing careplans and other documents relevant to operating department nursing.
Observational work
Aim of the study Research-based information is necessary as a basis for sound understanding, evaluation and development of any nursing specialty such as operating department nursing. Given the relative lack of previous research in this area, it was felt appropriate to conduct an exploratory study into operating department nursing first before an in-depth study could be carried out. This would then suggest whether further study was indicated. The aim of this exploratory study was therefore to: • describe how operating department nursing was viewed and practised by operating department nurses; and • highlight possible factors which might be influential in the performance of operating department nursing and which might direct and inform future study.
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According to Robson (1993), the directness of watching what people do and listening to what they say is fimdamentally important to real world research. He commented that 'direct observation in the field permits a lack of artificiality which is all too rare with other techniques' (p. 191). Similarly, the impact of observation as a key strategy for data collection has been extolled by many others (Schatzman & Strauss 1973; Hammersley & Atkinson 1983; Bodgan & Taylor 1984; Adler & Adler 1994). The researcher needed the observational strategy to give her opportunity to interact with nursing staff so that issues relating to practice could be discussed as they arose. With reference to Gold's typology (Gold 1958) and the work of Chambers (1994), a modified, interactive version of the observer role was adopted. This allowed the researcher the freedom to collect observational data, yet allowed her to mingle and converse with staff.
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Observational work was conducted over the period of 6 operating lists, totalling 32 hours of fieldwork. These sessions were selected to represent a cross-section of the working week and involved 23 staff: 14 nurses, 6 doctors and 3 technical/support staff. Key words and phrases were recorded in a small notebook which was kept in the researcher's theatre tunic. These notes were elaborated as soon as possible and were written up into a full set of fieldnotes at the end of each day.
° operating list and daily allocation records for each observation session; o the nursing care plan documents in use within this operating department; ® nursing entries on the care plan of each patient who had surgery during the study (n=22). Document review ran concurrently with other methods of data collection.
Access and ethical considerations Interviews Robson (1993) commented that an interview is a kind of conversation which has a specific purpose that of collecting information. A less structured interview format is most suitable when little is known about a subject (Brink 1989; Oppenheim 1992; May 1993; Robson 1993). The aim is to try to understand how ordinary individuals think and feel about the particular topic. For each of the 6 operating lists selected, one key member of staff was identified and interviewed. This nurse was the main provider of nursing care for patients during the operations on that particular list. Grades of nurses were therefore D (n=2), E (n=3) and F (n=l). In total, 5.5 hours of interview data were collected from these 6 nurses. Interviews were tape-recorded with the consent of participants and transcribed by the researcher. Immediately following the interview, reflexive notes were added to the completed report. This allowed the researcher to assess critically her performance during the interview and to keep a check on possible biases. -
Document analysis Document analysis is an unobtrusive method of research that has frequently been used by researchers as a supplement to observation and interviewing (Hammersley & Atkinson 1983; Field & Morse 1985; May 1993). It can provide insight into the understanding of a setting or group and is particularly useful in elucidating the personal values and beliefs, aspirations and intentions of the group or its individual members specific to a particular time-period. Analysis of care plans and other associated nursing records and documents was considered to be an integral and important part of this research. The following documents were reviewed:
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Once ethical approval for the study was granted, access to the site was secured through the appropriate line manager. A series of meetings were held to ensure that consent was given at all levels of the organization. Finally, individual nurses were approached and their approval for participation in the study was given. Ethical principles of informed consent and confidentiality were upheld throughout the study.
Ensuring accurate data Ensuring the accuracy of data is an important aspect of research. Qualitative researchers tend to review a study in terms of its authenticity and trustworthiness. Lincoln and Guba (1985) talked of assessing a study in terms of its credibility, transferability, dependability and confirmability. Typical procedures to ensure trustworthy data, as outlined by Powers and Knapp (1990), were carried out in this study. These included: ® detailed record keeping; • analytical notes accounting for personal actions and subjective thoughts and impressions of the researcher; • multiple approaches to verification of data, e.g. respondent, peer and expert review checks during various stages of the data collection and analysis; • simultaneous collection and analysis of data to examine their adequacy and to correc~ inaccuracies and imbalances. Furthermore, triangulation within method and across methods was used to ensure that data were accurate and free from bias (Denzin 1989).
Analysis of the data The process of data analysis is essentially a synthetic one in which the constructions that
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have emerged and been shaped by inquirer-source interaction are reconstructed into meaningful wholes (Lincoln & Guba 1985). Data analysis imposes order on the large volume of data that have been collected, so conclusions can be drawn and disseminated (Polit & Hungler 1995). In a naturalistic study, the analysis is cyclical and involves the constant interplay between theory, concepts and data (Woods & Catanzano 1987). Firstly, an initial analysis took place daily as the data were being collected. Once the data collection was completed, a more complete analysis took place. This summative analysis then allowed the data to be viewed in the context of the full study. Three phases of data analysis were identified: open coding, axial coding and constant comparison (Strauss 1987; Strauss & Corbin 1990). Initially, data were read and re-read, allowing the researcher to become 'immersed in' the data (Strauss 1987). Codes were allocated to words, phrases and sections of the data and simultaneously these codes were written on the transcript and on a separate index card (open coding). A meeting was then held with an experienced researcher and these codes were discussed. Codes were then compared and grouped. This process of grouping codes into categories is termed axial coding (Strauss & Corbin 1990). As this process developed, comparisons were also made between the concepts within each category and across the categories. Memos were written exploring the links between concepts and becoming increasingly more involved as the analysis progressed. Links were tested using further data to support or refute them. When two or more examples of a linkage were found, the proposition linking them could be accepted. This strategy was similar to that used by Fisher and Peterson (1993). Consistency in the themes generated in the data was verified within each method of collection, and also across the three methods used. This reflected the strategy of triangulation mentioned earlier.
Results and discussion These findings must be considered with recognition of the limitations of a small exploratory study. But they merit consideration since they are thought-provoking and contribute
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to further investigation and understanding of operating department nursing.
Beliefs about operating department nursing Defining role The literature review indicated that a comprehensive UK definition of operating department nursing was lacking. That this was reinforced in the study was therefore not a surprising finding. All of the nurses in the interview sample said that they had difficulty in expressing a clear and concise definition of what operating department nursing entailed. One nurse said nursing was difficult to define because it was done routinely every day and she did not give it much thought, it was an 'automatic role'. Another said it was difficult to define because the activities that nurses did were so varied. However, despite the difficulty in defining their role, there was agreement between nurses that, whatever it was, it was complex and specialized.
Components of operating department nursing Nurses in the study tended to view their role in a pragmatic fashion and, as a result, had no difficulty in describing the various activities that they did. This was consistent with functions outlined in the literature (Warren 1983; Groah 1983; Kneedler & Dodge 1991). The components of nursing in the operating department were related to three spheres of activity: patient, medical and technical elements.
(a) Patient-related elements Part of the nursing role in the operating department was carried out directly in relation to the patient. Such activities included: • • • • •
maintaining safety; monitoring; acting as advocate; protecting the patient's dignity; giving information, comfort and support.
While nurses in the study verbally embraced these functions under the broad notion of 'caring', observations revealed that they were not always easy to carry out in practice. For the most part, the activities nurses performed were
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connected with the physical requirements of surgery, for example, attaching monitors and positioning the patient for surgery. There was little interacting on a psychological basis with patients even when patients showed signs of anxiety or information deficit.
(b) Medically and technically related elements Nurses had a strong role in relation to medical assistance and technical preparation. Both the opinions and actions of nurses reinforced the point that assisting doctors was a key element of the nursing role within the operating department. Typical activities observed included setting out equipment and drugs for doctors and tidying up after doctors, for instance, picking up operating gowns from the floor where medical staff had dropped them. Of the interview sample, two nurses had undertaken the intravenous (IV) additives course. These extended roles were readily accepted by these nurses and viewed as helping the doctors out when they were busy, thereby increasing the rate of patient throughput. However, both nurses only undertook cannulation of patients when under observation by the anaesthetist on duty and did not engage in this role independently. McKee and Lessof (1992) have questioned whether taking on such activities contributes to nursing care. Evidence here would suggest that these roles, in the case of these two nurses, might serve to reinforce the authority which anesthetists had to supervise nurses and little else. The general trend within this unit was that medico-technical activities were popular amongst nurses. Half of the nurses in the interview sample said they preferred the scrub role to the anaesthetic role because of a preference for working with instrumentation. Two could not differentiate between role preferences, and one nurse preferred the anaesthetic role to the scrub role. This was a similar finding to that reported by Roberts (1989).
The nurse-patient relationship The nurse-patient relationship has been purported in the literature to be the central tenet of nursing (Henderson 1966; Altschul 1972; Wright 1989; Ersser 1998). However, this study
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a. During interviews, nurses had emphasized the importance of their relationships with patients, therefore it was expected that their actions would reflect this. This was not the case observed in their practice. b. Nurses said that intensity of interaction with patients depended on the time available. Data revealed even when the preoperative time stretched up to 40 minutes, nurses did not engage in interpersonal nursing with patients. Many opportunities for interactions were not seized. In fact, it appeared from observations made in this study that the longer a nurse spent with a patient, the less she interacted. Interestingly, interpersonal communication with patients did not feature highly in the past education of these particular nurses. Teaching and learning was reported to focus more on procedural and technical aspects of their role.
Medical influence on nurse-patient interaction
Caring for patients
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highlighted that, although the nurse-patient relationship was recognized by nurses as being of great importance, it was not a central feature of operating department nursing. For example, two nurses believed that patients were important because otherwise nurses would not have a job. One nurse spoke of meeting patients' needs with regards to 'drips and drugs', others gave a more enlightened image of activities like 'caring', 'comforting', 'reassuring', 'being there', and 'acting as advocate'. In practice, the actual relationship which nurses had with conscious patients was brief. This was not unanticipated, given the transitory nature of each individual patient's passage through the operating department. The time nurses spent with conscious patients prior to their anaesthetic ranged from 5 to 40 minutes (with an average of 12 minutes). The length of time that a nurse spent in the anaesthetic room with a preoperative patient appeared to have no bearing on the depth of that relationship. This was a surprising outcome for two reasons:
Another factor that affected the degree to which nurses interacted with patients seemed to be related to which anaesthetist was present. One anaesthetist adopted a particularly technical approach to his work and did not speak to patients much except to give them rather abrupt
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commands, such as 'move your hand', 'don't move', or "look the other way'. When working with this doctor, nurses did not talk to the patient either, even when they were not actually engaged in medical tasks. The available time they spent watching him as he worked and listening to him as he explained to them in medical language what he was doing. These findings gave support to the research of Fisher and Peterson (1993) who remarked on the highly influential position of the medical staff in affecting the quality of nursing care given to patients.
Barriers to communication: the disempowerment of patients Within the context of the nurse-patient relationship, various other barriers to interaction were apparent. Nurses said that they preferred to wear facemasks to protect themselves from patient secretions. In fact, the wearing of masks was observed to inhibit the interactions between nurses and patients. Masks decreased the audibility of nurses. Patients were frequently observed to indicate that they had not heard what nurses had said to them. Fox (1992) asserted that the actual wearing of the facemask as part of operating department uniform was concerned with power rather than cleanliness. He stated that masks were an indicator of the authority to perform surgery and was therefore a sign of role legitimacy, rather than a means of infection control. Staff in this department suggested that continual mask wearing was the result of tradition. It was not seen as a barrier to communication, but rather as a barrier to protect nurses from patients, for instance if blood or body fluids should spurt from a patient. In effect, it was observed to reinforce the disempowement of patients by constituting a barrier to communication between patients and nurses. Nurses generally did not introduce themselves to patients and did not wear name badges, therefore it was left to patients to assume that females were nurses and males were doctors. This was apparent when one patient asked an operating department assistant if he was going to be doing the operation and another patient asked the female anaesthetist how long she had been a nurse only for her to reply indignantly, 'Oh I'm not a nurse, I'm the doctor!'. Again, this indicated how some staff had the ability to disempower patients by keeping their identities hidden.
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The fact that patients had been asked to remove their glasses, hearing aids and false teeth before coming to the operating department was a clear inhibitor to communication. Similarly, the fact that patients were placed in the horizontal position immediately upon entering the anaesthetic room meant that they could not interact with nurses face-to-face. Instead, nurses assumed a superior position looking down over patients. Various patients indicated that they could not see without their glasses, could not hear without their hearing aids, and held tissues up to their mouth apologizing for not having their teeth in. The possibility of removing these prostheses in the anaesthetic room immediately prior to the induction of anaesthesia had not been considered by nursing staff, even though such ritualistic preparation of patients for surgery has received harsh criticism (Walsh & Ford 1989). Changing the pre-operative routine would firstly have meant a break with tradition. Secondly, it would have increased the responsibility of nursing staff to ensure that loss or damage did not occur while the patient was in surgery. Adherence to such practices has been indicative in the past of methods by which staff cope with the intense role demands placed upon them (Menzies 1970; Chapman 1983; Bailey 1985).
Perceptions about patients 'Good' patients Nurses indicated that there were certain patients they considered to be 'good'. For example, 'good' patients made a quick recovery, did not get upset in the anaesthetic room, or ask too many questions. That was not to say that patients who did not conform to treatment expectations were 'bad', but rather gave an indication that "good' patients were those who did not make any great demands on nursing time or skill. Findings in relation to patients who are perceived as popular or unpopular are not new (Stockwell 1972). However, it was interesting to note that in the operating department nurses also have a tendency to make value judgements about patients. In Stockwell's study, it was discovered that least nursing attention was directed at those who were neither popular or unpopular. Patient popularity was not gauged the same way in this study. Instead, it emerged that nurses were more likely to interact with patients who were 'safe', i.e. those patients who were having routine
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surgery, did not have cancer, and were not openly anxious. Nurses also reacted more intensely to those patients who themselves initiated the interactions, rather than those who were quieter. The inherent danger in this practice was the risk that quieter patients w h o were perhaps internally more anxious and feeling more vulnerable, were those at w h o m nurses did not direct nursing action.
focused on ensuring the physical safety of the patient rather than having any intended psychological impact. Therefore, the emergent nursing philosophy was medical and technical, governed and influenced by the needs of the medical profession within the situational restraints presented b y a complex environment. Nurses practised without any clear nursing leadership.
Patient vulnerability
The nursing process
Not all patients recognized the consultant surgeon or anaesthetist who was to perform their anaesthetic or surgery. One patient asked a nurse 'was that Mr X?' [the consultant surgeon], after he had exposed her breasts without consent, briefly p r o d d e d her and then disappeared. Consequently, patients placed implicit trust that all individuals who examined them were appropriately qualified and had legitimate access to the environment. Moreover, it was also apparent that not all patients were aware of who was actually going to be doing their surgery. Patients asked, 'What is the surgeon's name?' indicating that they were unaware as to who was going to be performing their surgery. The fact that patients were physically and emotionally exposed to a considerable n u m b e r of nameless people indicated not only the trust which patients placed in operating department staff, but also the vulnerability they were experiencing in the patient role. Yet, this did not seem to be of particular concern to nurses, despite the stress they placed on their role as a key cater for patients.
Nursing care in the operating department was guided by the nursing process, using a framework which was outlined on the patient documentation. This comprised a preoperative checklist that did not embrace any recognizable model of nursing. References to care-planning revealed that nurses did not view care to be any better as a result of using documentation their way. Given the inadequacies and ambiguities in the documentation, this was not surprising. Nurses stated that they had always performed the particular actions a n y w a y regardless having to record them. Therefore, nursing care was automatic rather than individualistic. Some of the entries were ticked as a matter of routine, rather than forming part of a more comprehensive nursing assessment. For instance, the entry on skin condition and pressure sores was frequently ticked without a nurse asking or examining them.
Care philosophy In the initial stages of this study, it was difficult to gauge the extent of the nursing philosophy in this site because while nurses said the focus of their day was the patients, their actions were not commensurate with this. This presented a confusing paradox because the majority of activities in which nurses engaged were connected to functions other than direct patient care activities. As was seen earlier, the nurse-patient relationship was short and superficial and so in itself could not be described as close, meaningful or therapeutic. There was no clear philosophy of nursing within the unit. Patient-related activities that were carried out
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Preoperative visiting Preoperative visiting was seen as an important part of the nursing role. However, it was intensely problematic in practice. All nurses commented on how difficult it was to fit preoperative visits into the routine of the working day. No pre-operative visits were carried out during the observational work as staff reported that they were too busy. Observations concurred with this. However, it was evident that m u c h effort was spent cleaning and tidying inside the operating department, thus suggesting that insufficient time was perhaps an excuse for not engaging in nurse-patient interaction. In the absence of pre-operative visits, it was difficult to gauge h o w nurses did manage to assess patients' needs with any degree of accuracy. No obvious patient assessment was carried out in the anaesthetic room prior to the induction of anaesthesia since nurses did not
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spend any significant time interacting with patients. Consequently, nursing actions that were carried out were done in accordance with the checklist rather than a nursing process philosophy.
Role performance
Development of a theoretical framework As well as describing how operating department nursing was viewed and practised by nurses, the exploratory work was carried out with the purpose of highlighting possible factors that might be influential in the performance of operating department nursing and that might direct and inform future study. From the data obtained in this study and from the limited amount of literature available, a theoretical framework was developed to represent the role performance of operating department nurses. The framework, illustrated in Figure 1, was generated from three key interrelated themes: nurses themselves; the context within which they work; and the resultant performance of their role. A number of concepts inherent within the overall framework also emerged as a result of the exploratory work. These provided tangible concepts that were instrumental in guiding the main phase of the research (McGarvey 1998), and are represented in Table 1. Given the lack of previous research into operating department nursing, this framework Table 1
Context
•
IL N u d e s
Fig. 1 Theoretical f r a m e w o r k f o r role per f o r m a n c e o f o p e r a t i n g d e p a r t m e n t nurses.
represents work at an early stage of development. Nevertheless, it provides a logical first step and structure upon which to develop further research into the role performance of operating department nurses within the context of modern health care.
Conclusions There were several issues that emerged in relation to nursing in the operating department as a result of this exploratory study. Firstly, nurses viewed operating department nursing in terms of the functions they performed. However, they had difficulty in articulating exactly what it was that nursing in the operating department entailed. Operating department nursing was seen as being complex, but nurses could give no
Key dimensions o f o p e r a t i n g d e p a r t m e n t nursing
Characteristics of nurses
Context
Role performance
• Personal characteristics
• Physical c o n t e x t
• Socialization into role
• Expectations and beliefs a b o u t t h e i r role
• Atmosphere
• N u r s e - p a t i e n t relationships
• Beliefs a b o u t patients
• O r gani zat i onal structure
• Nursing process
• Reasons f o r choosing this w o r k
• D o c t o r - n u r s e relationships
• Pre-operative visiting
• Personal-occupational conflicts
• Relationships w i t h wards
• Named nursing
• Educational p r e p a r a t i o n
• Support staff
• Non-nursing duties
• Ethos f o r care
• M o n i t o r i n g per f orm a n c e
• Role stability
• Accountability
• Technology
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further comprehensive or theoretical elaboration on that. Furthermore, nurses practised nursing in different ways. Half of the sample preferred to work with technology and medical staff than to spend time in the anaesthetic room with patients. Only one nurse out of the six had a clear preference for working in the anaesthetic room. For the most part, nurse-patient relationships were brief and focused on the routine physical care of patients rather than on identifying and dealing with any psychological needs they might have had. This was commensurate with the literature. Previous education of nurses tended to support this medical and technical focus of behaviour. Furthermore, it was evident that the manner in which nurses practised their role in this particular site was influenced by the context within which they worked. Inherent in the concept of context were factors such as: the effect of the medical profession, the absence of a nursing philosophy or leadership and mechanisms available for providing nursing care, and the characteristics of individual patients.
Limitations of the study It is accepted that this study was small in size and exploratory in nature. Consequently no generalizations can be made from the findings reported here. In addition, the qualitative focus of the study means that the study is more concerned with theory generation than testing. Attempts to ensure trustworthy data were made; however, relying on h u m a n involvement in this type of study means that bias must always be considered as a limitation. It is also accepted that the theoretical framework that emerged from this preliminary work now requires rigorous testing before it can be further endorsed as contributing to a theory of operating department nursing. Nevertheless, in the relative absence of other research into nursing in the operating department within the UK, this study has provided a tangible starting point from which more in-depth research can be undertaken. This study and that which followed it (McGarvey 1998) have provided key concepts and possible relationships relating to nursing within the operating department. Exploring, testing and validating such relationships in more depth and by quantitative means is the basis for the future practice of operating department nurses.
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Recommendations for further research It is suggested that further research into the role of nurses in operating departments is therefore crucial to the development of an efficient and effective service. Firstly, it is necessary to examine what exactly is the contribution of operating department nurses to patient care in the perioperative period. As yet, this has to be evaluated critically. This study suggested that nursing activity concentrates mainly on the physical aspects of care. Indeed, this is an important element in an environment where patient safety is critical. However, as Martin (1996) has indicated, it may be that nurses working in the operating department can also make a contribution to care in terms of improved patient outcomes by using psychological interventions, like decreasing post-operative pain through information given during pre-operative visits. Such interventions require deeper investigation. Secondly, research is needed to examine, in a more penetrating way, the factors that influence and inhibit the enactment of sound nursing practice. It emerged in this study that various factors affected the way nurses performed their role. Further examination of these issues could enlighten the future practice of nurses so that therapeutic practices could not only be identified, but also facilitated. There is no doubt that the experience of patients undergoing surgery is a difficult one, fraught with both tension and emotion. The challenge for nurses, particularly those working in the treatment intensive arena of the operating department, is to address how this experience might best be managed to yield positive outcomes,
Acknowledgements The author would like to acknowledge the following sources of funding: National Association of Theatre Nurses; Association of Operating Room Nurses; Northern Board Nurses Research Forum.
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