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The Influence of Context on Role Behaviors of Perioperative Nurses
McGarvey
- Chambers
- Boore
DECEMBER 2004, VOL 80, NO 6
The Influence of Context on Role
Behaviors of Perio perative Nurses Helen E. McGarvey, RGN; Mary G. A. Chambers, RGN; Jennifer R. P. Boore, RGN
P
erioperative nursing has evolved over approximately 120 years, largely as a result of developments in surgical technique, technological advances, and changes in the role of women in society. Although the profession developed out of the need for surgical assistance, new role developments are beginning to affect how care is provided to surgical patients. As with perioperative nurses globally, nurses in the United Kingdom work in settings that abound with technological advances, pioneering surgical techniques, and increasing workplace pressures. Furthermore, recruiting nurses to work in this speciality is challenging. As a result, providing high-quality patient care is an increasingly complex task. Northern Ireland is separate from, but has strong governmental links with, mainland United Kingdom. The National Health Service that exists throughout the United Kingdom was established in the 1940s, and it operates on the fundamental principle of free and equal access to health care for all individuals. The service has become increasingly strained over the years, however, as waiting lists for surgical procedures have grown and the nursing shortage has worsened. Changes in government policy and professionally driven agendas have affected nursing in general, and within operating departments, nurses have experienced considerable change.
STUDYAIM
AND
OBJECTIVES
The aim of this study was to conduct a focused investigation on the role of nurses in the operating department.
Specificallv, the obiectives were to examine the role performance of a sample of perioperative nurses in Northern Ireland and investigate the effect of the operating department context on the performance of the nursing role. .I’
LITERATUREREVIEW A literature review found that although various perioperative research studies had been carried out in the 30 years preceding this study, few were relevant to the goals of this study. In addition, the majority of research originated in the United States and, thus, could be applied only tentatively to the Northern Ireland setting. The development of the nursing role in the operating department and an analysis of research about the perioperative role
ABSTRACT 0 USING A CASE STUDY APPROACH, researchers conducted a focused exploration of the role of perioperative nurses.
0 DATA WERE COLLECTED in three different hospitals during 358 hours of observation and 34 hours of interviews with 35 nurses. Researchers also analyzed nursing documents, including the care plans of 230 patients. 0 FINDINGS SHOW that various contextual mechanisms are influential in the role performance of perioperativenurses. 0 THIS STUDY HIGHLIGHTS the importance of providing adequate support for perioperative nurses to perform their role in an intensely stressful environment. Patient-focused leadership and the promotion of a caring philosophy are needed to strengthen perioperative nursing and, ultimatel y improve patient care. AORN J 80 (December
2004) 1103-1120. AORN I O U R N A L
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Role performance is influenced by a person's values, attitudes, and beliefs and the context in which the role is performed.
are reported elsewhere.' Although the term perioperative nursing encompasses the nursing role from the time the decision is made for surgery until the resolution of surgical sequelae,' for the purposes of this study, the term is restricted to describing the nursing role within the four walls of the operating department (ie, the immediate preoperative, intraoperative, and immediate postoperative periods).
THEORETC I AL
FRAMEWORK
The theoretical basis for this study comes from role theory. This is appropriate because nursing literature repeatedly uses the term role, and it is a term with which nurses already are familiar. Furthermore, the focus of this study is on people and their behaviors in a specific occupational context. One researcher suggests that role theory is "a science concerned with the study of behaviors that are characteristic of persons within contexts."' IF4) Another researcher views role theory as
study, however, it was chosen as the most appropriate theoretical background for this study. Role is an exceptionally diverse term, and the literature is divided about how it should be defined. For the purposes of this study, role was defined as "behaviors characteristic of one or more persons in a
PRELIMINARY STUDY The absence of any previous significant research on this topic in the United Kingdom meant that a preliminary study had to be carried out to determine whether the topic was worth further investigation before resources could be used. The preliminary study provided a theoretical framework that was used to guide the main study. The details of the preliminary study are presented elsewhere.'
DESIGN AND METHODS
The basic criterion for studying role behavior is to identify the relevant social system or subsystem and then locate recurring events that fit together: This a collection of concepts and a variety can be done by ascertaining the role of hypothetical formulations that expectations of a given set of related predict how actors will perform in a offices because such expectations are the given role or under what circummain elements in maintaining the role stances certain types of behaviors can system and inducing the required role be expected4(p") behavior. In the past, role theorists have The underlying assertion of role theory adopted methods of research that involved observing roles and that relevant to this research is that required research participants to report 0 a person's values, attitudes, and beliefs are linked to the roles he or she their own or others' expectations in relaplays within the social environment;5 tion to their role.",qThis allowed in-depth examination of role and role perform0 role performance is influenced by context and the individuals who per- ance. A case study design was selected because it best facilitated the investigaform in that context;' and 0 role theory supports the link tion of role behavior within its natural between the expectation of role per- context. In addition, to embrace the flexibility required in this study, a qualitaformance and the behavior itself.' No recent works relating to the use tive approach was chosen. Case study design involves an intenof role within perioperative nursing emerged during the literature search. sive exploration of a single unit of study Given its relevance to the topic under in its natural setting."' One researcher
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suggests that it has a particular use when 0 the questions of "how?" and "why?" are being asked, 0 the researcher has little control over events, and 0 the focus is on a contemporary phenomenon within its real-life context.'" The researcher believed that whatever the phenomena, they take their meaning as much from their context as they do from themselves. In this study, each operating department was conThe modified, sidered as an individual unit or case. complete The operating department from each of three observer role separate hospitals was purposively selected from a11owed the a database so that sufficient data could be colresearcher lected to make the study to collect data credible. The hospitals, therefore, were geographically separate and ranged and integrate in size from 300 to 1,000 beds. with team Within the qualitative members approach and case study design of this research, without having three methods of data collection were selected. to engage in These included 0 observation, work practices in 0 interviews, and 0 document analysis. the setting. OBSERVATION. A modified, complete observer role was adopted." This allowed the researcher freehom to collect the data and integrate with team members without the obligation of having to engage in work practices within the setting. Data collection took place during 358 hours and 60 operating sessions (ie, time slots booked for a particular surgeon). These sessions were planned so that observations
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incorporated the full selection of operating lists (ie, surgical schedules) for each theatre for each session during the work week. Field notes were written at regular intervals during the day and were transcribed at the end of each observational session. INTERVIEWS. Interviews were conducted with 35 nurses of different grades, ranging from student nurses to nurse managers, and amounted to a total of 34 hours of interview time. The nurses interviewed were core staff members involved in each of the observation sessions. Interviews were audiotape recorded with the participants' permission and were replayed and transcribed after each session. DOCUMENT ANALYSIS. Document analysis was carried out on a variety of documents pertaining to each site. These included daily roster sheets, educational resources for staff members, and the nursing care plans of 230 patients who underwent surgery during the observation sessions.
DATAANALYSIS Qualitative studies generally result in large amounts of data that researchers must sift through to produce meaningful results. For this study, the analysis involved preliminary coding'*followed by pattern matching and explanation building.IoData analysis also used memos, diagrams, and matrices." Memo writing involves theorizing to tie concepts and ideas together on paper. These ideas then are put into diagrams. After this is completed, connections between data can be made using matrices (ie, tables that show the interaction between variables derived from the data). ENSURING ACCURATE DATA. Normally, the terms reliability and validity do not apply in qualitative research and are replaced by the terms credibility, transferability, dependability, and confirmability as methods of ensuring that the
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TABLE1
Methods Used to Ensure Rigor in the Study Method
Application
Triangulation
Data were compared by time (ie, during 1 year); space (ie, 3 sites); and person (ie, 35 participants) and between methods (ie, observation, interview, document analysis)
research has been conducted with rigor. "-'" Various methods were Prolonged involvement 6 to 8 weeks allowed the researcher to used during the study to gauge each setting and allowed behaviors ensure trustworthiness of to normalize the data (Table 1). Persistent observation Allowed sufficient time to idenhfy and RESEARCHISSUES. Ethical focus on relevant issues approval to conduct the study was obtained from Use of a theoretical Provided a structured map for data committees at the univerframework collection sity and the hospitals concerned. Access to each Peer debriefing Peers were involved to ensure the site was secured by conresearch process was consistent and sent from hospital and accurate nurse managers before individual nurses were Member checks Original and interpreted data were given invited to participate in to participants so they could check the study. Principles of accuracy informed consent and confidentiality were upAudit trail The research process was clearly explained held throughout the for others to scrutinize and follow study. Several research issues, however, emerged as being important during the study. Their interest was generated during These issues are discussed more fully time spent in the operating department elsewhere,'; but in short, they included as students, and the inclusion of a thethe considerable influence gatekeepers atre placement during a nurse's educahad on the extent to which data could tion program was considered by manbe collected and the role conflicts expe- agers to be an important recruiting rienced by a researcher who also had strategy. For the rest of the nurses, nursing knowledge and therefore, was working in the operating department aware of issues such as unsafe nursing was a result of chance and was not practices. always welcomed. Nurses spoke of feeling devastated and of hating theatre work in the beginning. Such feelings RESULTS This section describes the actual role tended to subside after six months of performances of perioperative nurses work in the operating department. in the study. Table 2 provides a breakDEFINING NURSING-ROLE PERCEPTION. down of the roles held by nurses in the Nurses were asked to describe what study. Although the majority of nurses their role meant to them. Some definiin the sample had extensive work tions were more refined than others. experience in the perioperative envi- Ten (29%) said they had never thought ronment, their positions were not nec- about defining their role before, that it essarily permanent, and a degree of was complex, automatic, and they did it role change occurred. each day without thinking about it. This REASONSFOR WORKING NI THE OPERATING corresponded with responses from the DEPARTMENT. Only half of the sample of preliminary study. qualified nurses had actively chosen to Some nurses had a more patientwork in the operating department. focused view of their role than others. AORN JOURNAL
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TABLE2
Positions and Grades of Perioperative Nurses Parh'cipating in the Study Position
and grade 0-2
Years of Years in role at the time of the stu& experience 3-5 6-10 L i - i 15 +6 0 - 2 3 - 5 6 -10 11-15 16+
Senior nurse manager or nurse specialist grade H or I (n = 4)*
3
Theatre sister, grade F or G (n = 3)** Senior staff nurse, grade F (n = 4)t
4
Staff nurse,grade E (n = 9)H
3
Staff nurse, grade D (n = 7)s
5
Enrolled nurse, grade D (n = $5
2
Student nurse (n = 1)
Totals (n = 34, excluding student nurse)
17
* RN with a specific managerial or specialist responsibility ** RN in charge of a single theatre or group of theatres t clinically-based RN with some managerial experience clinically-based RiV with more than 2 years' postregistration experience § clinically-based RN with less than 2 years' postregistration experience % ! clinically-based nurse who undergoes a shortened training program
Nursing in the operating theatre, to me, is about caring for patients who are having an operation. . . . Looking after their needs, protecting them from the hazards of the environment, and offring them reassiirance and trying to alleviate the anxiety associated with coming for surgery. Others had a more technically orientated view of their role.
My role is about making a safe environment, assisting the nnaesthetist . . . and the siirgeon in the scrub role. . . . and protecting patients from the hazards of the environment.
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Most nurses mentioned the word "care" in relation to looking after patients, and dimensions of physical and psychological care were reported. The nurses believed that a good nurse was one who gave holistic care, and the ability to give this care was what distinguished nurses from other health care workers, including physicians. THE NURSE-PATIENT RELATIONSHIP. From the outset of the study, it was evident that the nurse-patient relationship was a transient one. Patients stayed in the operating department for relatively short periods of time and often were unconscious for the majority of their stay. Nurses also were transient, and
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although an encounter with a conscious patient might last only five to 10 minutes, it was not unusual for two or three nurses to look after a patient in this time because nurses were reallocated to perform other duties. Organizational demands superceded nursepatient continuity. PHILOSOPHIES OF NURSING. An overall philosophy of nursing was not apparent in any of the three sites. The main emphasis was on getting the work done safely and efficiently. Ultimately, this involved minimal contact with conscious patients. Patients who wanted to talk placed demands on nurses, which delayed them from carrying out their paperwork and preparation work. Although there were two main influences on nurses (ie, managers, physicians), the main driving force behind nursing actions was the medical profession, and nurses adapted their own role to fit physicians' requirements. For instance, the nurses in the study spoke of having time to establish a relationship with patients before the patients were anesthetized, but they only sent for patients at the physician's request. There was no evidence of nurses transporting patients to the OR a few minutes early so they could establish rapport with them. Nursing was based on a series of tasks associated with each position that were performed largely in response to medical need. A collective nursing voice promoting the value of care and the rights of patients did not emerge. RESEARCHAND R ~ A LA ~ O N . Interview data show that the nurses were aware of research that was relevant to perioperative nursing practice. For instance, nurses spoke about the relationship between preoperative anxiety and postoperative recovery; shaving the surgical site and the incidence of postoperative infection; and body temperature, positioning, and pressure sore prevention. Despite being aware of what was considered to be appropriate research, however, the nurs-
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es in the study had difficulty translating research into practice. MODELS AND THE NURSING PROCESS. Nurses at each study site stated that the nursing process (ie, methods aimed at ensuring continuity of care for patients) was used to provide nursing care. Two sites used the Roper, Logan, and Tiemey model of nursing, which is a model based on 12 u activities of daily living (eg, eating, drinking, maintaining safety) and a Analysis continuum from dependence to independence.lR care plans The third site used an environmental and physiconfirmed that cal checklist. The concept of the the nurses used nursing process was not readily embraced by nonspecific nurses. Some believed it was not helpful in prophrases like viding care. Nurses complained that the nursing ""reassurance process required too much paperwork, espegiven" and cially for minor procedures, and was too gen"'patient appears eral to provide individualized care. relaxed" but did Given the negativity expressed toward models not qualify and care plans, the routine way in which they these comments were completed was not a surprise. Nurses indifurther. cated they "wrote the same thing for every patient." Analysis of care plan documentation confirmed a ritualistic approach to care planning. Nurses used nonspecific and meaningless phrases like "reassurance given" and "patient appears relaxed," but did not qualify these comments further. A number of inaccuracies and omissions also were noted in the recording process. For example, 0 pressure areas were documented as
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”okay” when no checks were observed, ”patient reassured” was written when no interaction with the nurse was apparent; and ”diathermy pad on right leg” was recorded when observations showed that it was on the left leg or even that no pad had been used. Given the emphasis nurses placed on the care plan as a legal document, the observed inaccuracies and omissions were surprising. Most the There were two main reanurses believed sons for inaccurate care plans. First, more inaccupreoperative racies and omissions occurred when the contivisits are an nuity of nursing work was interrupted because important nurses were reallocated (eg, during breaks and strategy in shift changes). Second, some nurses who had not nursing surgical developed relationships with patients tended to pa tients; engage in ”pseudo care planning,” in which time however, fewer was devoted to completing specific information than 25% of (ie, addresses, physicians’ names) but not to patients received recording accurate information that related to a visits during patient’s psychological state.
of
the study.
CON TI NU^ PREOPERATIVE
OF CARE AND
VISITS. Each site
had a system for making preoperative visits. This entailed nurse visiting patients on the ward the night before or morning of surgery. The purposes of this visit, as reported by nurses, are to 0 start and build a relationship with the patient, 0 assess the patient to determine his or her nursing needs in relation to
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overall surgical care, give the patient any information he or she requires about his or her impending surgery, and offer reassurance and comfort where necessary. Most of the nurses believed that preoperative visits are an important stiategy in caring for surgical patients because of a link between preoperative information and a number of postoperative variables, such as recovery time and pain relief. Visits did not occur frequently, however, and fewer than 25% of patients received visits during the time of the study (Table 3). Given the significance nurses attributed to preoperative visits for care planning and for the psychological welfare of the patients, these figures were surprising. Several key factors influenced preoperative visits. These included 0 heavy workload, 0 medical staff member control, 0 organizational factors, and 0 exhaustion and low motivation. There undoubtedly were times when the workload prevented visits from being carried out. Nurses struggled to keep up with the work, especially when the schedule was particularly busy and throughput was high. This was compounded by staff members’ absences and evening shifts when only a skeleton staff was on duty. Visits were seen as a resource issue, and with restricted resources, other tasks were given priority. Medical staff members had the power to control the extent to which preoperative visits took place. One surgeon, for instance, prevented nurses from visiting his patients at all. Medical staff members ultimately were in control of the procedure, and the nurses did not want to give patients information that may not have been accurate; thus, nurses in the study tended to focus on a small but very general collection of questions and statements
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TABLE3
Preoperative Visits Camed Out During the Study Site A
Site B
Site C
Totals
Number of patients scheduled for surgery during the observation sessions
92
81
57
230
Number of patients who received a preoperative visit
12
24
15
51
Percentage of preoperative visits performed
13%
30%
26%
22%
about care that would not mislead patients. The nurses cited both ward organization and the organization of the operating list as mhibitors to making preoperative visits. Wards were reported to be busy, and bed shortages meant patients often were sitting in corridors. These conditions were perceived to be unsuitable circumstances for visits to occur. The nurses also reported having time limits within which to undertake visits, perhaps 20 minutes to see all the patients on the morning’s schedule. There were days when staff members spoke of being exhausted and under stress. There also were days, however, when this was not the case, and on these occasions, staff members still perceived preoperative visits as problematic. Low motivation clearly was an issue. The overall picture of preoperative visits was one in which nurses were torn between the expectation that they carry out visits and the personal realization that visits were difficult and, sometimes, impossible. At the one site where visits occurred most frequently, staff members had the support of a senior clinical nurse who had mfluence in motivating staff members, generating ideas, and setting practice standards. The value of clinically-based specialist nurses thus appears to be important in role enactment.
the care that would be provided to this patient on his or her arrival in the operating department. In the absence of the named nurse, an associate would be appointed to continue the care. This concept was fundamentally problematic in each of the study sites for two reasons. First, the boundary within which the named nurse was expected to perform was unclear, and there were varying interpretations about where the role should end. There was general agreement that the role began with the first nurse-patient interaction, whether that was on the ward during a preoperative visit, in the holding area, or in the anesthetic room. The point at which the relationship terminated, however, was a matter of some ambiguity. Opinions differed about whether it ended when the patient was transferred to the OR bed, when he or she was attached to the anesthesia machine, or when he or she was draped for surgery. There was a period of time, therefore, when no single person had responsibility for the patient. This was a time when patients’ bodies most frequently were exposed, sometimes for up to 20 minutes. Not only did this have implications for the patient’s d i p t y but also for the maintenance of his or her body temperature. The named nurse did not appear to have any responsibility for the patient during surPATIENT RESPONSIBILITY-NAMED NURSING. gery, and a key caregiver with ultimate The idea of ”named nursing” (ie, pri- responsibility was not evident. The mary nursing) was endorsed at all sites. nurses said everyone was responsible, One nurse-the named nurse-was but in reality, observations showed that allocated to be responsible for a no one assumed overall care. patient’s care while the patient was in Second, the nurses’ feelings toward the operating department. This nurse named nursing varied, and there was no was expected to visit a patient preoper- clear consensus that named nursing was atively, assess his or her needs, and plan a positive strategy for the operating AORN JOURNAL
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department. The nurses believed that it was a good idea, but it just did not work. Staff members also were resentful that it had been introduced in a top-down approach; however, no nurse had actively approached a manager in search of a workable compromise or solution. There was a prevailing attitude that making any move to change this imposed practice would be pointless. INFLUENCES ON ROLE PERFORMANCE. Rather than being influenced by formal educational processes, the role performance of nurses was molded within the work setting. The practical nature of perioperative nursing means that nurses are The constantly learning on the job. All staff members implications took an induction program during orientation not counting to their respective units; however, the majority of swabs were more learning took place while worked. The shapserious than the nurses ing of nursing practice occurred in two waysimplications by role modeling and by not interacting reinforcement. Nurses in the study spoke about ”picking with a patient. things up“ and “watching what other people are doing.” ” Students modeled the roles of staff nurses, and staff nurses modeled the roles of theatre sisters. The theatre sisters’ role was focused more on administrative and medical functions than on patient care, so nurses had little guidance regarding appropriate ways of communicating with patients. In this sense, nursing leadership was weak. When theatre sisters did work with patients, it was in the same fleeting and patronizing manner that medical staff members usedpatting them on the shoulder and telling them ”everything will be okay.” Only one of the theatre sisters was
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observed to engage in any meaningful interaction with patients; this was a junior theatre sister whose responsibility was more clinical than managerial. In addition, a subtle process of reinforcement maintained nursing behavior within each of the study sites. This was not an overt and positive reinforcement by nursing staff members through performance appraisal. Instead, behavior was shaped by negative reinforcement. The implications of not doing certain tasks were severe, and this served as an impetus to perform these tasks. For example, the implications of not counting swabs were serious; the implications of not interacting with a patient were seen to be less serious. Theatre sisters were observed to chastise staff members for not hanging up swabs or for failing to stick name labels on documentation, but no attention was paid to whether nurses interacted with patients. CONTEXTUAL INFLUENCES. The context within which the nurses worked presented considerable challenges. Operating departments were observed to be clinical, unwelcoming, and stressful for both patients and staff members. Two key themes emerged from the data: allocation/reallocation and medical domination/nurse deference. Allocation of staff members to operating suites occurred on a daily basis. In principle, there was a core team of nurses, and, when necessary, additional staff members were allocated. This provided a team who could work together to care for patients. More important than being a good team player, however, was the need for a nurse to be flexible. Flexibility was fundamentally important, and rather than being essential for good care, it was a management requirement that allowed a department to be run with the smallest possible number of staff members. Reallocation had several serious implications for nursing staff members,
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Optimal use of the workforce through reallocation superceded the continuity of patient care. External demands on nurses' time caused them considerable tension. however. Junior staff members, who already were struggling to settle into the environment, found constant reallocation unsettling. These nurses found themselves in a cyclical pattern of not knowing the routine or where to find supplies; as a result, they tended to stand in the corner until they were told to do something. This annoyed senior staff members, and consequently, they perceived junior staff members to be incompetent and criticized them in an attempt to jolt them into learning. Junior staff members became more flustered and withdrawn, so the problem was further compounded. Reallocation also negatively affected the continuity of patient care. For instance, nurses who had undertaken preoperative visits might be allocated somewhere else, so they did not see the patient come to the theatre. Nurses engaging in patient interaction in the anesthesia room were sent to scrub for the procedure, so a patient in the anesthesia room was cared for by various nurses during a short stay. The practical reality of reallocation meant that optimal use of the workforce superceded the continuity of patient care. Although nurses were trying to care for patients, external requirements on their time demanded efficiency, safety, and throughput. This resulted in considerable tension for the nurses. The second theme was medical domination and nurse deference. Initially, nurse-physician relationships appeared to be good, but as fieldwork became more detailed and probing, it was evident that nurses in the study practiced under the intense domination of the medical professionals. Some physicians were more controlling than others. Some relationships were friendly and jovial, and staff members worked well together. A few medical staff members were moody or rude, however, and they shouted at and
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patronized nurses in front of other surgical team members. One reason for the tension was the demanding way physicians treated nurses, showing little appreciation for the fact that nurses might have a patient-centered role outside the role of medical assistant. In addition, despite an increase in the number of graduate nurses and feminist influences of recent decades, nurses working in the operating department still were treated like handmaidens by physicians. Nurses assumed this position of unquestioning inferiority both in their actions and their beliefs. They disliked medical staff members who were arrogant or disorganized because this threatened the stability of their role; however, they rarely protested against their treatment. Interestingly, nurses had better relationships with anesthesiologists than they did with surgeons. On a number of occasions, anesthesiologists acted as buffers between physicians and nurses.
DISCUSSION The results of this study substantiate the views of role theorists who state that the performance of a role is inextricably linked to individuals who perform in that role and the overall context within which the actual role behaviors occur. Contexts have predictable components and greatly structure the lives of those who participate in them. The operating department is no exception to this in two components in particular-the organizational structure and the medical profession, both of which play a major part in the performance of the perioperative role. Key to relationships within the study is the idea of a role-set. A role-set is a "complement of social relationships in which persons are involved simply because they occupy a particular social The role-set of perioperative nurses includes patients, medical staff
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members, other nurses, ancillary staff members, relatives, and others. The complexity of relationships within the perioperative role-set often leads to role conflicts and ambiguities. Furthermore, problems arise because members are not apt to be equally powerful in shaping the behavior of others. In this study, nurses were relatively powerless within their own role-set. PHYSICIANS AND NURSES. The relationship between nursing and medicine has a formidable history. It has been reported that the relationship between physicians and nurses has improved over the years."."' Within the perioperative arena, one author commented
The surgeon is no longer the most important person in the operating rooin-the patient is now the centre of attention and the niirse is no longer a inere recipient of the physician's orders. With nlivances in niirsing knozuledge, the theatre niirse is nozu able to provide a service to patients as iizdividuals." (F""~ It would seem that this view is an optimistic one. The view put forward by others,22,2' that relationships between physicians and nurses are inherently problematic, is supported by this study. The relationship between physicians and nurses was not one of equal partnership or of multidisciplinary teamwork, but of ownership-a repressive and patriarchal relationship similar to the case of asymmetrical professional dominance described some 30 years ago in a classic medical text.'4 In sustaining this position, it is possible for physicians to hold nurses in strict control with a series of demands and reprimands, leaving nurses to negotiate and perform their role from a position of relative weakness in the operating department hierarchy. Considering the context within which
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they worked, however, it cannot necessarily be assumed that this is a bad situation for the nurses. With the lack of organizational support for proactive nursing, conformity to a medically subservient role provided nurses in this study with a degree of safety and security. It did not place any untoward demands on them, nor did it require them to challenge other members of the role-set; thus, the role-set remained stable. In addition, many nurses had a preference for carrying out medically oriented tasks, and in many respects, these were more determinable thin nursing tasks. Drawing up IV medication is more clearly The future defined than giving psychological care, which is periopera tive by its nature a rather vague and nebulous activnursing must be ity. It is understandable, therefore, that more focus was placed on procedures realized in terms than on the phenomenopracticing logical state of patients. The issue of carrying good nursing out physicians' work is a central tenet of the exrather than tended role debate in the United Kingdom. In reperforming as cent years, nurses increasingly have underbasic-level taken some of the roles previously believed to be physicians. the domain of physicians. Although certain nurses may have the skills and motivation to undertake such roles, this study suggests that the future of perioperative nursing must be realized in terms of practicing good nursing rather than performing as basic-level physicians. Given the hazy manner in which the nurses in this study tended to define their role, such developments may only confuse nurses and dilute nursing skills further. Great care in role development is needed.
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A FLEXIBLE WORKFORCE. The impact of organizational structure on nursing work cannot be underestimated. "The method whereby nursing work is organized is possibly the most important factor in influencing the ways in which nurses performed their Constraints on the workforce meant that managers frequently used a reallocation strategy. The effect of team nursing using a core of staff members, therefore, was limited. Both individual nurses and the nursing team as Although the a whole were disempowered. Nursing work nurses did was carried out as task work (ie, a series of tasks attempt to use that was accomplished with minimal planning the nursing and preparation). Thus, shortages were covprocess to ensure staff ered easily by other nurses flexible enough continuity to perform any task in patient care, the any specialty. Although nurses in this study did attempt to organizational use the nursing process to ensure continuity of system the patient care, the organizational system of the operating operating departments worked against them. departments The organizational conworked against text is influential in how particular sets of values are prioritized.2h In this them. case, managerial throughput superceded nursing principles. The issue, therefore, is for managers to balance the importance of throughput with the value attributed to the nurse-patient relationship. KEEPING EVERYONE HAPPY. It Was Clear from the data that nurses in the study experienced multiple expectations in their nursing role. These expectations
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came from three principle sources: managers w60 winted the work completed quickly to meet goals, physicians who wanted medical assistance to facilitate their own role, and patients who indicated by their actions and questions that they required information and reassurance.
Physicians need clever pairs of hands to assist them in their technical tasks. Hospital administrators need zuellregimented pairs of feet zuhich respond in iiniform zuays to dijierent marching orders and to different battle plans. Patients need human cornpassion, carers zuko respect them as persons and not merely as bodies.27irh22' The resolution of role strain is a complicated process that is not well researched.'8 Role strain can place a considerable burden on a person. One suggested coping method is to adjust the degree of involvement a person has in the setting3 One researcher termed this role distance, in which an individual adopts an air of casualness toward others, sometimes uses humor inappropriately, and sometimes appears over confident.?"It is possible that such behaviors observed in this study were the result of nurses trying to manage their role strain. It should be noted, however, that although such behaviors may be useful in managing strain, they also tend to influence the quality of care given to patients.lRIn the perioperative setting, where the nurse-patient relationship is all important, it is necessary to determine more effective coping mechanisms to manage role strain.
CONCLUSIONS Context was an important influence on the role performance of nurses in this study. Work organization did not support patient-focused nursing; it supported a
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system of getting the work done as quickly as possible. The medical profession had a strong influence on the nursing role. Physicians viewed nurses as medical assistants and expected them to perform as such. A nursing philosophy was not apparent. Nurses subscribed to the prevailing medical and administrative models of work. Nurses cared for patients using care strategies that were largely ineffective due to contextual demands. Nursing behavior was administratively modeled by the nursing hierarchy and negatively reinforced by the medical profession. As a result of these events, nurses employed a range of coping mechanisms to manage the dissonance between what was represented as ideal practice and what could realistically be achieved within the context of the operating department.
LIMITATIONS OF THE CASE STUDYAPPROACH The case study approach has been criticized for lacking rigor; having little scientific basis for generalization; being time-consuming; and resulting in massive, unreadable documents."JJ"J' On reflection, these criticisms are not specific to case study method, but potentially are true of any research approach. A multiple-case design was undertaken so that some of these issues could be addressed, and this was believed to increase the soundness of the study.
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ods of nursing that promote continuity of patient care, and 0 adopting an appraisal system that encourages career development for nurses. Role performance of perioperative nurses in Northern Ireland requires careful examination and explication. A philosophical shift must occur for nurses to understand and value their own therapeutic input into patient care. Nurses need to 0 work toward defining their role more clearly, 0 become more proactive and accept responsibility for the nursing role, 0 develop programs of clinical supervision to monitor their own role performance, and 0 research the needs of patients undergoing surgery and the effectiveness of nursing interventions on patient care and well-being. 03.
Helen E. McGarvey, RGN, RNT, BSc (Hons), DPhil, PCGTHE, is a lecturer in surgical nursing, University of Ulster, Coleraine, Northern Ireland.
Mary G. A. Chambers, RGN, RNT, DN, BEd (Hons), DPhil, CertBT is a professor of mental health nursing and chief nurse, South West London and St George's Mental Health NHS Trust, London. Jennifer R. I? Moore, RGN, RNT, RM, BSc (Hons), PhD, FRCN, is a professor of nursing, University of Ulster, Coleraine, Northern Ireland.
A context that facilitates therapeutic nursing within the perioperative setting needs to be created. This could be This study zuasfunded in part by a grant front AORN and an award from the achieved by National Association of Theatre Nurses. 0 moving toward a partnership model of care and away from medical NOTES dominance, 1 . H E McGarvey, M Chambers, J R 0 providing stress counseling and Boore, "DevelopmentGand definition of the other support for nurses, role of the operating department nurse: A 0 encouraging and developing methreview," ]oiirtznl ($Advanced Niirsirig 32
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tive research: The decision trail," Joirrizal of (November 2000) 1092-1100. 2. "A model for perioperative nursing prac- Advanced Nursing 19 (May 1994) 976-986. 17. H E McGarvey, M G Chambers, J R tice," A O R N Joiirnal41 (January 1985) 188Boore, "Collecting data in the operating 194. department: Issues in observational 3. B J Biddle, Role Tkeory: Expectatio17, methodology," lntensive and Critical Care Identities, atid Behaviors (New York: AcaNiirsing 15 (October 1999)288-297. demic Press, 1979). 4.M E Conway, "Theoretical approaches to 18. N Roper, W W Logan, A J Tiemey, The Elements of Nursing: A Model for Nitrsirig the study of roles," in Role Tkeory: PerspecBased on a Model of Living, fourth ed (New tizles for Health Professionals, ed M E Hardy, York Churchill Livingstone, 1996). M E Conway (New York Appleton19. L I Stein, "The doctor-nurse game," Century-Crofts, 1978) 17. Archiues of General Psychiatry 16 (June 1967) 5. R K Merton, Social Tkeory atid Social 699-703. Strircture (New York Free Press, 1968). 20. L I Stein, D T Watts, T Howel "The 6.B A Hurley, "Socialization for Roles," in doctor-nurse game revisited," Tke New Role Theory: Perspectives for Health ProfesEngland Journal of Medicine 322 (Feb 22, sioiinls, ed M E Hardy, M E Conway (New 1990) 546-549. York: Appleton-Century-Crofts, 1978) 2921. C P Wicker, "Primary nursing. A reas72. suring presence," Niirsing Times 86 (July 187.H E McGarvey, M G Chambers, J R 24,1990) 56-61. Boore, "Exploratory study of nursin in an operating de artment: Preliminary indings 22. B J Fisher, C Peterson, "She won't be dancing much anyway: A study of suron the role o the nurse," Intensive and geons, surgical nurses, and elderly Critical Care Niirsirzg 15 (December 1999) patients," Qualitative Health Research 3 (May 346-356. 8.D Katz, R L Kahn, Tke Social Psychology of 1993) 165-183. 23. J K Cook, M Green, R V Topp, "ExplorOrganizations, second ed (London: John ing the impact of physician verbal abuse on Wiley, 1978) 187-221. erioperative nurses," A O R N Joiirnal74 9.B J Biddle, "Recent developments in role theory," Aniiiial Review of Sociology 12 (1986) September 2001) 317-331. 24. E Freidson, Professiorz of Medicine: A 67-92. Study of the Sociology of Applied Kriozuledge 10. R K Yin, Case Stirdi Research: Design and (New York Dodd, Mead, and Co, 1975). Methods, second ed (T ousand Oaks, Calif 25. D Field, Niirsing the Dying (London: Sage, 1994). Tavistock/Routledge, 1989) 120. 11.R L Gold, "Roles in sociological field 26. S Braye, M Preston-Shoot, Enipozuering observation," Social Forces 26 (March 3, Practice in Social Care (Philadelphia: Open 1958) 217-223. University Press, 1995) 53-54. 12.A L Strauss, Qiialitative Analysis for 27.A Perry, "A sociologist's view: The Social Scieiitists (New York: Cambridge handmaiden theory," in Nursing: Its Hidden University Press, 1987) 28-33. Agendas, ed M Jolley, G M Brykczynska 13.J Corbin "Coding, writing memos, and (London: Edward Arnold, 1993) 62. diagramming," in Froin Practice to Grounded Tlieory: Qualitative Research in Niirsin ed W 28. M E Hardy, "Role stress and role C Chenitz, J M Swanson (Menlo Parf; Calif: strain," in Role Tkeory: Perspectives for Healtk Professionals, ed M E Hardy, M E Conway Addison Wesley Publishing Co, 1986) 102(New York: Appleton-Century-Crofts, 119. 1978) 73-110. 14. M B Miles, A M Huberman, Qualitative 29. E Goffman, Wkere tke Action Is: Tkree Data Analysis: An Expanded Sourcebook, second ed (Thousand Oaks, Calif Sage, - 1994) Essays (London: Allen Lane, 1969) 68-84. 30. D L Jorgensen, Participant Observatioii 278-279.' (Newbury Park, Calif: Sa e, 1989) 19-20. 15.C Robson, Real World Research: A 31. R E Stake, "The art o case study Resoiirce for Social Scientists and Practitioner research" in Handbook of Qualitative Researck&s (Oxford, United Kingdom: Researck, ed N K Denzin, Y S Lincoln Blackwell, 1993)402-407. 16.T Koch, "Establishing rigour in qualita- (Thousand Oaks, Calif: Sage, 1994) 236-247.
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The Influence of Context on Role
Behaviors of Perio perative Nurses Helen E. McGarvey, RGN; Mary G. A. Chambers, RGN; Jennifer R. P. Boore, RGN
P
erioperative nursing has evolved over approximately 120 years, largely as a result of developments in surgical technique, technological advances, and changes in the role of women in society. Although the profession developed out of the need for surgical assistance, new role developments are beginning to affect how care is provided to surgical patients. As with perioperative nurses globally, nurses in the United Kingdom work in settings that abound with technological advances, pioneering surgical techniques, and increasing workplace pressures. Furthermore, recruiting nurses to work in this speciality is challenging. As a result, providing high-quality patient care is an increasingly complex task. Northern Ireland is separate from, but has strong governmental links with, mainland United Kingdom. The National Health Service that exists throughout the United Kingdom was established in the 1940s, and it operates on the fundamental principle of free and equal access to health care for all individuals. The service has become increasingly strained over the years, however, as waiting lists for surgical procedures have grown and the nursing shortage has worsened. Changes in government policy and professionally driven agendas have affected nursing in general, and within operating departments, nurses have experienced considerable change.
STUDYAIM
AND
OBJECTIVES
The aim of this study was to conduct a focused investigation on the role of nurses in the operating department.
Specificallv, the obiectives were to examine the role performance of a sample of perioperative nurses in Northern Ireland and investigate the effect of the operating department context on the performance of the nursing role. .I’
LITERATUREREVIEW A literature review found that although various perioperative research studies had been carried out in the 30 years preceding this study, few were relevant to the goals of this study. In addition, the majority of research originated in the United States and, thus, could be applied only tentatively to the Northern Ireland setting. The development of the nursing role in the operating department and an analysis of research about the perioperative role
ABSTRACT 0 USING A CASE STUDY APPROACH, researchers conducted a focused exploration of the role of perioperative nurses.
0 DATA WERE COLLECTED in three different hospitals during 358 hours of observation and 34 hours of interviews with 35 nurses. Researchers also analyzed nursing documents, including the care plans of 230 patients. 0 FINDINGS SHOW that various contextual mechanisms are influential in the role performance of perioperativenurses. 0 THIS STUDY HIGHLIGHTS the importance of providing adequate support for perioperative nurses to perform their role in an intensely stressful environment. Patient-focused leadership and the promotion of a caring philosophy are needed to strengthen perioperative nursing and, ultimatel y improve patient care. AORN J 80 (December
2004) 1103-1120. AORN I O U R N A L
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Role performance is influenced by a person's values, attitudes, and beliefs and the context in which the role is performed.
are reported elsewhere.' Although the term perioperative nursing encompasses the nursing role from the time the decision is made for surgery until the resolution of surgical sequelae,' for the purposes of this study, the term is restricted to describing the nursing role within the four walls of the operating department (ie, the immediate preoperative, intraoperative, and immediate postoperative periods).
THEORETC I AL
FRAMEWORK
The theoretical basis for this study comes from role theory. This is appropriate because nursing literature repeatedly uses the term role, and it is a term with which nurses already are familiar. Furthermore, the focus of this study is on people and their behaviors in a specific occupational context. One researcher suggests that role theory is "a science concerned with the study of behaviors that are characteristic of persons within contexts."' IF4) Another researcher views role theory as
study, however, it was chosen as the most appropriate theoretical background for this study. Role is an exceptionally diverse term, and the literature is divided about how it should be defined. For the purposes of this study, role was defined as "behaviors characteristic of one or more persons in a
PRELIMINARY STUDY The absence of any previous significant research on this topic in the United Kingdom meant that a preliminary study had to be carried out to determine whether the topic was worth further investigation before resources could be used. The preliminary study provided a theoretical framework that was used to guide the main study. The details of the preliminary study are presented elsewhere.'
DESIGN AND METHODS
The basic criterion for studying role behavior is to identify the relevant social system or subsystem and then locate recurring events that fit together: This a collection of concepts and a variety can be done by ascertaining the role of hypothetical formulations that expectations of a given set of related predict how actors will perform in a offices because such expectations are the given role or under what circummain elements in maintaining the role stances certain types of behaviors can system and inducing the required role be expected4(p") behavior. In the past, role theorists have The underlying assertion of role theory adopted methods of research that involved observing roles and that relevant to this research is that required research participants to report 0 a person's values, attitudes, and beliefs are linked to the roles he or she their own or others' expectations in relaplays within the social environment;5 tion to their role.",qThis allowed in-depth examination of role and role perform0 role performance is influenced by context and the individuals who per- ance. A case study design was selected because it best facilitated the investigaform in that context;' and 0 role theory supports the link tion of role behavior within its natural between the expectation of role per- context. In addition, to embrace the flexibility required in this study, a qualitaformance and the behavior itself.' No recent works relating to the use tive approach was chosen. Case study design involves an intenof role within perioperative nursing emerged during the literature search. sive exploration of a single unit of study Given its relevance to the topic under in its natural setting."' One researcher
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suggests that it has a particular use when 0 the questions of "how?" and "why?" are being asked, 0 the researcher has little control over events, and 0 the focus is on a contemporary phenomenon within its real-life context.'" The researcher believed that whatever the phenomena, they take their meaning as much from their context as they do from themselves. In this study, each operating department was conThe modified, sidered as an individual unit or case. complete The operating department from each of three observer role separate hospitals was purposively selected from a11owed the a database so that sufficient data could be colresearcher lected to make the study to collect data credible. The hospitals, therefore, were geographically separate and ranged and integrate in size from 300 to 1,000 beds. with team Within the qualitative members approach and case study design of this research, without having three methods of data collection were selected. to engage in These included 0 observation, work practices in 0 interviews, and 0 document analysis. the setting. OBSERVATION. A modified, complete observer role was adopted." This allowed the researcher freehom to collect the data and integrate with team members without the obligation of having to engage in work practices within the setting. Data collection took place during 358 hours and 60 operating sessions (ie, time slots booked for a particular surgeon). These sessions were planned so that observations
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incorporated the full selection of operating lists (ie, surgical schedules) for each theatre for each session during the work week. Field notes were written at regular intervals during the day and were transcribed at the end of each observational session. INTERVIEWS. Interviews were conducted with 35 nurses of different grades, ranging from student nurses to nurse managers, and amounted to a total of 34 hours of interview time. The nurses interviewed were core staff members involved in each of the observation sessions. Interviews were audiotape recorded with the participants' permission and were replayed and transcribed after each session. DOCUMENT ANALYSIS. Document analysis was carried out on a variety of documents pertaining to each site. These included daily roster sheets, educational resources for staff members, and the nursing care plans of 230 patients who underwent surgery during the observation sessions.
DATAANALYSIS Qualitative studies generally result in large amounts of data that researchers must sift through to produce meaningful results. For this study, the analysis involved preliminary coding'*followed by pattern matching and explanation building.IoData analysis also used memos, diagrams, and matrices." Memo writing involves theorizing to tie concepts and ideas together on paper. These ideas then are put into diagrams. After this is completed, connections between data can be made using matrices (ie, tables that show the interaction between variables derived from the data). ENSURING ACCURATE DATA. Normally, the terms reliability and validity do not apply in qualitative research and are replaced by the terms credibility, transferability, dependability, and confirmability as methods of ensuring that the
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TABLE1
Methods Used to Ensure Rigor in the Study Method
Application
Triangulation
Data were compared by time (ie, during 1 year); space (ie, 3 sites); and person (ie, 35 participants) and between methods (ie, observation, interview, document analysis)
research has been conducted with rigor. "-'" Various methods were Prolonged involvement 6 to 8 weeks allowed the researcher to used during the study to gauge each setting and allowed behaviors ensure trustworthiness of to normalize the data (Table 1). Persistent observation Allowed sufficient time to idenhfy and RESEARCHISSUES. Ethical focus on relevant issues approval to conduct the study was obtained from Use of a theoretical Provided a structured map for data committees at the univerframework collection sity and the hospitals concerned. Access to each Peer debriefing Peers were involved to ensure the site was secured by conresearch process was consistent and sent from hospital and accurate nurse managers before individual nurses were Member checks Original and interpreted data were given invited to participate in to participants so they could check the study. Principles of accuracy informed consent and confidentiality were upAudit trail The research process was clearly explained held throughout the for others to scrutinize and follow study. Several research issues, however, emerged as being important during the study. Their interest was generated during These issues are discussed more fully time spent in the operating department elsewhere,'; but in short, they included as students, and the inclusion of a thethe considerable influence gatekeepers atre placement during a nurse's educahad on the extent to which data could tion program was considered by manbe collected and the role conflicts expe- agers to be an important recruiting rienced by a researcher who also had strategy. For the rest of the nurses, nursing knowledge and therefore, was working in the operating department aware of issues such as unsafe nursing was a result of chance and was not practices. always welcomed. Nurses spoke of feeling devastated and of hating theatre work in the beginning. Such feelings RESULTS This section describes the actual role tended to subside after six months of performances of perioperative nurses work in the operating department. in the study. Table 2 provides a breakDEFINING NURSING-ROLE PERCEPTION. down of the roles held by nurses in the Nurses were asked to describe what study. Although the majority of nurses their role meant to them. Some definiin the sample had extensive work tions were more refined than others. experience in the perioperative envi- Ten (29%) said they had never thought ronment, their positions were not nec- about defining their role before, that it essarily permanent, and a degree of was complex, automatic, and they did it role change occurred. each day without thinking about it. This REASONSFOR WORKING NI THE OPERATING corresponded with responses from the DEPARTMENT. Only half of the sample of preliminary study. qualified nurses had actively chosen to Some nurses had a more patientwork in the operating department. focused view of their role than others. AORN JOURNAL
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TABLE2
Positions and Grades of Perioperative Nurses Parh'cipating in the Study Position
and grade 0-2
Years of Years in role at the time of the stu& experience 3-5 6-10 L i - i 15 +6 0 - 2 3 - 5 6 -10 11-15 16+
Senior nurse manager or nurse specialist grade H or I (n = 4)*
3
Theatre sister, grade F or G (n = 3)** Senior staff nurse, grade F (n = 4)t
4
Staff nurse,grade E (n = 9)H
3
Staff nurse, grade D (n = 7)s
5
Enrolled nurse, grade D (n = $5
2
Student nurse (n = 1)
Totals (n = 34, excluding student nurse)
17
* RN with a specific managerial or specialist responsibility ** RN in charge of a single theatre or group of theatres t clinically-based RN with some managerial experience clinically-based RiV with more than 2 years' postregistration experience § clinically-based RN with less than 2 years' postregistration experience % ! clinically-based nurse who undergoes a shortened training program
Nursing in the operating theatre, to me, is about caring for patients who are having an operation. . . . Looking after their needs, protecting them from the hazards of the environment, and offring them reassiirance and trying to alleviate the anxiety associated with coming for surgery. Others had a more technically orientated view of their role.
My role is about making a safe environment, assisting the nnaesthetist . . . and the siirgeon in the scrub role. . . . and protecting patients from the hazards of the environment.
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Most nurses mentioned the word "care" in relation to looking after patients, and dimensions of physical and psychological care were reported. The nurses believed that a good nurse was one who gave holistic care, and the ability to give this care was what distinguished nurses from other health care workers, including physicians. THE NURSE-PATIENT RELATIONSHIP. From the outset of the study, it was evident that the nurse-patient relationship was a transient one. Patients stayed in the operating department for relatively short periods of time and often were unconscious for the majority of their stay. Nurses also were transient, and
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although an encounter with a conscious patient might last only five to 10 minutes, it was not unusual for two or three nurses to look after a patient in this time because nurses were reallocated to perform other duties. Organizational demands superceded nursepatient continuity. PHILOSOPHIES OF NURSING. An overall philosophy of nursing was not apparent in any of the three sites. The main emphasis was on getting the work done safely and efficiently. Ultimately, this involved minimal contact with conscious patients. Patients who wanted to talk placed demands on nurses, which delayed them from carrying out their paperwork and preparation work. Although there were two main influences on nurses (ie, managers, physicians), the main driving force behind nursing actions was the medical profession, and nurses adapted their own role to fit physicians' requirements. For instance, the nurses in the study spoke of having time to establish a relationship with patients before the patients were anesthetized, but they only sent for patients at the physician's request. There was no evidence of nurses transporting patients to the OR a few minutes early so they could establish rapport with them. Nursing was based on a series of tasks associated with each position that were performed largely in response to medical need. A collective nursing voice promoting the value of care and the rights of patients did not emerge. RESEARCHAND R ~ A LA ~ O N . Interview data show that the nurses were aware of research that was relevant to perioperative nursing practice. For instance, nurses spoke about the relationship between preoperative anxiety and postoperative recovery; shaving the surgical site and the incidence of postoperative infection; and body temperature, positioning, and pressure sore prevention. Despite being aware of what was considered to be appropriate research, however, the nurs-
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es in the study had difficulty translating research into practice. MODELS AND THE NURSING PROCESS. Nurses at each study site stated that the nursing process (ie, methods aimed at ensuring continuity of care for patients) was used to provide nursing care. Two sites used the Roper, Logan, and Tiemey model of nursing, which is a model based on 12 u activities of daily living (eg, eating, drinking, maintaining safety) and a Analysis continuum from dependence to independence.lR care plans The third site used an environmental and physiconfirmed that cal checklist. The concept of the the nurses used nursing process was not readily embraced by nonspecific nurses. Some believed it was not helpful in prophrases like viding care. Nurses complained that the nursing ""reassurance process required too much paperwork, espegiven" and cially for minor procedures, and was too gen"'patient appears eral to provide individualized care. relaxed" but did Given the negativity expressed toward models not qualify and care plans, the routine way in which they these comments were completed was not a surprise. Nurses indifurther. cated they "wrote the same thing for every patient." Analysis of care plan documentation confirmed a ritualistic approach to care planning. Nurses used nonspecific and meaningless phrases like "reassurance given" and "patient appears relaxed," but did not qualify these comments further. A number of inaccuracies and omissions also were noted in the recording process. For example, 0 pressure areas were documented as
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”okay” when no checks were observed, ”patient reassured” was written when no interaction with the nurse was apparent; and ”diathermy pad on right leg” was recorded when observations showed that it was on the left leg or even that no pad had been used. Given the emphasis nurses placed on the care plan as a legal document, the observed inaccuracies and omissions were surprising. Most the There were two main reanurses believed sons for inaccurate care plans. First, more inaccupreoperative racies and omissions occurred when the contivisits are an nuity of nursing work was interrupted because important nurses were reallocated (eg, during breaks and strategy in shift changes). Second, some nurses who had not nursing surgical developed relationships with patients tended to pa tients; engage in ”pseudo care planning,” in which time however, fewer was devoted to completing specific information than 25% of (ie, addresses, physicians’ names) but not to patients received recording accurate information that related to a visits during patient’s psychological state.
of
the study.
CON TI NU^ PREOPERATIVE
OF CARE AND
VISITS. Each site
had a system for making preoperative visits. This entailed nurse visiting patients on the ward the night before or morning of surgery. The purposes of this visit, as reported by nurses, are to 0 start and build a relationship with the patient, 0 assess the patient to determine his or her nursing needs in relation to
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overall surgical care, give the patient any information he or she requires about his or her impending surgery, and offer reassurance and comfort where necessary. Most of the nurses believed that preoperative visits are an important stiategy in caring for surgical patients because of a link between preoperative information and a number of postoperative variables, such as recovery time and pain relief. Visits did not occur frequently, however, and fewer than 25% of patients received visits during the time of the study (Table 3). Given the significance nurses attributed to preoperative visits for care planning and for the psychological welfare of the patients, these figures were surprising. Several key factors influenced preoperative visits. These included 0 heavy workload, 0 medical staff member control, 0 organizational factors, and 0 exhaustion and low motivation. There undoubtedly were times when the workload prevented visits from being carried out. Nurses struggled to keep up with the work, especially when the schedule was particularly busy and throughput was high. This was compounded by staff members’ absences and evening shifts when only a skeleton staff was on duty. Visits were seen as a resource issue, and with restricted resources, other tasks were given priority. Medical staff members had the power to control the extent to which preoperative visits took place. One surgeon, for instance, prevented nurses from visiting his patients at all. Medical staff members ultimately were in control of the procedure, and the nurses did not want to give patients information that may not have been accurate; thus, nurses in the study tended to focus on a small but very general collection of questions and statements
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TABLE3
Preoperative Visits Camed Out During the Study Site A
Site B
Site C
Totals
Number of patients scheduled for surgery during the observation sessions
92
81
57
230
Number of patients who received a preoperative visit
12
24
15
51
Percentage of preoperative visits performed
13%
30%
26%
22%
about care that would not mislead patients. The nurses cited both ward organization and the organization of the operating list as mhibitors to making preoperative visits. Wards were reported to be busy, and bed shortages meant patients often were sitting in corridors. These conditions were perceived to be unsuitable circumstances for visits to occur. The nurses also reported having time limits within which to undertake visits, perhaps 20 minutes to see all the patients on the morning’s schedule. There were days when staff members spoke of being exhausted and under stress. There also were days, however, when this was not the case, and on these occasions, staff members still perceived preoperative visits as problematic. Low motivation clearly was an issue. The overall picture of preoperative visits was one in which nurses were torn between the expectation that they carry out visits and the personal realization that visits were difficult and, sometimes, impossible. At the one site where visits occurred most frequently, staff members had the support of a senior clinical nurse who had mfluence in motivating staff members, generating ideas, and setting practice standards. The value of clinically-based specialist nurses thus appears to be important in role enactment.
the care that would be provided to this patient on his or her arrival in the operating department. In the absence of the named nurse, an associate would be appointed to continue the care. This concept was fundamentally problematic in each of the study sites for two reasons. First, the boundary within which the named nurse was expected to perform was unclear, and there were varying interpretations about where the role should end. There was general agreement that the role began with the first nurse-patient interaction, whether that was on the ward during a preoperative visit, in the holding area, or in the anesthetic room. The point at which the relationship terminated, however, was a matter of some ambiguity. Opinions differed about whether it ended when the patient was transferred to the OR bed, when he or she was attached to the anesthesia machine, or when he or she was draped for surgery. There was a period of time, therefore, when no single person had responsibility for the patient. This was a time when patients’ bodies most frequently were exposed, sometimes for up to 20 minutes. Not only did this have implications for the patient’s d i p t y but also for the maintenance of his or her body temperature. The named nurse did not appear to have any responsibility for the patient during surPATIENT RESPONSIBILITY-NAMED NURSING. gery, and a key caregiver with ultimate The idea of ”named nursing” (ie, pri- responsibility was not evident. The mary nursing) was endorsed at all sites. nurses said everyone was responsible, One nurse-the named nurse-was but in reality, observations showed that allocated to be responsible for a no one assumed overall care. patient’s care while the patient was in Second, the nurses’ feelings toward the operating department. This nurse named nursing varied, and there was no was expected to visit a patient preoper- clear consensus that named nursing was atively, assess his or her needs, and plan a positive strategy for the operating AORN JOURNAL
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department. The nurses believed that it was a good idea, but it just did not work. Staff members also were resentful that it had been introduced in a top-down approach; however, no nurse had actively approached a manager in search of a workable compromise or solution. There was a prevailing attitude that making any move to change this imposed practice would be pointless. INFLUENCES ON ROLE PERFORMANCE. Rather than being influenced by formal educational processes, the role performance of nurses was molded within the work setting. The practical nature of perioperative nursing means that nurses are The constantly learning on the job. All staff members implications took an induction program during orientation not counting to their respective units; however, the majority of swabs were more learning took place while worked. The shapserious than the nurses ing of nursing practice occurred in two waysimplications by role modeling and by not interacting reinforcement. Nurses in the study spoke about ”picking with a patient. things up“ and “watching what other people are doing.” ” Students modeled the roles of staff nurses, and staff nurses modeled the roles of theatre sisters. The theatre sisters’ role was focused more on administrative and medical functions than on patient care, so nurses had little guidance regarding appropriate ways of communicating with patients. In this sense, nursing leadership was weak. When theatre sisters did work with patients, it was in the same fleeting and patronizing manner that medical staff members usedpatting them on the shoulder and telling them ”everything will be okay.” Only one of the theatre sisters was
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observed to engage in any meaningful interaction with patients; this was a junior theatre sister whose responsibility was more clinical than managerial. In addition, a subtle process of reinforcement maintained nursing behavior within each of the study sites. This was not an overt and positive reinforcement by nursing staff members through performance appraisal. Instead, behavior was shaped by negative reinforcement. The implications of not doing certain tasks were severe, and this served as an impetus to perform these tasks. For example, the implications of not counting swabs were serious; the implications of not interacting with a patient were seen to be less serious. Theatre sisters were observed to chastise staff members for not hanging up swabs or for failing to stick name labels on documentation, but no attention was paid to whether nurses interacted with patients. CONTEXTUAL INFLUENCES. The context within which the nurses worked presented considerable challenges. Operating departments were observed to be clinical, unwelcoming, and stressful for both patients and staff members. Two key themes emerged from the data: allocation/reallocation and medical domination/nurse deference. Allocation of staff members to operating suites occurred on a daily basis. In principle, there was a core team of nurses, and, when necessary, additional staff members were allocated. This provided a team who could work together to care for patients. More important than being a good team player, however, was the need for a nurse to be flexible. Flexibility was fundamentally important, and rather than being essential for good care, it was a management requirement that allowed a department to be run with the smallest possible number of staff members. Reallocation had several serious implications for nursing staff members,
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Optimal use of the workforce through reallocation superceded the continuity of patient care. External demands on nurses' time caused them considerable tension. however. Junior staff members, who already were struggling to settle into the environment, found constant reallocation unsettling. These nurses found themselves in a cyclical pattern of not knowing the routine or where to find supplies; as a result, they tended to stand in the corner until they were told to do something. This annoyed senior staff members, and consequently, they perceived junior staff members to be incompetent and criticized them in an attempt to jolt them into learning. Junior staff members became more flustered and withdrawn, so the problem was further compounded. Reallocation also negatively affected the continuity of patient care. For instance, nurses who had undertaken preoperative visits might be allocated somewhere else, so they did not see the patient come to the theatre. Nurses engaging in patient interaction in the anesthesia room were sent to scrub for the procedure, so a patient in the anesthesia room was cared for by various nurses during a short stay. The practical reality of reallocation meant that optimal use of the workforce superceded the continuity of patient care. Although nurses were trying to care for patients, external requirements on their time demanded efficiency, safety, and throughput. This resulted in considerable tension for the nurses. The second theme was medical domination and nurse deference. Initially, nurse-physician relationships appeared to be good, but as fieldwork became more detailed and probing, it was evident that nurses in the study practiced under the intense domination of the medical professionals. Some physicians were more controlling than others. Some relationships were friendly and jovial, and staff members worked well together. A few medical staff members were moody or rude, however, and they shouted at and
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patronized nurses in front of other surgical team members. One reason for the tension was the demanding way physicians treated nurses, showing little appreciation for the fact that nurses might have a patient-centered role outside the role of medical assistant. In addition, despite an increase in the number of graduate nurses and feminist influences of recent decades, nurses working in the operating department still were treated like handmaidens by physicians. Nurses assumed this position of unquestioning inferiority both in their actions and their beliefs. They disliked medical staff members who were arrogant or disorganized because this threatened the stability of their role; however, they rarely protested against their treatment. Interestingly, nurses had better relationships with anesthesiologists than they did with surgeons. On a number of occasions, anesthesiologists acted as buffers between physicians and nurses.
DISCUSSION The results of this study substantiate the views of role theorists who state that the performance of a role is inextricably linked to individuals who perform in that role and the overall context within which the actual role behaviors occur. Contexts have predictable components and greatly structure the lives of those who participate in them. The operating department is no exception to this in two components in particular-the organizational structure and the medical profession, both of which play a major part in the performance of the perioperative role. Key to relationships within the study is the idea of a role-set. A role-set is a "complement of social relationships in which persons are involved simply because they occupy a particular social The role-set of perioperative nurses includes patients, medical staff
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members, other nurses, ancillary staff members, relatives, and others. The complexity of relationships within the perioperative role-set often leads to role conflicts and ambiguities. Furthermore, problems arise because members are not apt to be equally powerful in shaping the behavior of others. In this study, nurses were relatively powerless within their own role-set. PHYSICIANS AND NURSES. The relationship between nursing and medicine has a formidable history. It has been reported that the relationship between physicians and nurses has improved over the years."."' Within the perioperative arena, one author commented
The surgeon is no longer the most important person in the operating rooin-the patient is now the centre of attention and the niirse is no longer a inere recipient of the physician's orders. With nlivances in niirsing knozuledge, the theatre niirse is nozu able to provide a service to patients as iizdividuals." (F""~ It would seem that this view is an optimistic one. The view put forward by others,22,2' that relationships between physicians and nurses are inherently problematic, is supported by this study. The relationship between physicians and nurses was not one of equal partnership or of multidisciplinary teamwork, but of ownership-a repressive and patriarchal relationship similar to the case of asymmetrical professional dominance described some 30 years ago in a classic medical text.'4 In sustaining this position, it is possible for physicians to hold nurses in strict control with a series of demands and reprimands, leaving nurses to negotiate and perform their role from a position of relative weakness in the operating department hierarchy. Considering the context within which
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they worked, however, it cannot necessarily be assumed that this is a bad situation for the nurses. With the lack of organizational support for proactive nursing, conformity to a medically subservient role provided nurses in this study with a degree of safety and security. It did not place any untoward demands on them, nor did it require them to challenge other members of the role-set; thus, the role-set remained stable. In addition, many nurses had a preference for carrying out medically oriented tasks, and in many respects, these were more determinable thin nursing tasks. Drawing up IV medication is more clearly The future defined than giving psychological care, which is periopera tive by its nature a rather vague and nebulous activnursing must be ity. It is understandable, therefore, that more focus was placed on procedures realized in terms than on the phenomenopracticing logical state of patients. The issue of carrying good nursing out physicians' work is a central tenet of the exrather than tended role debate in the United Kingdom. In reperforming as cent years, nurses increasingly have underbasic-level taken some of the roles previously believed to be physicians. the domain of physicians. Although certain nurses may have the skills and motivation to undertake such roles, this study suggests that the future of perioperative nursing must be realized in terms of practicing good nursing rather than performing as basic-level physicians. Given the hazy manner in which the nurses in this study tended to define their role, such developments may only confuse nurses and dilute nursing skills further. Great care in role development is needed.
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A FLEXIBLE WORKFORCE. The impact of organizational structure on nursing work cannot be underestimated. "The method whereby nursing work is organized is possibly the most important factor in influencing the ways in which nurses performed their Constraints on the workforce meant that managers frequently used a reallocation strategy. The effect of team nursing using a core of staff members, therefore, was limited. Both individual nurses and the nursing team as Although the a whole were disempowered. Nursing work nurses did was carried out as task work (ie, a series of tasks attempt to use that was accomplished with minimal planning the nursing and preparation). Thus, shortages were covprocess to ensure staff ered easily by other nurses flexible enough continuity to perform any task in patient care, the any specialty. Although nurses in this study did attempt to organizational use the nursing process to ensure continuity of system the patient care, the organizational system of the operating operating departments worked against them. departments The organizational conworked against text is influential in how particular sets of values are prioritized.2h In this them. case, managerial throughput superceded nursing principles. The issue, therefore, is for managers to balance the importance of throughput with the value attributed to the nurse-patient relationship. KEEPING EVERYONE HAPPY. It Was Clear from the data that nurses in the study experienced multiple expectations in their nursing role. These expectations
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came from three principle sources: managers w60 winted the work completed quickly to meet goals, physicians who wanted medical assistance to facilitate their own role, and patients who indicated by their actions and questions that they required information and reassurance.
Physicians need clever pairs of hands to assist them in their technical tasks. Hospital administrators need zuellregimented pairs of feet zuhich respond in iiniform zuays to dijierent marching orders and to different battle plans. Patients need human cornpassion, carers zuko respect them as persons and not merely as bodies.27irh22' The resolution of role strain is a complicated process that is not well researched.'8 Role strain can place a considerable burden on a person. One suggested coping method is to adjust the degree of involvement a person has in the setting3 One researcher termed this role distance, in which an individual adopts an air of casualness toward others, sometimes uses humor inappropriately, and sometimes appears over confident.?"It is possible that such behaviors observed in this study were the result of nurses trying to manage their role strain. It should be noted, however, that although such behaviors may be useful in managing strain, they also tend to influence the quality of care given to patients.lRIn the perioperative setting, where the nurse-patient relationship is all important, it is necessary to determine more effective coping mechanisms to manage role strain.
CONCLUSIONS Context was an important influence on the role performance of nurses in this study. Work organization did not support patient-focused nursing; it supported a
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system of getting the work done as quickly as possible. The medical profession had a strong influence on the nursing role. Physicians viewed nurses as medical assistants and expected them to perform as such. A nursing philosophy was not apparent. Nurses subscribed to the prevailing medical and administrative models of work. Nurses cared for patients using care strategies that were largely ineffective due to contextual demands. Nursing behavior was administratively modeled by the nursing hierarchy and negatively reinforced by the medical profession. As a result of these events, nurses employed a range of coping mechanisms to manage the dissonance between what was represented as ideal practice and what could realistically be achieved within the context of the operating department.
LIMITATIONS OF THE CASE STUDYAPPROACH The case study approach has been criticized for lacking rigor; having little scientific basis for generalization; being time-consuming; and resulting in massive, unreadable documents."JJ"J' On reflection, these criticisms are not specific to case study method, but potentially are true of any research approach. A multiple-case design was undertaken so that some of these issues could be addressed, and this was believed to increase the soundness of the study.
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ods of nursing that promote continuity of patient care, and 0 adopting an appraisal system that encourages career development for nurses. Role performance of perioperative nurses in Northern Ireland requires careful examination and explication. A philosophical shift must occur for nurses to understand and value their own therapeutic input into patient care. Nurses need to 0 work toward defining their role more clearly, 0 become more proactive and accept responsibility for the nursing role, 0 develop programs of clinical supervision to monitor their own role performance, and 0 research the needs of patients undergoing surgery and the effectiveness of nursing interventions on patient care and well-being. 03.
Helen E. McGarvey, RGN, RNT, BSc (Hons), DPhil, PCGTHE, is a lecturer in surgical nursing, University of Ulster, Coleraine, Northern Ireland.
Mary G. A. Chambers, RGN, RNT, DN, BEd (Hons), DPhil, CertBT is a professor of mental health nursing and chief nurse, South West London and St George's Mental Health NHS Trust, London. Jennifer R. I? Moore, RGN, RNT, RM, BSc (Hons), PhD, FRCN, is a professor of nursing, University of Ulster, Coleraine, Northern Ireland.
A context that facilitates therapeutic nursing within the perioperative setting needs to be created. This could be This study zuasfunded in part by a grant front AORN and an award from the achieved by National Association of Theatre Nurses. 0 moving toward a partnership model of care and away from medical NOTES dominance, 1 . H E McGarvey, M Chambers, J R 0 providing stress counseling and Boore, "DevelopmentGand definition of the other support for nurses, role of the operating department nurse: A 0 encouraging and developing methreview," ]oiirtznl ($Advanced Niirsirig 32
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tive research: The decision trail," Joirrizal of (November 2000) 1092-1100. 2. "A model for perioperative nursing prac- Advanced Nursing 19 (May 1994) 976-986. 17. H E McGarvey, M G Chambers, J R tice," A O R N Joiirnal41 (January 1985) 188Boore, "Collecting data in the operating 194. department: Issues in observational 3. B J Biddle, Role Tkeory: Expectatio17, methodology," lntensive and Critical Care Identities, atid Behaviors (New York: AcaNiirsing 15 (October 1999)288-297. demic Press, 1979). 4.M E Conway, "Theoretical approaches to 18. N Roper, W W Logan, A J Tiemey, The Elements of Nursing: A Model for Nitrsirig the study of roles," in Role Tkeory: PerspecBased on a Model of Living, fourth ed (New tizles for Health Professionals, ed M E Hardy, York Churchill Livingstone, 1996). M E Conway (New York Appleton19. L I Stein, "The doctor-nurse game," Century-Crofts, 1978) 17. Archiues of General Psychiatry 16 (June 1967) 5. R K Merton, Social Tkeory atid Social 699-703. Strircture (New York Free Press, 1968). 20. L I Stein, D T Watts, T Howel "The 6.B A Hurley, "Socialization for Roles," in doctor-nurse game revisited," Tke New Role Theory: Perspectives for Health ProfesEngland Journal of Medicine 322 (Feb 22, sioiinls, ed M E Hardy, M E Conway (New 1990) 546-549. York: Appleton-Century-Crofts, 1978) 2921. C P Wicker, "Primary nursing. A reas72. suring presence," Niirsing Times 86 (July 187.H E McGarvey, M G Chambers, J R 24,1990) 56-61. Boore, "Exploratory study of nursin in an operating de artment: Preliminary indings 22. B J Fisher, C Peterson, "She won't be dancing much anyway: A study of suron the role o the nurse," Intensive and geons, surgical nurses, and elderly Critical Care Niirsirzg 15 (December 1999) patients," Qualitative Health Research 3 (May 346-356. 8.D Katz, R L Kahn, Tke Social Psychology of 1993) 165-183. 23. J K Cook, M Green, R V Topp, "ExplorOrganizations, second ed (London: John ing the impact of physician verbal abuse on Wiley, 1978) 187-221. erioperative nurses," A O R N Joiirnal74 9.B J Biddle, "Recent developments in role theory," Aniiiial Review of Sociology 12 (1986) September 2001) 317-331. 24. E Freidson, Professiorz of Medicine: A 67-92. Study of the Sociology of Applied Kriozuledge 10. R K Yin, Case Stirdi Research: Design and (New York Dodd, Mead, and Co, 1975). Methods, second ed (T ousand Oaks, Calif 25. D Field, Niirsing the Dying (London: Sage, 1994). Tavistock/Routledge, 1989) 120. 11.R L Gold, "Roles in sociological field 26. S Braye, M Preston-Shoot, Enipozuering observation," Social Forces 26 (March 3, Practice in Social Care (Philadelphia: Open 1958) 217-223. University Press, 1995) 53-54. 12.A L Strauss, Qiialitative Analysis for 27.A Perry, "A sociologist's view: The Social Scieiitists (New York: Cambridge handmaiden theory," in Nursing: Its Hidden University Press, 1987) 28-33. Agendas, ed M Jolley, G M Brykczynska 13.J Corbin "Coding, writing memos, and (London: Edward Arnold, 1993) 62. diagramming," in Froin Practice to Grounded Tlieory: Qualitative Research in Niirsin ed W 28. M E Hardy, "Role stress and role C Chenitz, J M Swanson (Menlo Parf; Calif: strain," in Role Tkeory: Perspectives for Healtk Professionals, ed M E Hardy, M E Conway Addison Wesley Publishing Co, 1986) 102(New York: Appleton-Century-Crofts, 119. 1978) 73-110. 14. M B Miles, A M Huberman, Qualitative 29. E Goffman, Wkere tke Action Is: Tkree Data Analysis: An Expanded Sourcebook, second ed (Thousand Oaks, Calif Sage, - 1994) Essays (London: Allen Lane, 1969) 68-84. 30. D L Jorgensen, Participant Observatioii 278-279.' (Newbury Park, Calif: Sa e, 1989) 19-20. 15.C Robson, Real World Research: A 31. R E Stake, "The art o case study Resoiirce for Social Scientists and Practitioner research" in Handbook of Qualitative Researck&s (Oxford, United Kingdom: Researck, ed N K Denzin, Y S Lincoln Blackwell, 1993)402-407. 16.T Koch, "Establishing rigour in qualita- (Thousand Oaks, Calif: Sage, 1994) 236-247.
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