Perioperative nursing in public university hospitals: an ethnography

Perioperative nursing has been explored from different angles for more than a decade [1]-[3]. The interaction between nursing care and technology has been discussed in particular detail [2],[4]. This discussion has raised a number of questions about the tendency to view nursing in operating rooms (ORs) as invisible to the patient and as surgical interventions without nursing activities [5],[6].

Perioperative nursing as an act of technology includes the knowledge and skills to work proficiently with instruments, equipment, and machinery [7]-[9]. Numerous advances in technology such as robots, digital displays, artificial organs, magnetic sensors, and communications technology [7],[10] require that nurses also become educated in information technology (IT) [8]. In ORs, the team members work and activities are structured around the management of the “operating list” [11].

The surgical event is viewed as a social and technical process [12] that involves the entire team, including the surgical nurse, circulating nurse, anesthesia provider, surgical technician, and surgeon. Furthermore, the content of perioperative nursing is viewed as a number of activities that often occur simultaneously. The use of specific instrumentation and procedures illustrates the central nature of the actions in ORs, where the dominant goal is to conduct a successful operation for the treatment of a specific disease or injury [6] with a focus on patient safety and prevention of surgical infection [13],[14].

From a patient perspective, technology can be quite frightening, despite the fact that nurses find all aspects of perioperative nursing and the large display of technology familiar [15]. According to Sweeny [8], the use of technology and related transitions can reduce human contact. A recent review highlighted the transitions that increased patients’ anxiety [16], adding importance to the implementation of individualized nursing care in the perioperative setting.

However, the involvement of such care (e.g., when using the term “advocacy”) in perioperative nursing in the OR is unclear. A descriptive study of OR nurses’ perceptions of the implications the concept “advocacy” included interrelated and overlapping themes such as protection, communication/vocalizing, doing, comfort, and caring [17]. When Westerling and Bergbom [18] evaluated effective perioperative nursing care from the patient’s perspective, they found that the value of being acknowledged as an individual carried particular importance to the patients, and that the ability of patients to share their perioperative experience with familiar nurses made the patients feel calm, safe, and secure. This perspective was first identified by Rudolfsson et al. [19] and later actualized by Rudolfsson [4] in their elaboration of a model illustrating the perioperative dialogue/ethos, showing that the patients felt that it was safe to hand over the responsibility to the nurse when they felt acknowledged, listened to, and met with empathy. Likewise, another study demonstrated the creation of continuity through preoperative dialogue, its manifestation in intraoperative dialogue, and its closure in postoperative dialogue [20]. Although the interaction between nursing care and technology has been taken for granted by many OR nurses [6], the interaction has also been viewed as a challenge [21]-[24] because perioperative nursing has been, and remains, inextricably linked to the development of technology with the risk of eroding the quality of care [6]. Therefore, perioperative nursing is constantly faced with new challenges and opportunities that necessitate continual updates of nursing knowledge and technical skills [3],[25]. In light of the longstanding relationship between nursing and technology, it is interesting that only few studies with this focus have been performed [21]-[24]. Furthermore, these studies are >10 years old.

With this background, the purpose of the present study was to investigate the actual content of perioperative nursing in highly specialized ORs in public university hospitals. The research question was: What is the content of perioperative nursing and how do nurses facilitate interactions between nursing care and technology in highly specialized ORs in public university hospitals?

This ethnography was based on participant observations and interviews inspired by practical ethnographic principles [26]-[28]. We directly observed OR nurses in the field and interviewed them about their experience to capture the concrete, everyday practice in ORs and understand the content of perioperative nursing. The participants comprised 24 registered female nurses selected from 8 surgical specialties at 3 urban geographical locations in 2 public university hospitals to ensure diverse and nuanced data. The surgical specialties included orthopedic, thoracic, gastrointestinal, breast, ear-nose-throat, neurosurgical, urological, and gynecological surgery. The participants’ ages ranged from 31 to 63 years. They had from 3 to 24 years of nursing experience in ORs. A minimum of 3 years of clinical nursing experience was required for enrollment in this study to ensure a strong nursing identity and clinical knowledge [29],[30].

Data were collected through field observations of each participant for a period of 3 to 5 days for 5 to 8 hours per day depending on the participant’s daily work in the OR. This time period was based on both experience from another field study and the aim of achieving empirical saturation [31]. This saturation was achieved when the nuances in the nurses’ experiences decreased though changes in settings and geography.

During the field observations, the authors (E.E.S. and I.Ø.O.) produced handwritten field notes [27]. Each participant observation was followed by an ethnographically inspired interview [26]. The interviews were based on semistructured interview guides individually created based on the previous field observations. One interview question was: “You told me you had technical flair. Could you please tell me more about this flair?” The interviews were intended to contribute to a deeper understanding of the context-bound events from the participant observations [28]. The overall study period included 122 operations performed during 9 months, amounting to 273 hours in 44 days and 6 nights. This strategy allowed for repetitions over time and set aside the “tip-of-the-iceberg” assumption [27].

The results of the analysis led to two main findings. The first main finding concerned OR nurses’ interaction between skills and understanding, and the second concerned OR nurses’ interaction between nursing care and technology. In the Results section, each citation of an observation or interview statement has been assigned a reference number for one of the 24 participants, who practiced as either the circulating nurse (CN) or surgical nurse (SN).

The purpose of this descriptive study was to investigate the content of perioperative nursing in highly specialized ORs in public university hospitals and elucidate perioperative nurses’ interactions between nursing care and technology. The findings suggest three different levels in which perioperative nurses navigate between nursing care and technology. Thus, this study supports earlier research regarding nurses’ ability to combine technical and relational skills [6],[21]-[24]. Bull and FitzGerald [6] reported similar findings from an ethnographic study in Australia. They stated that the necessity of combining technological proficiency and caring in the OR was taken for granted by nurses. However, our study suggests that this is not always the case when the interaction between nursing care and technology is declining or failing.

Research-based knowledge is needed to inform leaders and nurses about the technological and nursing tasks involved in perioperative nursing [39],[40] and to apply this knowledge to patient safety [16]. According to Scheel [36], the cognitive-instrumental mode of action in this study is presented by the nurses’ different levels of technological skills, which range from technical flair to a lack of technical skills. The aesthetic-expressive mode of action is observed by the way Informant 23 referred to the patient in a respectful manner. The opposite occurred when Informant 17 stated that she did not care about patient contact. The third mode of action, the moral-practical mode, is represented by Informant 23, who applied her experiential knowledge about ostomy care. This was what the patient and the actual situation demanded from the nurse. The opposite occurred when Informant 17 prevented a colleague from speaking up for the benefit of the patient.

These three different modes of action require unification [36]. At the interaction level, the interactions among the three modes of action are always part of the current patient–nurse interaction. At the declining interaction level, the cognitive-instrumental or aesthetic-expressive mode of action is particularly prioritized depending on the individual nurse. Thus, the three modes of action do not always interact at this level. This leads to the risk of inadequate nursing care unless the OR is staffed with nurses with different skills who can ensure an interaction among the three modes of action. The failing interaction level was characterized by a lack of interaction among the three modes of action. According to Scheel’s [36] terminology, this is not nursing. This interpretation was confirmed by Bull and FitzGerald [6] who concluded that the combination of technological proficiency and patient-focused ethics of care defines whether nurses’ actions in the OR can be characterized as “nursing” (interaction level) rather than “technical” tasks (failing interaction level). In other words, there is a risk that technology undermines care. However, the present study also showed that nurses at the declining interaction level prioritize nursing care, perhaps because of their lack of technical flair. Interestingly, however, most studies on perioperative nursing have focused on nursing care in contrast to OR nurses’ technical skills [2],[4],[41],[42]. Barnard [21] and Sandelowski [23] are well known for their theoretical studies on nursing and technology. Similarly, Barnard and Gerber (1999) investigated nurses’ understanding of technology through interviews. Nevertheless, the study was based on ethnographic principles and thus revealed new dimensions in technical skills. Some nurses possessed technical flair, while others were technically unskilled. This raises new questions and concerns about nurses’ varying technical skills and may thus inspire further research and discussion.

In this study, nurses at the interaction level combined nursing care and technology with self-reflection and a great understanding of the interdisciplinary team. Nursing practice was characterized by flexibility and excellence because the same nurse interacted with all three modes of action [37] in that she managed all tasks in the OR. Nurses at the declining interaction level prioritized either the technical or the nursing care dimension, and self-reflection was directed toward elements of the tasks in the OR. A match between two different nurses in the OR is required to ensure interaction among all three modes of action. This limits the implementation of perioperative nursing because the nurses cannot perform all of the tasks in the OR. Nurses at the failing interaction level lacked self-reflection and showed no interest in the patient. New technological challenges were limited by the nurses’ lack of technical skills. Nursing practice was characterized by inflexibility and rigidity because the nurses worked in isolation with limited collaboration with the other staff members. This interpretation was confirmed by Coe and Gould [43] and Finn [44], who claimed that well-functioning interdisciplinary teamwork is described as excellent. Thus, the present study’s findings regarding flexible versus inflexible nursing practice add to the discussion on generalist versus specialist nurses [45], as well as to the discussion on seeing the big picture in nursing, which indicates a desire to provide good care to both patients and staff [46]. An individual who fails to see the big picture might act rigidly, rather than appropriately, resulting in blind action due to mechanical and automatic thinking.

The findings in this study suggest three different levels at which perioperative nursing care and technology interact in highly specialized ORs in public university hospitals. This categorization of perioperative nursing into levels is not new. In a quantitative, descriptive, correlational study of perioperative nurses’ ability to think critically, Fesler-Birch [3] calculated the average level of critical thinking to be 2.12 on a scale of 1 to 4, in which 1 indicates no critical thinking and 4 indicates complex critical thinking. Because critical thinking may be central to nurses’ ability to meet patients’ expectations regarding care and skill, this average level of 2.12 can be costly from a patient perspective, in that as intraoperative problems arise, quick clinical judgment decision making may weaken. Fesler-Birch’s study cannot be compared to the present study in that the two were based on different methodologies. However, a number of new questions are raised when comparing one study to the other. For example, could a correlation exist between perioperative nursing at the failing interaction level, which is characterized by nurses’ lack of self-reflection, and level 1 critical thinking, which is characterized by the absence of critical thinking? On the contrary, could a correlation exist between perioperative nursing at the interaction level, which is characterized by nurses’ self-reflection, and level 4 critical thinking, which is characterized as complex? If so, both the failing interaction level and level 1 critical thinking can be costly from a patient perspective. Although there is no solid basis for this conclusion, these questions may inspire further research and discussion.

Perioperative nursing in highly specialized ORs in public university hospitals is performed at three different levels depending on the interaction between nursing care and technology. This leads to different characteristics of practice: Practice at the interaction level is characterized by flexibility and excellence because nurses exhibit interaction among (a) technological activities based on technical flair, (b) an understanding of the individual patient and self-reflection based on dialogue and communication, and (c) acting in relation to the patients’ overall situation. Nurses at the interaction level perform all tasks in the OR. Practice at the declining interaction level is characterized by less flexibility because nurses prioritize either (a) technological and instrumental activities based on technical flair or (b) nursing care based on an understanding of the individual patient. Nurses at the declining interaction level are unable to perform all tasks in the OR. Finally, practice at the failing interaction level is characterized by inflexibility and rigor because nurses’ self-reflection and interest in the patient are lacking. New technological challenges are limited by nurses’ lack of technical skills or technophobia. Nurses at the failing interaction level work in isolation with limited collaboration with other staff in the OR.

The findings of this study are useful in organizational, clinical, and educational settings in updating policies for perioperative nursing and enlarging perioperative nurses’ understanding of the relationship between nursing care and technology. Considering that practice at the declining interaction level and failing interaction level is characterized by inflexibility and isolation, nurses at these two levels must develop their competency to the flexible and excellent interaction level. An important task for nurse leaders with respect to recruiting and retention is to be aware of the need for proficiency in this field. The present findings also have some potential in relation to other areas where technology is increasing in the nursing field; e.g., the use of telehealth and technology to support older people in their homes as well as other highly technical areas such as high-dependency units and intensive (coronary) care.

Our discussion is an example of how to use nursing theory in research and expressions such as nursing care and technology, which might lead to constrained nursing practices if misunderstood. Further empirical studies are required to challenge our conclusion that nurses perform perioperative nursing in highly specialized operating departments at three different levels depending on the interaction between nursing care and technology.