Background
The operating room (OR) is a hospital unit with advanced technology that requires a multidisciplinary team to handle life-threatening situations with frequent interpersonal conflicts [1]. It is a place where patients confront potentially harmful risks and are unconscious due to anesthesia, leaving them reliant on life activities. In these fast-paced and high-stakes environments, operating room (OR) nurses play a crucial role in ensuring the safety and well-being of patients undergoing surgery, where high ethical standards must be upheld [2, 3].These nurses frequently encounter ethical issues that challenge their professional responsibilities, decision-making processes, and personal values [4‐6].
Ethical issues are complex problems that can be new situations, everyday issues, or dilemmas that are difficult to resolve and necessitate a moral solution, and thus must be decided among several alternatives [7]. Issues such as maintaining patient dignity, ensuring informed consent, balancing privacy with surgical efficiency, and addressing conflicts within interdisciplinary teams are central to OR nurses daily practice [4, 5, 8].
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Issues in ethics can lead to moral distress, psychological and physical symptoms such as anxiety, despair, worthlessness, resentment and anguish, decreased job satisfaction and even improper or inadequate nursing care [9]. Immoral behaviors in healthcare often occur in the operating room (OR), requiring continuous improvement in professional skills and moral competence for OR nurses, as alloying unauthorized observers in OR, operating on wrong site or patients, resource misuse and/or incorrect material registration, suspicious drug usage, compromised sterilization standards, and instruments are often retained within patients [8‐10].
Studies revealed that Nurses working in OR had double duties for ethical issues encountered during their clinical practice. A Swedish study revealed that OR nurses face two moral dilemmas in patient care: possessing professional skills for procedures and maintaining professional relationships with patients and colleague [4]. Farther more studies in Turkey and Iran revealed that OR Nurses in theater complexes face moral challenges like respecting values, committing to organizational pledges, and adhering to professional and ethical principles [5, 6]. Perioperative nursing care in Malawi as well as Ethiopia faces challenges due to resource distribution, staff shortages, work load, and lack of ethical codes, affecting decision-making processes among OR nurses [11‐13].
Few strategies are used to resolve ethical issues in the OR. Among these strategies, the World Health Organization, the International Council of Nurses (ICN), and the American Nurses Association (ANA) have developed and implemented professional codes of ethics [14‐16]. The International Council of Nurses (ICN) recommends that Operating Room nurses adhere to their country’s code of ethics, which outlines the profession’s values and conduct in addressing ethical issues, based on universal principles of beneficence, nonmaleficence, justice, and autonomy [17]. Adherence to professional ethics in nursing professions fosters a sense of reliance, safety, and peace in patients, reduces hospitalization time, fosters proper interactions between nurse-patient and nurse-colleagues, and ultimately reduces hospital stay costs [18‐21].
Despite the structured protocols in place, OR nurses often face situations where ethical considerations are complex, particularly in emergency settings, resource-limited environments, or when dealing with vulnerable patient populations. The high-pressure nature of the operating room, combined with the need for quick, life-saving decisions, can sometimes lead to compromises in patient dignity, privacy, or autonomy. These ethical challenges may also affect nurses emotionally and professionally, contributing to moral distress and impacting their job satisfaction [9, 10].
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In addition, codes of ethics in healthcare settings are primarily used for patient-related matters and should be updated to better serve the evolving nursing context [11, 12, 22]. The Ethiopian Nurses Association’s code of ethics for registered nurses is being revised but is not yet in clinical use [11]. The International Council of Nursing (ICN) code of ethics states that many countries lack ethical codes for nursing specialties like OR [17], leading to confusion and uncertainty among nurses, ultimately causing patient dissatisfaction [19].
Phenomenological research into the lived experiences of OR nurses provides a valuable lens to explore how they navigate these ethical challenges. By capturing their personal experiences, this study aims to uncover the nuanced ethical dilemmas they face, how they resolve these conflicts, and the support systems or coping mechanisms available to them. This exploration is crucial for developing strategies to better support OR nurses in handling ethical issues, improving patient care outcomes, and fostering a more ethically sound operating room environment. Therefore, this study aimed to explore the ethical experiences of operating room nurses at Adama Hospital Medical College, Adama, Oromia, Ethiopia, in 2022.
Methods
Study setting and period
The study was conducted at Adama Hospital Medical College (AHMC), from March 15 to April 15, 2022. Adama is located in central Ethiopia, it is situated at an elevation of 1712 m and is 99 km south east of Addis Ababa [23]. AHMC, the largest public hospital in Ethiopia’s Oromia regional state, it serves over 7 million people and receives referrals from various regions. It is the only public hospital among five in Adama city, with a large operation room units, making it the most suitable for purposive selection. Currently, the hospital has a large operating room (OR) with six tables as a major OR, an orthopedic OR with three tables and an obstetric OR with two tables. Thus the hospital fulfils maximum variation to select purposively. The administrative records report the hospital human resource profile shows that the hospital has 34 specialists, among them 12 general surgeons, 1 ENT sub specialist, 1 urology-surgeon, 1 neurology-surgeon, 9 gynecologists, and 1 anesthesiologist. The administrative report also showed that there are 12 anesthetists and 90 department specific OR nurses comprised within the hospital as per the administrative records report [24].
Study approach
The study employed a phenomenological design grounded in Heidegger’s philosophy [25] and hermeneutic phenomenology [26]. Martin Heidegger’s philosophy guides qualitative researchers in understanding study participants’ experiences, emphasizing interpretation within phenomenological research as an interpretive endeavor, while Hermeneutics is a systematic method used to interpret phenomena and gain a deeper understanding of lived experiences.
Populations
All operating Room nurses working in AHMC were our source population while those with rich experience of the subject and ability to express and fulfill inclusion criteria during study period were our study population.
Inclusion and exclusion criteria
To participate in the study, participants needed to have at least two years of work experience in the operating room, significant experience with the subject, and the ability and willingness to express themselves and engage in the study. Perioperative nurses on sick leave, annual leave, or maternity leave were excluded from the study.
Sample size determination and sampling techniques
Eighteen experienced operation room nurses were recruited using criterion-based purposive sampling with maximum variation such as age, gender, years of experience, and working unit. The sample size was determined based on information needs, with saturation of information as a guiding principle, and sampling was conducted until no new information was obtained [27]. The study included 10 women and 8 men, as shown in (Table 1). Oral and written consent was obtained. The majority of the participants were operating room nurses.
Table 1
Socio-demographic characteristics of study participants in AHMC, Adama, Ethiopia, 2022
Participants | Age | Sex | Level of Education | Total Working experience |
|---|---|---|---|---|
P1 | 35 | F | BSc | 14 |
P2 | 39 | M | BSc | 15 |
P3 | 49 | F | BSc | 20 |
P4 | 50 | F | MSc | 23 |
P5 | 34 | M | MSc | 12 |
P6 | 29 | M | BSc | 7 |
P7 | 32 | F | BSc | 13 |
P8 | 27 | F | MSc | 11 |
P9 | 48 | M | MSc | 20 |
P10 | 32 | F | Bsc | 10 |
P11 | 49 | F | MSc | 22 |
P12 | 40 | F | Bsc | 19 |
P13 | 32 | M | Bsc | 12 |
P14 | 29 | F | Bsc | 13 |
P15 | 34 | M | Bsc | 14 |
P16 | 38 | M | MSc | 14 |
P17 | 23 | F | Diploma | 5 |
P18 | 25 | M | BSc | 5 |
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Data collection tools and methods
A semi-structured interview guide was used to conduct an in-depth interview. The tool was created using similar research and some guides that were modified to fit the study’s objects [3, 4, 22, 28]. All interviews were conducted by first author. Memo was used to record facial expression of participants and newly found themes. To facilitate interviewing, the tool was first developed in English and then translated by first Author into the local language “Afan Oromo.” Probing questions were asked to make the interview clearer and deeper. The goal of the study was stated prior to the start of the interview, and participants provided informed consent to record the interviews. A pretest was conducted with two operating room nurses at Bishoftu Referral Hospital, meeting inclusion criteria. Interviews were conducted between 1:30 − 2:15 h, with a mean duration of 1:45 h. Participants were thanked for their cooperation and time for participating in the study.
Trustworthiness
A pretest was done to guarantee data rigor. Data collection, verification, and translation were done by the first author to take note of the participant’s facial expressions, as well as prepare a conducive setting for the interview. In addition, to ensure the rigor of the study, four major criteria were employed: credibility, confirmability, dependability, and transferability [29]. Investigators conducted member checks on participants during the data gathering and analyzing procedure to confirm their reliability. To ensure those participants’ experiences at each level were accurate and clear, data or findings were returned to them, and improvements were made as needed. Furthermore, long-term and continuous data engagement, as well as participant variety in terms of demographic factors (e.g., gender, age, and job experience and working units), aided the credibility and transferability of the results. The study was thoroughly documented, with an audit trail set up to track unique themes, explain code merging, and define theme meaning. To discover biases, the researchers were invited to reflect on their beliefs and interests, and the study conclusions were based on participant remarks.
Data analysis
The data were analyzed using Van Manen’s approach by the principal investigator and immediately following the first interview and simultaneous data collection [26]. The study involved conducting interviews and creating a code book using Atlas ti - software. The code book was updated to include new codes discovered during data collection. Data analysis was conducted concurrently with data collection, with the principal investigators transcribed interviews in Afan Oromo and translated them into English. The researchers independently identified potential themes, codes, and quotes, and then pooled observations. Preliminary code lists were created, and related codes were generated by categories. Six steps were followed during analysis: familiarizing with the data, generating initial code, searching for themes, reviewing themes, defining and naming themes, and producing a report.
Standard definition of terms
Ethics
is the set of moral principles that guide individuals’ behavior, encompassing both theoretical and applied categories. Theoretical ethics explores the meaning and objectives of morality and responsibility, while applied ethics aids in making the right and wrong decisions, dividing morality into theoretical and applied categories [5, 15].
Professional ethics
Ethical issues
Code of ethics
Is a formal statement of a group’s ideas and values, serving as a guide for professional actions and public commitment. These codes are typically higher than legal standards and must never be lower than the profession’s legal standards. Perioperative nurses must adhere to their respective countries’ Code of Ethics.
Results
Socio-demographic characteristics of study participants
A total of 18 operating room nurses (10 women and 8 men) with a mean age of 34.325 years, a mean total work experience of 14.125 years and a mean work experience in OR of 5.675 years participated in this study as shown in (Table 1) below.
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Emerged themes
Analysis of the interviews data initially led to construction of 1,129 codes. But, after repeated data analysis, subsequent deletion of duplicate codes and merging similar items, two main themes and eight sub-themes for regarding common ethical issues raised in OR were emerged (Table 2).
Table 2
Extracted themes and sub-themes regarding common ethical issues in making ethically sound decisions in AHMC, Adama, Ethiopia, 2022
Identified Themes regarding Ethical issues | |
|---|---|
Themes | Sub-themes |
Issues related to safeguarding patient dignity | Preoperative Communication and Consent |
Ethical Considerations in Emergency Surgeries | |
Privacy in the Operating Room Environment | |
Cultural and Gender Sensitivity during anesthesia and consciousness levels | |
Ignoring patients’ expectations | |
Staff Professionalism and Respectful Interaction | Issues of staff rapport and teamwork sprit |
Issue of personal & professional Competence | |
Issues of bearing once own responsibility | |
Issue of caring for patient with justice | |
Omission to follow sterilization standards and aseptic techniques | |
Identified themes regarding ethical issues encountered OR nurses
Two themes were constructed regarding common ethical issues encounter nurses in OR; Issues related with safeguarding patient dignity and staff professionalism and respectful interaction.
Issues related with safeguarding patient dignity
The first theme, issues related with safeguarding patient dignity was composed of five subthemes. Here are subthemes for research study findings related to safeguarding patient dignity in the operating room.
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Preoperative communication and consent
The participants of the study reported that communicating patients in an untruthful manner is the other ethical issue seen in perioperative setting. A participant with 23 years of work experience highlighted said, “Some of our employees speak to patients in an untrustworthy manner. One must respect the promise made to his or her patient as an individual, regardless of social status or background, and should always tell the truth. This attitude should be extended to their family caregivers as well as the surgical team.” (P4).
Another participant with 12 years of experience stressed by sharing his experience that, “Some of our employees engage in unethical behavior with patients. One must always tell the truth and respect the promise made to his or her patient as an individual, regardless of social status or background.” (P5).
Participants of study reported that one of ethical problems/issues happen in perioperative setting regarding to safeguarding patient dignity is issue of informed consent. They reported that patients’ informed consent is not fully performed during patients undergoing surgery and they are included in the research without their permissions. In this regard an OR nurse with 10 years of work experience stressed that, “Typically, patients are brought to the operating room without having signed a consent form. Their surgical information is also taken without their permission. Again I said! One of the most common issues is that surgical procedures are performed on patients without their permission.” (P10).
Again, participants also shared their experiences with situations where informed consent was not respected, leading to criticism for not adhering to patients’ rights to know about their illness, choose treatment options, and refuse treatment. One of the participants stated that, “I have seen the practice of obtaining consent from patients for major procedures by our colleagues, but I have not seen the practice of informing patients in detail about their treatment. As a result, they sign stating that they are unfamiliar with the procedure in detail. On the other hand, our colleagues believed that consent was simply a formality for obtaining signatures for procedures, and that the patient and family were not properly informed.” (P18).
The study reveals that honesty and truthfulness in communication are the most effective strategies for addressing ethical issues in perioperative settings for promoting collaboration and patient wellbeing. With these regard, one of the participants with 12 in OR years of work experience suggested by sharing her experience by stating that, “Once upon a time, I gave a surgeon a small artery during intraoperative phase. But the instrument lost inside the patient’s abdomen. During counting, the instrument was missed, and I was stressed. However, I said the count was correct because time was running out. Residents were beginning to close the patient’s abdomen. But, I was afraid that if I told the surgeon, I would get in trouble. But, because the patient could have a post-operative infection due to a foreign body left in the abdomen, I quickly told the truth, and they discovered it quickly. Honesty among the perioperative team is required for eternity to gain the trust and satisfaction of patients and colleagues.” (P3).
Ethical considerations in emergency surgeries
Another participant shared his experience by stating: “When a patient who developed pneumothorax after tracheostomy at emergency department was come to OR, I faced the scenario that the patient’s family argued that they were not adequately informed and given treatment options”. (P6)
Another participant share her experience by stating: “The necessary intervention without the client/patient’s consent only as an exception and in case of an emergency, when immediate therapeutic action is required to save the client/patient’s life” (P17).
Privacy in the operating room environment
Assessing how exposure and physical vulnerability during surgery affect patient dignity and privacy.
Most participants reported that observers in operating rooms often perform training and education without patients’ consent in our hospital, which poses threats to infection and violates the principle of privacy, despite being treated as normal. An OR nurse with 10 years of work experience stressed that, “More than 20 people including routine surgical staffs attained narrow operating room for training without permission of patient, which makes OR overcrowded and source of infection. This issue also violates the patient’s privacy principle.” (P5).
Participants share their experiences by suggesting way to overcome the issue. A participant of 35 years old with 6 years of work experience confirms that, “Over traffic in perioperative settings can cause stress and psychological safety issues for patients, and negatively impact team performance. Maintaining a quiet environment, especially during preoperative is crucial for the theatre team to ensure patient safety and prevent harm to the patient.” (P1).
Cultural and gender sensitivity during anesthesia and consciousness levels
The majority of participants agree that patients’ privacy is crucial especially in perioperative settings, as they are highly susceptible to loss their privacy due to their unconscious status as a result of anesthesia. A participant with 6 years of work experience in OR share her experience “A few days ago, myomectomy procedure was performed with spinal anesthesia, allowing the patient to remain fully conscious. During catheterization, a woman felt uncomfortable due to a male resident ready to catheterize her. So I asked him to give the procedure our sister and go out, until the procedure was complete, ensuring her comfort. I do that because the focus was on patient privacy, rapport, and fostering positive relationships between the care giver and patient.” (P3).
Ignoring patients’ expectations
Participants also stated that ignoring patients’ expectation is one of the most ethical issue encountered in perioperative setting. They reported that in the operating room sometimes our staffs omit patients’ decisions and the right of their treatment option.
A participant with 5 years of experience in OR stated by sharing his experience that, “I remember that once upon a time, we had a patient who in the past undergone Laparatomy. At that time her skin was sutured with a stapler and end up in many scars. For second time myoma was relapsed and again she come for surgery and she stressed to suture with material that end up her skin with disgusting scar. In contrast the same thing has happened because surgical team was harried to finish the case and go out. Due to this, the patient was very upset and had many scars left. Look! How ignoring patients expectation harms performance outcome and patients psychology.” (P13).
Staff professionalism and respectful interaction
The send theme, issues related with Staff Professionalism and Respectful Interaction was composed of five subthemes. These are: - Issue of personal & professional Competence, issues of bearing once own responsibility, Issue of caring for patient with justice and Omission to follow sterilization standards and aseptic techniques.
Issues of staff rapport and teamwork sprit
The study revealed that participants encountered difficulties in making ethically sound decisions in perioperative settings, especially in teamwork and rapport-building among Operation Room staff. A nurse with 19 years of working experience in nursing and works in Operation Room for three years shared her experience by stating that, “Sometimes, people make you dissatisfied by speaking to you in disrespectful language and disrespect, this leads to decreased motivation, diverted focus, and potential complications in a procedure, posing a risk to patients’ safety. At that time, I prefer silence and perform my duties in the operating room alongside my colleagues.” (P12).
Most of the study participants suggested that positive relationships and teamwork are crucial for ethical decision-making in perioperative settings. Appreciating colleagues’ privacy, position, personality, differences, and knowledge sharing enhances empathy and collaboration skills, leading to a calm work environment and optimal patient care. This approach fosters a sense of calm and collaboration. An Operation Room Nurse with 22 years of working experience suggested that, “On individual bases, I experience constructive and inspired if my colleagues, who are younger and not qualified than me, give awareness to my experiences and opinions. I discharge my responsibilities in my work place with enhanced courage and further inspiration.” (P11).
Another OR nurse with 5 years of work experience suggested that, “Respectful rapport between nurses, anesthesia team, and surgeons is crucial for patient outcomes and safety. It saves resources, reduces work stress, and reduces heavy workload in the operating room. Hostility can lead to poor patient outcomes and prolonged hospital stays” (P1).
Another Operation Room Nurse with 12 years of work experience suggested that, “In operating theatre different professionals with different professions and with different tasks work together to achieve a common goal, understand the complexity of the clinical situation, make appropriate decisions, and perform safe surgery. The performance of all these members has a direct effect on outcomes of surgical work. Hence owning a spirit of cooperation in the operating room was crucial.” (P9).
Issue of personal & professional competence
The participants mentioned that among ethical issues that frequently occur in perioperative settings is the inability to proactively aim for the growth and development of themselves and other team members with knowledge, skill, and attitude which hinders the enhancement of personal and professional competence. A participant with nine work experience highlighted: “The majority of our staff, including myself, are not prepared to be efficient and successful at our task and improve certain character traits; we only do the task for the sake of our lively hood. Sorry to say, not only accomplishments at work, but also a virtuous personality. Overall, we are not aiming for excellence.”(P6).
An OR Nurse with 13 years of work experience also confirms the above idea by stressing that, “As far as I can tell, most of the time, especially among nurses, they are passive in their pursuit of scientific knowledge. Even if OR activities are an excellent example of effective teamwork for sharing whatever you require to ensure the best possible outcome, and do everything possible during surgery to ensure that the patient is transferred to the recovery room without complications that need enriching yourself in terms of knowledge, skill, and attitude, I have observed a passive reaction in our team to striving for personal and professional excellence.” (P7).
Participants in the study suggested that maintaining personal and professional competence can help overcome ethical issues in perioperative settings, given the complexity and uniqueness of patient care. They suggested that, OR nurses should continuously update their empirical and esthetical information and practice to give principled and ethical patient care. In this regard, An OR nurses with 6 years of work experience suggested that, “As I told you earlier, when I tried to scrub the BPH case I failed to practice it well and the urethral blockage happens twice and it made the surgeon angry, the operation lasted longer which exposed the patient to extra anesthesia time. After that day, I tried to have information for the case in the operating room, and I also participated in training courses that are held so that I am always updated.” (P1).
Issues of bearing once own responsibility
The majority of participants reported that bearing responsibility is sometimes ethical issue encountered nurses in perioperative setting. They reported that most of surgical team in our setup shows little sense of commitment to conducting the right job description and not be punctual. In this regard one of OR Nurse with 5 years of work experience reported that, “Most of our employees fail to discharge their responsibilities in terms of keeping patient charts, being on time, leaving work within recommended time frames, and labeling and recording patient samples, which directly or indirectly harms patient outcomes. Receiving quality care, on the other hand, is the right of all patients, while making it is the responsibility of all nurses, and failing to follow this principle causes patients’ distrust of nurses, worries, and harms patients.” (P18).
Again participant with 13 years of work experience stressed that, “Sometimes, some staffs do not arrive on time, even if the surgery is scheduled to begin early in the morning to ensure patient safety.” However, due to their tardiness, patients may face surgery delays and cancellation after fasting for an extended period of time. This demonstrates a failure to accept personal responsibility.” (P16).
Participants of this study suggested that staffs in perioperative setting should bear a sense of commitment to carry out the right job description. They suggested that receiving quality care is the right of all patients and discharging it is the responsibility of all nurses which helps to overcome challenges that hinder making ethically sound decision on ethical issues.
In this regard, one of operating OR nurse with 5 years of working experience suggested by sharing his experience that, “Some time ago our staff circulating a case in our room gave the sample of a patient to a student to label and record on perioperative nursing registration. As a chance, the student did not do this correctly hence the patient’s biopsy was lost, and the purpose of that surgery was only for biopsy. Well, it was the responsibility of our staff circulating the case to label and record it on perioperative nursing record. But, the nurse action was being futile and breach discharging responsibility.” (P16).
Issue of caring for patient with justice
Most of time the issue of justice and fairness encounter in health care setting in terms of unfair distribution of care resources as suggested by participants of the study. They stated that these issues may lead to prejudice and unfair distribution of care resources, since the patient’s relatives are not present in the operating room to monitor how care is provided to their patients, it is the duty of a morally committed nurse to treat all patients fairly without discrimination. A contributor with 6 years of work experience said by sharing his experience that, “Giving service in a discriminating manner is becoming a habit in this era, which is a bottleneck issue in the health care setting. Last year, I had a female patient come in from rural for emergency surgery. Unfortunately, our staff did not treat the patient properly. He did not change the sterile mask for the patient or even the tubes of the anesthesia machine because the patient’s personal hygiene was poor. In contrast, on another round when we worked together, he carefully completed his task for a relative of one of the hospital’s officials and was extremely respectful and polite.” (P1).
The study found that fairness and justice are crucial for addressing ethical issues in healthcare settings, particularly in perioperative settings where OR nurses encounter diverse patients with differing religious beliefs, social status, economic status, and language. The majority of participants believe that differences in care giving practices could lead to discrimination and unfair distribution of healthcare resources, unless a principle of fairness is implemented. An OR nurses with 10 years of work experience in OR suggested that “The reality that the patient’s accompanying person are not present in the OR complex to observe how care is provided to the patient, it is the duty of a morally committed OR nurse’s to treat all patients fairly without bias.” (P2).
Omission to follow sterilization standards and aseptic techniques
Another most commonly encountered ethical issue in OR is failing to follow proper sterilization and aseptic technique as majority of participants of this study’s experienced. In this regard one of OR nurse with work experience of 10 years said that “Most of the time, nurses in this OR are responsible for following sterilization of instruments and observing aseptic technique. Although it is the responsibility of the entire surgical team, operating room nurses can play an important role in preventing and controlling post-operative complications by adhering to the principles of aseptic and sterile regarding hand scrub equipment used in surgery, skin preparation (prep), and surgical drape. But, some of our staffs are negligent in this regard and commits malpractice.” (P5).
Aseptic technique observance in the operating room is a fundamental factor in providing indirect care for patients under surgical operation. “I opened a surgery set and found a hair in it. Under such conditions, I give back the set to CSR, and never use these sets for the operation.” (P7).
The participants this study also suggested that, monitoring of principles of sterilization and aseptic technique is also the responsibility of surgical teams. If a principle of sterilization and aseptic techniques was not monitored well, surgical site infection is the most common complication after surgery which may sometimes forces patients reopening and may predisposes patient for long-term hospitalization.
In this regard one of OR nurse suggested that, “By appropriately observing the principles of aseptic and sterile techniques such as surgical hand scrub, equipment processing, cleansing surgical site and assisting surgical drape, OR nurses’ should take part in a vital position in preventing and controlling surgical site infection and other complications due to breach of this principle.” (P18).
Discussion
This study was intended to explore the lived experiences of OR nurse regarding ethical issues at Adama Hospital Medical College. Semi-structured interviews were performed, and data analysis revealed two main themes; Issues related with safeguarding patient dignity and Issues related with Staff Professionalism and Respectful Interaction. Ethical issues are complex and challenging to resolve. They might be new issues, daily issues, or complex situations [3, 7]. Capturing OR nurses’ personal experiences through phenomenological study will help to explore the ethical dilemmas they faced, their resolution methods, and available support systems. This is crucial for developing strategies to better support OR nurses in handling ethical issues, aiming to improve patient care outcomes and foster an ethically sound operating room environment.
The first main theme of this study regarding ethical issues mostly encountered in perioperative setting was issues related with safeguarding patient dignity. Sub-themes included under these main themes were Preoperative Communication and Consent, Ethical Considerations in Emergency Surgeries, Privacy in the Operating Room Environment, Cultural and Gender Sensitivity during anesthesia and consciousness levels and ignoring patients’ expectations.
Regarding safeguarding patient dignity, the current study, supported by the study conducted in Turkey emphasized safeguarding patient dignity focusing on Ethical considerations in emergency surgeries, cultural and gender sensitivity during anesthesia, and ignoring patients’ expectations. The study reported that passing consent hurriedly during emergency surgery, allowing visitors in narrow OR while educating students, and ignoring patients’ expectations during catheterization were natural phenomena as they intended to save a life, consequently, patients’ privacy was breached, and their dignity and security can be threatened, their self-esteem can be lost, psychological causing stress and negative outcomes [30]. However, Norwegian studies contradict the current finding as honesty and truthfulness in communication breach of patients’ consent were common ethical issues in OR of the current study report, while the Norwegian studies’ findings revealed such scenarios were intolerable. These studies emphasize the significance of respecting patient dignity in fostering self-esteem and preventing stress during perioperative settings [28, 31]. Again, about safeguarding patient dignity, the research finding done in Iran advocates staff smooth perioperative communication and consent by highlighting the role of operating room nurses by stating that they play a crucial role in patient safety by fostering calmness, confidence, and effective communication, ensuring faster recovery and preventing stress in contradiction to the current study [32]. In addition, the study conducted elsewhere advocates the importance of safeguarding patient dignity in nursing care in the arena of cultural and gender sensitivity during anesthesia and conscious sedation and respecting patients’ expectations, should not be bypassed in any ground, stating that safeguarding dignity is a crucial aspect patients perceive by contradicting this study [33].
International and national professional associations advocate safeguarding patients dignity, emphasizing cultural and gender sensitivity in anesthesia and consciousness levels, while respecting patients’ expectations and safeguarding their dignity. The International Council of Nurses (ICN) recommends that Operating Room nurses adhere to their country’s code of ethics, which outlines the profession’s values and conduct in addressing ethical issues, based on universal principles of beneficence, nonmaleficence, justice, and autonomy [17]. The American Nurses Association (ANA) Code of Ethics emphasizes the significance of ethical care in operating rooms, requiring nurses to adhere to safe guidelines and provide patient support [31]. Privacy is crucial for patient security and support, and respecting patients’ autonomy in nursing and healthcare is essential for a healthy patient experience [12].
The second main theme of this study regarding ethical issues mostly encountered in perioperative setting was issues related with Staff Professionalism and Respectful Interaction. Sub-themes included under these main themes were: - Issues of staff rapport and teamwork sprit, Issue of personal & professional competence, issues of bearing once own responsibility, Omission to follow sterilization standards and aseptic techniques and Issue of caring for patient with justice.
Regarding Staff Professionalism and Respectful Interaction, the current study was in line with the result of study conducted in Sweden reported that, performing safe surgery for patients is based on constructive communication with patients and among members of the surgical team and teamwork [34]. Again, the study done in Norwegian university hospital emphasize the importance of respect and teamwork in operating room, as it can protect patient safety and enhance surgical team performance, emphasizing the need for humility [31]. Finding of study conducted in Japan stated that, safe patient surgery relies on constructive communication and teamwork among surgical team members, highlighting the importance of staff professionalism and respectful interaction [35]. Again, effective communication, cooperation, teamwork, and respecting colleagues are essential for safe surgery outcomes, as highlighted by a study in Iran, reducing medical errors and complications [36]. In addition, the results of a studies conducted elsewhere highlighted the importance of respecting colleagues’ professional work, regardless of age, race, religion, gender, or sexual orientation, for delivering high-quality care and safe surgery [37, 38].
In line with the issue of personal & professional competence, Issues of bearing once own responsibility, Issue of caring for patient with justice and issues of sterilization standards and aseptic techniques, the study conducted in USA discovered that professional commitments include professional competence, be honest with the patient, keep secrets, proper interaction with the patient, equitable distribution of limited resources, scientific knowledge, maintaining trust and professional responsibilities [39]. Again, the study done in Canada, stated that delays in the operating room processes have a negative effect on both patients and health care staff due to punctuality [40]. The result of this study done in Sweden was also stated that starting surgery at the arranged time is a respectful attitude towards the patient and colleagues as stressed by finding of study conducted elsewhere [41]. According to study conducted in Croatia stated that providing professional services by nurses without a sense of professional commitment is difficult with a negative impact on the quality of care [42]. In line with the findings of two studies conducted in Iran [22, 43], where as regarding to dedication to truthfulness, fairness, and punctuality and bearing responsibility for your action. Another study conducted in Iran highlights the importance of promoting professional competence and continuous improvement as key ethical behaviors in operating rooms [3]. The study conducted in Malawi [13] highlights the importance of moral competence, including kindness, compassion, responsibility, discipline, accountability, honesty, and respect for human rights.
The result of the study was similar with International guidelines such as American Nurses Association (ANA) [14], AORNA [43] and ICN [17] suggesting that devotion to professional commitments to continuously update their empirical and esthetical information and practice to give principled and ethical patient care, being honest and truth telling, punctuality, acting as a team to attain a particular goal, for restoring or improving patients’ wellbeing, fairness and justice is the root for overcoming challenges in solving ethical issues in health care setting. The study finding done in Iran reported that all surgical team, including operating room nurses, is required to strictly adhere to sterile principles [44]. AORNA advocates that the surgical team, comprising nurses, surgeons, and anesthesiologists, is tasked with ensuring patient safety and adhering to aseptic principles in the operating room [43].
Limitations of the study
The finding represents the perspectives of OR nurses on common ethical issues, potentially overlooking important insights from other health professionals, patients, and their families. Nurses were chosen from various operating rooms within the Adama Hospital Medical College hospital to address the limitation of a reflection of the experiences of a small group of operating room nurses from one hospital.
Conclusion
The findings of this study demonstrated the lived experience of operating room nurses to common ethical issues raised in operation during their clinical care. Concepts such as preoperative communication and consent, ethical considerations in emergency surgeries, privacy in the operating room environment, cultural and gender sensitivity during anesthesia and consciousness sedations and respecting patients’ expectations, staff rapport and teamwork, personal & professional competence, bearing once own responsibility, caring for patient with justice, and sterilization standards and aseptic techniques were crucial for participants to overcome challenges during clinical care. Identification of ethical principles and standards, and adherence of nurses to it under the supervision of ethics experts, supports of stake holders, and establishment of effect ethical committee will enhance the quality of nurses’ interactions with patients and colleagues, leading to improved quality of surgical patient care. The findings can be used in nursing student education to develop moral attitudes. Further research is needed to explore the experiences of other health professionals in ethical issues to improve patient rights and safety in operating rooms, with the hope that the results of this study will be applied effectively.
Acknowledgements
We are deeply thankful to Addis Ababa University for funding the study. We extend our gratitude to Adama Hospital Medical College for their cooperation and to the participants for their invaluable contributions. Our appreciation also goes to all the data collectors who were involved throughout the process.
Declarations
Ethics approval and consent to participants
The research obtained ethical approval from the Institutional Review Board (IRB) at Addis Ababa University’s College of Health Sciences, School of Nursing and Midwifery, under protocol No: 47/22/SNM. Following this, an official approval letter from the Department of Nursing, along with a support letter and a copy of the ethical clearance, was submitted to Adama Hospital Medical College (AHMC) for data collection. All necessary permissions were secured from AHMC. Participants’ anonymity was preserved, and their names were not disclosed. They were briefed on the study’s purpose, benefits, and risks, and written consent for participation and audio recording was obtained from all participants prior to the start of the study.
Consent for publication
Not applicable.
Competing interests
The authors declare no competing interests.
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