Documenti di Didattica
Documenti di Professioni
Documenti di Cultura
N
P
URSING
ERIOPERATIVE
IN
C
ULTURE
Lillemor Lindwall and Irne von Post
Key words:
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is performed often or regularly within a culture, but can also be an ethical act that is
1
considered to be bad that someone performs repeatedly and finds difficult to stop.
Culture as a concept is described as spiritual and material culture and is charac7 A perioperative nursterized by the habits and acts that affect culture as a whole.
1
ing culture can be understood as having both spiritual and material aspects.
Spiritual culture is seen as the humanistic side of a culture, formed by ideals,
8 and based on cultural elements.
9
upbringing, morals, traditions and education,
Nurses habits in a perioperative nursing culture are formed by education and basic
10 Perioperative material culture is characterized
values, as well as ethos and ethics.
by advanced, high-tech equipment in the operating theatre, which has been created
to serve life and health, meet the demands of specialist medical requirements
11 The habits found in this culture result from the
and facilitate nurses work.
demands for asepsis and safety, but also for productivity. According to Nightingale,
12
nurses habits and behaviour have an effect on patients experiences of well-being.
The habits that form operating theatre culture are dominated by the biomedical
9 and on
model. 13 Widespread research has been conducted on transcultural nursing
14 but we have found no research focuspatient autonomy in intercultural nursing,
ing on habits in a perioperative nursing culture, and this therefore became the aim
of our present study.
Method
8 was chosen to describe habits in perioperative nursing
A hermeneutical approach
culture in an attempt to understand them in a new way. The research process
was influenced by the researchers theoretical caring perspective with regard to
ontological questions and epistemological interest. Because of the explorative character of the research question, focus group discussions were used to collect data.
16
The focus group text was analysed using hermeneutical text analysis.
15
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The focus groups discussions lasted for approximately one hour each, and were
overseen by a group leader. The theme question concentrated on nurses experiences
of habits in perioperative nursing culture. The aim was to create an open atmosphere
and stimulate the group to exchange their experiences of and views on the topical
themes. 15,17 The ethical responsibility of the group leader was to ensure that they did
not affect the dynamics and dialogue between group members. The discussions were
audio-taped and transcribed verbatim.
The study was approved by the Ethics Committee of Mlardalen University
(2005/263). Participation was voluntary. This was important because of the requirement for the perioperative nurses to be willing to talk freely about their experiences.
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In the fourth stage the text was again treated in its entirety in order to arrive at
a higher abstract level than had been achieved in earlier interpretations.
Eight subcategories emerged from the understanding. These are described below
and illustrated by direct quotations.
Findings
Habits that promote ethical values
A temporary friendship with patients
A temporary friendship is formed with patients as a habit and an ethical act in which
nurses promise to be there when patients need them and to be someone patients
will recognize in the operating theatre. Nurses assume responsibility for ensuring
that patients need never feel alone or abandoned on the operating bed.
Caring, for me, is like a temporary friendship, in which, during our time together,
I guide the patient through the operation process.
This habit presents the welcoming nature of the culture, allowing patients their
dignity. Friendship creates a pleasant atmosphere and allows patients to be the king
or queen in the operating room, making them feel they are the most important person there, and that everyone will do their best for them.
Showing respect for each other
The habit of showing respect for colleagues creates an atmosphere of well-being,
warmth, calm and harmony around patients. Nurses show respect for each other
674
and others professional tasks; no professional task is considered less important than
another because everyone must participate in protecting patients dignity and
ensuring that the care provided is seen as both safe and professional in its nature.
The mutual respect shown for each other allows nurses to see patients as entities of
body, soul and spirit.
A caring atmosphere is one where everyone is pleasant to each other and where everyone is happy at their place of work. Nurses look at patients when they talk to them.
They talk quietly and in gentle terms about what will happen in the operating theatre.
They show that this patient is their main concern.
The habit of showing respect for one another creates an atmosphere of respect for
individuals as human beings. Nurse managers allow nurses to agree with patients
wishes, such as: Be with me throughout the operation. This ethic is kept alive and
immediate to allow continuance of mutual respect.
Caring is given an increased value, both by senior staff and within the profession as a
whole, so that nurses are clearly seen as professionals. They are then proud of their
work and of the profession to which they belong.
The habit of showing respect for one another leads to people caring for each other
and seeing each other as unique individuals, and everyone feeling that they are all
part of a professional team. Nurses are then generous and tolerant towards one
another, and are noticed, listened to and appreciated by ward supervisors and colleagues alike. They are proud of the fact that they are nurses who can influence their
work situation and use their knowledge effectively. They feel able to discuss with
each other their experiences related to patients situations.
Time for reflection about ethics and caring
The habit of finding time to reflect on ethical questions and on what is and what is
not part of a caring culture creates a tolerant atmosphere. Nurses need to discuss
with each other the quality of the care provided, their professional code of ethics,
ethical dilemmas and conflict within the caring process, but also the overall aims
and basic values of the operating room.
Nurses are prepared to take responsibility for caring and promoting discussion on the
professional code of ethics and ensuring that the ethics of daily nursing are always a
current issue. Time must be allowed for, and value placed on, preparing for each new
patient.
Being given time to reflect on ethical questions creates a warm atmosphere within
a perioperative nursing culture, allowing time for learning and discussion of such
subjects as a vision for the future of the operating theatre, what is considered ethically defensible, and what protects and what infringes patients dignity. Time for
ethical reflection presupposes that patients can share their thoughts with nurses
before, during and after the operation. The essence of this habit is that it enables an
ethic and a set of values that help carers to decide on their ethical standpoint.
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The habit of treating patients as operation cases will often include being insensitive to the fact that patients may have to wait before being taken into the operating
theatre, or have to wait for the arrival of the surgeon, perhaps for a long time, giving the impression that something has gone wrong. If promises made during the
planning of an operation are broken it is not surprising that patients may feel alone
and abandoned, despite all the people around them.
When routines fail the patient is left waiting unnecessarily. Nurses lose their focus on
the patient when things have to be rescheduled. Patients may receive information from
several different people. I dont think they are able to take it all in.
Neither time nor space is created for personal discussion if patients are receiving
information from several people. Patients sense of dignity is offended when all
around them are rushing about and working at such a tempo that patients are somehow left behind. Such habits hinder progress in working routines and create ill feeling and ethical conflict, especially for nurses who would rather regard patients as
human beings comprising body, soul and spirit.
Not acknowledging one another
Nurses not acknowledging one another and not regarding others as colleagues
is a habit that will hinder co-operation at work, create unhealthy competition, and disrupt and cause jealous guarding of ones own preserve at work. Colleagues are seen
to be acting dishonestly and people no longer trust each other. It becomes difficult to
know what holds good and which skills and competencies need to be applied.
It is not a healthy state of affairs when people do not acknowledge one another, do not
appreciate each others different professional skills, regardless of whether one is a nurse
anaesthetist or a theatre nurse.
This habit gains momentum when senior staff members do not show interest in
suggestions put forward by nurses. The atmosphere is permeated by feelings of insecurity when department heads belittle nurses competence, and when nurses are not
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given the opportunity to use their professional scientific nursing knowledge. A lack
of interest on the part of senior staff for new proposals means that there will be no
room for new habits to develop within the culture and staff will lose their interest
in the work of daily nursing.
Not talking about ethics and caring
In a perioperative nursing culture there are many excellent nurses who cannot find
the words to talk about their daily caring work. They are unable to express how they
help patients to feel good in the operating theatre. They see the patients, they understand patients needs and wishes, but lack the words to describe what they see.
Everyone subconsciously cares deeply for the patient but somehow this is not expressed
verbally. Unfortunately there are many very good nurses who cannot express their
thoughts about nursing in words.
The habit of being unable to express ones thoughts or to talk about ones work
as a nurse means that good nurses remain unnoticed. They may quietly strive not
to disclose patients identity in sensitive situations, but they cannot find the right
words to discuss their approach.
The medical profession practices both hidden and open exercise of power. There
are physicians who have learned that the work atmosphere is better if all nursing
specialties are invited to participate when decisions are to be made. However, this
is not a common habit.
The surgeons are in a position of considerable power, but they have learned that the
working atmosphere becomes much easier if the staff are consulted when a decision has
to be made.
Weak management will allow informal bosses to hold sway under the surface.
Habit allows such dominating people to steer things unseen. Sometimes it is just one
person who assumes this power in the operating theatre and sometimes it is groups
among the staff who want to take charge.
Weak senior staff with strong informal bosses who direct things based on their ignorance of nursing practice. Little emperors are to be found in all branches of the hospital.
Their influence is dependent on the strength of leadership demonstrated by senior staff.
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The hidden power structure creates a feeling of insecurity among colleagues. The
power of little emperors is governed by the level of leadership shown by senior
staff. The more restricted the working routine for individuals, the greater their desire
to be elevated, to assume power, and to direct and organize others. The habit of
this hidden power structure creates a conflict of values among nurses.
Achieving more in less time
Achieving more in less time is a habit that has developed in recent years as a result
of increased demands for productivity. This demand often comes from senior staff
who do not fully understand nurse anaesthetists or theatre nurses responsibilities
with regard to patients. The pressure to achieve more in less time makes work feel
more stressful and more routine. The nurses feel they are bad nurses, abandoned
and alone with their responsibilities, when they do not have time to get to know
patients well enough.
Nurses have to take on varying degrees of responsibility depending on the availability
of doctors and their competence, and they are pressurized to achieve more in less time.
Decisions that have been taken within the team are sometimes changed by others who
are not directly involved. This adversely affects job satisfaction and demands a lot of
energy from the team with these responsibilities.
A culture aimed at getting more out of less time prevents professional development. The tone of the culture forces nurses to stop thinking in order to survive the
stress, and leaves them in a state where they give up any hope of being able to be
there for patients. This frame of mind, centred on increased productivity, will not
always be in line with the ethical values of carers.
Discussion
The results of this study have revealed three categories of habits in perioperative
nursing culture: habits that promote ethical values, hinder progress, and set the tone.
These habits, when so readily accepted, can be understood as a form of tacit knowledge because they are just there. The results show that nurses acquire habits through
6 and
being members of a perioperative nursing culture or of a particular social group,
19
that the prevailing culture has formed them and taken control of them. Kuhn
believes that habits, in the same way as knowledge, are acquired through culture and
cannot be clearly defined, but our results show that they can be described. It appears
that habits have a certain similarity to tacit knowledge, they are hidden away, they
are just there, and they become part of the culture through their practice by nurses
2 0 people are only indiand because they are not clearly defined. According to Polanyi,
rectly or subconsciously aware of tacit knowledge. Habits that conform with tacit
knowledge are not always given expression, articulated or reflected upon. If habits
2 0 claims, that tacit knoware unexpressed, do they exist at all? Or is it, as Polanyi
ledge is never articulated because it cannot be described, because it must remain hidden away or because we have never bothered to try to describe it? The results of this
study show that there are nurses who never talk about caring and ethics, seeing their
work as something self-evident, and something one gets on with and does not talk
Nursing Ethics 2008 15 (5)
678
about. By not talking about their work, that knowledge is not reflected upon. It is
not
documented or passed on in articulated form, but remains just a habit, something
that is incompletely defined. Are all people within a certain culture aware of these
habits but do not, however, question their existence because they have always been
there and because they are never discussed? These are questions that this research
leaves unanswered, but they should be given more attention than has been possible
in this study. We hope to have shown that it is possible to describe these habits and
2 1 no habit passes completely unnoticed,
to give them a voice. According to Molander,
but affects even those who are not a part of that habit, because this is something
that
must be acquired, not as a spectator but as a participant. Habits, like traditions, are
passed on without being subjected to dissection because they can be understood as
part of unreflected practice. Yet that which remains undiscussed can sometimes be
put into words, be subject to critical reflection and, under the right conditions, be
improved and reintroduced back into a culture.
22
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which people appreciate their worth as human beings, but some exaggerate this.
People are seen as proud when they hold themselves in high regard; this opinion is
5 exhorts striking the right middle way between despisclearly warranted. Aristotle
ing or thinking too highly of oneself and others. Another important habit that can
be developed to the benefit of patients and nurses is that of regularly taking time to
reflect on ethics and caring. This means that nurses and leaders acknowledge each
other through mutual reflection, agree on common goals, and create a set of basic
4 ethics will provide the foundation on which the
values. According to Eriksson,
habits of a culture will be based.
Among the habits that set the tone in a perioperative nursing culture is a hidden
power structure, which allows informal leaders and little despots to exaggerate
and
allow their conceit or desire for power to take over. In Aristotles opinion, people
who go too far are conceited and do not know themselves or the effect of their
actions. When a hidden power structure predominates, an unhealthy atmosphere is
created in which not all nurses are allowed to take their place in the group and to
express their views; people are no longer aware of the rules that apply. If a hidden
29
power structure is allowed to predominate, this could be a sign of weak leadership
because informal leaders are allowed to decide matters. An informal leader is normally someone who seeks to gain power over others within a culture. Moral knowledge is more than just having power over someone because it requires reflection
8 believes that
and the ability to weigh one alternative against another. Gadamer
moral knowledge is affected by a concrete situation and that it demands a sensitivity and awareness for a unique set of circumstances.
Limitations
When considering the implications of the findings, it is important to recognize that
this study was carried out by using focus groups consisting of only a limited number of perioperative nurses. The findings cannot therefore be generalized, but they
could still serve to contribute to an area in perioperative nursing culture that has not
been widely researched.
The perioperative nurses taking part in the focus discussion groups were volunteers with varying degrees of experience in perioperative nursing care. Group interaction analysis 17 showed considerable consensus about the way in which the nurses
discussed habits in the operating theatre. They enjoyed sharing different points of
view, but also interrupted and sometimes finished each other s sentences. No
attempt
was made to validate any facts that were stated in the discussions. The focus group
discussions therefore represented the reflections and experiences of the nurses present. Despite the limitations of the study, the findings do have relevance to a perioperative nursing culture. The hermeneutical approach made it possible to deepen
our understanding of the habits that exist and see how they affect carers in a specific context. However, since both authors were the researchers, they could help
each
other to see what might have been missed individually, and the reliability of the
study was enhanced by the fact that each of us conducted our own independent
interpretation of the text, before meeting together to agree unanimously on a final
interpretation and identify the categories that resulted from the study. In this way it
30
was possible to achieve joint co-examiner reliability.
Nursing Ethics 2008 15 (5)
680
Implications
The findings of this research draw attention to the habits that exist in a perioperative nursing culture. According to the results, further research needs to be
conducted
to focus on other habits that did not come to the surface in this study. The results
also make us conscious of the fact that senior staff must be aware that they are
responsible for the habits that prevail, how those habits are developed, and how
they
set the tone in a perioperative nursing culture. These habits are regarded by the
people concerned as being self-evident and instinctive, thus they should be the subject of further careful research.
Conclusion
It is important to understand the habits evident in operating theatre cultures, in
which nursing theory and habit become united. Caring science has a duty to acquire
knowledge of caring, its ethos and ethics, the work of relieving human suffering,
and how to create a caring atmosphere in order to promote health and well-being.
Habits should be centred on the essence of caring,
caritas, and the habits of a perioperative nursing culture should spring from the ethos of perioperative caring and
its dignity. 1,2 The results make us aware that there is a need to identify the good and
bad habits found in a perioperative culture and to extract the bad habits from it.
Acknowledgement
The authors would like to thank all the participants for their contribution to this
study.
Lillemor Lindwall, Mlardalen University, Vsters, Sweden.
Irne von Post, bo Academy University, Vasa, Finland.
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