Non-technical skills in operating room nursing: Ethical aspects

Background

The term non-technical skill is used by several technical professions, ^13,14 of which perioperative nursing is one. Non-technical skills may be defined as ‘the cognitive (decision-making, situation-awareness) and interpersonal (communication, teamwork, leadership) skills that underpin technical proficiency’ (p. 19). ¹⁵ The authors furthermore maintain that non-technical skills ‘are considered particularly important to prevent errors’ (p. 19). ¹⁵ This clearly indicates that perioperative nurses ‘are responsible for nursing decisions that are not only clinically and technically sound, but also morally appropriate and suitable for the specific problem of the patient undergoing treatment’ (p. 654). ⁹ In line with this, the Association of Perioperative Registered Nurses ¹⁶ (AORN) holds respect for human rights, ethical values and human dignity as ‘a fundamental principle that underlies all nursing practice’. King ⁹ differentiates between the technical and moral issues in perioperative nursing thus: ‘The technical or medical aspects of nursing practice answer the question, “What can be done for the patient?” The moral component involves the patient’s wishes and answers the question, “What ought to be done for the patient?”’ (p. 654).

In the American Nurses Association’s (ANA) Code for Nurses with Interpretive Statements is pointed out that it is the operating room nurses’ obligation to be the advocate for the patients as well as for themselves and their colleagues. In relation to the patient, this entails to provide ‘safe, professional and ethical patient care’ (p. 189). ¹⁷ Regarding themselves and colleagues, the obligation means to acquire the knowledge needed to do the work in question and to follow legal guidelines affecting nursing practice. ¹⁷ Lindwall and Von Post ¹ add that nurses need to discuss with each other – and in our view with the entire operating room team when need be – ‘ethical dilemmas and conflicts within the caring process, but also the overall aims and basic values of the operating room’ (p. 674). Furthermore, being respectful, contribute to a good atmosphere, and demonstrate a caring attitude towards patients and co-workers are central ethical skills in the operating room. ¹⁸ Also Husted and Husted ¹⁰ include the relational aspect of ethics when they claim that the function of ethics in nursing is for a nurse to nurture ‘a patient’s power to recover health and well-being and the nurse’s own ability to nurture’ (p. 175).

Data analysis

The third author conducted the interviews. She and the second author transcribed the interviews verbatim. The first author is not a perioperative nurse and therefore has an outsider view of the data. All three authors took part in the data analysis which was thematic and hermeneutic in character where depth of understanding was attained through a circular investigation of the interviews. ²¹ Braun and Clarke’s ²² six analytic phases for thematic analysis were used: (1) the authors familiarised themselves with the interview data. As to this, Gadamer ²¹ holds that rigour is obtained through reading and re-reading the interview texts while striving to ‘remain open to the meaning of the other person or the text’ (p. 268). (2) Interesting features were coded and collated into potential themes (phase 3). Phases 4 (reviewing themes) ²² and 5 (defining and naming themes) ²² were done collaboratively by all the authors. (6) The first author wrote a preliminary paper text which then was discussed and developed further collaboratively. All the while we tried to be open and curious, communicate authentically, and realise that the fusion of horizons through the reading of texts leads to the creation of something new ²¹ and avoid bias.

Ethical considerations

The project was approved by the Norwegian Social Science Data Services in care of the hospital’s Data Protection Officer. The interviewees were informed in writing and orally that participation was voluntary and that they were free to withdraw from the project whenever they wanted without giving any explanation. They all gave their written informed consent to participate. Interview transcriptions are stored safely according to Ethical Research Guidelines. ²³ Recorded interviews were deleted after transcription.

Limitations and critical remarks

A clear limitation of this study is that only 23.4% (11 of 47) of potential interviewees chose to participate in the study. There is furthermore a danger of selection bias as perioperative nurses with less than 5 years’ experience from mentoring perioperative students were excluded. This choice was based on the primary aim of this study. However, according to Benner, ²⁴ less experienced nurses may focus more on technical skills and on doing things ‘by the book’.

The fact that this is a single unit study limits this research as workplace cultures may vary, and interviews conducted in other hospitals may have given different results. Although two male interviewees reflect the male proportion of operating room nurses in Norway, it is an inadequate number of interviewees for studying possible gender differences in how experiences and feelings are perceived and expressed.

Both the second and the third authors work in the perioperative unit in question, the third author, who conducted the interviews, in a supervisory capacity. This may have influenced the interviewees’ willingness to give frank descriptions of their experiences and thus affected the interview conversations and the credibility of the study. To what extent the interviewees’ feeling of loyalty and/or dependence on the interviewer as a representative of the unit’s middle-range leadership may have impacted on the results is impossible to say. To minimise bias and strengthen trustworthiness as far as possible, the first author, a nursing professor with no connection to either the unit or the interviewees, was invited into the project as mentor and co-data analyser. Analysis of the interviews seems to indicate that the interviewees have been frank in their responses as they did not seem to hesitate to criticise organisational and leadership issues during the interviews.

Respect and care for the patient

The operating room nurses pointed out the importance of working efficiently in preparation for and during surgeries. Efficiency depends on everyone knowing what to do and having the right instruments ready and in their right place. However, efficiency must never be prioritised at the expense of respect for and the care of the patient. A caring attitude was seen as vital and reflected in how the job was done. As interviewee 5 put it, ‘It is not only supposed to be efficiency and production. That may reflect [negatively] on the patient’. This statement reflects that the operating room nurses sometimes find that they are ‘the patient’s advocate’ (p. 7). As the patient’s advocates, they sometimes had to step in and inform the operating team members that the anaesthetist’s needs and the surgeon’s preferences regarding the patient’s positioning on the operating table is not right for the patient. Defending the patient’s dignity was part of the same pattern of caring for and respecting the patient, for instance. by shielding patients who are being catheterised. Sometimes ‘people have made jokes about the patients’ position on the table. I have had to speak up about that at times’ (Interviewee 6).

Quite often, the operating room nurses therefor asked themselves whether they did the best possible job for their patients: ‘Is this ok for the patient?…is his position on the table ok, is this pillow ok or will he do better without?’ (Interviewee 8). This quotation indicates that the question of how the job is performed needs to be coupled with what attitude the job is done. Interviewee 4, for instance, held that she used ‘the time while I take them from the pre-operative room to the operating theatre to talk about’ issues important for the patient when on the operating table. This ‘leads to a conversation, and then the patient often spontaneously says things I use’ to do what is best for him or her.

Thus, listening to the patient was pointed out as an important part of patient care. This was an essential part of making the patient feel ‘seen’, respected and cared for in the best possible way. To find adequate time for this is often difficult, however, as the perioperative unit tends to be very busy and the demands on getting things done with great efficiency are high. The tempo may be exhausting when operating room nurses are ‘rushed off their feet’.

Making the patient feel safe and in good hands

The operating room nurses pointed out that a relaxed and confident atmosphere makes the patients feel well looked after. Many of our interviewees therefore complained about the noise level sometimes reached in theatre, particularly when due to unnecessary talk and load voices as this could be upsetting and seem unprofessional to the patients.

Hence, the manner in which the operating room team collaborates is important for the patient to feel safe and de facto be safe. Poor teamwork may have dire consequences. The interviewees pointed out that not only the patient, but every member of the perioperative team depend on them doing a good job. They therefore always had safety in the back of their minds, with particular focus on the patients’ safety. It is whenever ‘everyone feels that the patient is the focus, […] the teamwork is good, and everything flows’ (Interviewee 7) that the quality of the work done is at its peak.

Many patients may be anxious, and to be there for the patient through the holding of the hand or using words to calm them down is important, especially for patients in local anaesthesia. The nurses found it rewarding to work in a caring manner, and it was particularly gratifying ‘when patients say, “You have taken so good care of me.” Then I think that the team that surrounds them functions well’ (Interviewee 8).

Respect within the perioperative team

According to the perioperative nurses, reciprocal respect within the operating room team includes respect for each other’s tasks and responsibilities, being prepared for the task at hand, and talking to each other in a friendly manner. This creates good rapport within the team, which again opens for the exchange of information and for questions, which are basic for patient safety. It was pointed out that whenever someone in the team is inconsiderate towards his co-workers and sees himself as above the rest, this creates inefficiency and insecurity within the team. Communication, therefore, ‘is influenced by whether everyone has confidence in one-another’ (Interviewee 6) as well as treating each other with respect. Several of the interviewees pointed out the importance of the operating room atmosphere being good. How things were communicated tended to influence the mood within the team: ‘Sometimes the atmosphere is good and suddenly it changes as someone new enters the room. And it can work the other way: the mood can be sharp and negative, and it changes as soon as another person enters’ (Interviewee 5).

Some of the interviewees held that they tried to speak up if there were any communicative problems, or if something was wrong, but made sure to do so in a polite and respectful manner. Also, if they disagreed with the surgeon during the operation, particularly if they worried that something could have negative consequences for the patient, they might say so, but never in a way that could distract the surgeon during surgery and thus endanger the patient. Hence, good manners and reciprocal respect were pointed out as important together with a focus on the common goal, that is, what is the best for the patient.

Respecting and caring for the patient in a rushed environment

Ethics and a moral attitude appear so integrated in our interviewees’ way of reflecting and acting towards their patients that it seems not only to be an important part of their non-technical skills but also a basis for all their nursing activity. An important aspect of this activity is, according to our interviewees, to show the patients care and consideration and find the time to listen to them.

Lindwall and Von Post ¹ hold that

[t]ime for ethical reflection [in the operating room] 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. (p. 674)

In Norway, and probably in many other parts of the world, operating room nurses rarely see their patients before they arrive in the operating department. This means that the nurse–patient relationship is restricted to the so-called intraoperative dialogue, ⁶ which mainly takes place in the operating room and which according to Rudolfsson ⁴ has as its aim ‘to protect human dignity, alleviate suffering, and create well-being through continuity of care’ (p. 27). One may wonder whether this creates a setting and adequate time for patients to open up and share their thoughts with the operating room nurses. However, although the routines described by our interviewees strongly indicate that this is not so, they also show that it is something that is very important to them and do their best to accomplish. Hence, our interviewees make the most of the time they do have together with their patients while they are awake, for instance, through greeting and talking with them while fetching them from the pre-operative room to the operating theatre. Interviewee 4 found that this was adequate time for many patients to open up and tell her things of which she took careful note to individualise her care as far as the surgical procedure would allow.

It is part of the human existence ‘that we normally meet with a natural confidence in each other’ (p. 17). ¹² However, before a surgical procedure, nervousness and worry may overshadow this ‘natural’ confidence. In line with our findings, Rudolfsson et al. ⁷ point to the importance of ‘the nurse’s ability to create a calm atmosphere. This inspires confidence and instils faith…and makes the patient feel that he/she is a unique human being’ (p. 82). In their conversation with their patients, our interviewees seemed primarily to address the most pressing areas that are possible to cope with within the boundaries of their purview, and to calmly reassure them and create an atmosphere of trust. This is, for instance, done by ‘ensuring that patients need never feel alone or abandoned on the operating bed’ (p. 673). ¹ To our interviewees, it therefore was important that the patients were met with consideration, support, and when needed, a hand to hold on to.

The need to defend the patient’s dignity was also mentioned by some interviewees. This is in line with the first provision of the ANA Code for Nurses with Interpretive Statements which addresses the patient’s dignity and uniqueness. ¹⁶ Also, Lindwall and Von Post ¹ point to the perioperative nurses’ responsibility to protect their patients’ dignity and to ensure that safe and professional nursing care is provided. Rasmussen et al. ¹⁸ describe this as respecting the patients by ‘treating them as if they were awake and not speak negatively or disrespectfully about patients in general anaesthesia’ (p. 10). This is part of patient advocacy, feeling responsible for the patient and feeling that one does a good job. ²⁵

Two and a half millennia ago, Aristotle ²⁶ wrote that since ‘we are studying not to know what goodness is, but how to become good men [or women],…we must apply our minds to the problem of how our actions should be performed’ (p. 93). Although he was discussing how to do practical science, his words resonate with the caring attitude found in our interview data as the nurses ask themselves whether they are doing the best job possible for their patients.

Respect within the perioperative team

Blomberg et al. ² found in their study that ‘suffering in care can be a result of health professionals’ behaviour towards the patient and each other in the surgical team’ (p. 10). This is because ‘[l]ack of respect may lead to insecurity, poor concentration and a poor working environment’ (p. 10). ² This resonates with our findings where the interviewees pointed out that both the patient and every member of the perioperative team depend on reciprocal consideration and that everyone does a good job.

The fact that major errors may result from poor non-technical skills rather than the lack of technical prowess was first recognised within aviation and air crews. ¹³ Compared with the cockpit of an aeroplane, the operating theatre is a much more complex environment with a wide variety of patients and technical challenges. It furthermore involves multiple tasks being done simultaneously and the interaction of several specialities in a wide scope of complex, technical and social contexts. Within the operating room team, everyone is therefore dependent on each other for excellence. Jenkins ¹³ holds that there is a growing body of evidence that training in non-technical skills enhances patient safety, and ‘a lack of non-technical skills has been shown to be associated with poor surgical outcomes’ (p. 898). A non-technical skill important for patient safety is respecting each other within the operating room team. Løgstrup ¹² points out that ‘our life with and toward each other is constituted by being surrendered to the other [which] means that our reciprocal relationship always is a relationship of power’ (p. 65). He furthermore holds that ‘[b]ecause there is power in all and every interpersonal relationship we are always limited – in the decision of whether we will use our power over other people in our own interest or in the interest of others’ (p. 66). ¹² This limitation is created by responsibility.

It is obvious from our data and other studies that non-technical skills, not the least communication and collaboration, involve all members of the perioperative team. ^11,13,14,27 Lack of respect will influence the team negatively and thus be detrimental for patient safety. Several of the operating room nurses talked about how important communication is for the atmosphere during surgery and how a member of the operating room team may either create a feeling of reciprocal respect and a good ‘flow’ within the team or have a negative effect on the atmosphere through the way they communicate and act towards each other. Team members who created a good atmosphere were highly valued and seen as role models. ¹⁸ Our interviewees clearly reflected the responsibility towards others and the interhuman ethical demand pointed out by Løgstrup. ¹²