Difficulties in intraoperative care.
Abstract: Difficult situations which occur intraoperatively have a direct impact on nurses working within the area. A study was undertaken focusing nurses' confrontations with difficult situations where the narrations from twelve nurses were taped. A phenomenological method was used to analyse this information and revealed how difficult intraoperative situations arise and how the nurses found different ways of handling these situations.

KEYWORDS Intraoperative care / Perioperative practice / Difficult care / Anaesthesia nursing / Operating room nursing
Article Type: Report
Subject: Medical research
Medicine, Experimental
Nurses
Authors: Mauleon, Annika Larsson
Ekman, Sirkka-Liisa
Pub Date: 10/01/2012
Publication: Name: Journal of Perioperative Practice Publisher: Association for Perioperative Practice Audience: Academic Format: Magazine/Journal Subject: Health; Health care industry Copyright: COPYRIGHT 2012 Association for Perioperative Practice ISSN: 1750-4589
Issue: Date: Oct, 2012 Source Volume: 22 Source Issue: 10
Product: Product Code: 8000200 Medical Research; 9105220 Health Research Programs; 8000240 Epilepsy & Muscle Disease R&D; 8043100 Nurses NAICS Code: 54171 Research and Development in the Physical, Engineering, and Life Sciences; 92312 Administration of Public Health Programs; 621399 Offices of All Other Miscellaneous Health Practitioners
Accession Number: 309315291
Full Text: Introduction

Results from our earlier studies about newly graduated nurse anaesthetists' experiences and views on anaesthesia nursing (Larsson Mauleon & Ekman 2002), care for the elderly in the anaesthesia context (Larsson Mauleon 2005), and anaesthesia of older patients as experienced by nurse anaesthetists (Larsson Mauleon et al 2005) showed that nurses experienced ethical dilemmas and felt confined when they were not able to carry out the quality and support that they intended when caring for patients during the intraoperative period. The aim for this study was to describe the difficult intraoperative care situations that nurses were exposed to and the ways in which these nurses handled the situations.

Methods

The phenomenological method (Giorgi 1994, Giorgi & Giorgi 2003) provided the researcher with an opportunity to give an insight into nurses' everyday difficulties during the intraoperative period. This approach emphasises (Husserl 1989, Giorgi 1994) the way in which one experiences the life-world in terms of meaning and practices. It also highlights the way a person constitutes and is constituted by these meanings. Fourteen hours of narrated difficult situations from twelve nurses were collected by tape-recorded interviews and analysed, in order to describe the phenomenon of being exposed to difficult situations and ways of handling these situations.

Settings

The study was performed at two orthopaedic, surgical and anaesthesia units, in an urban area of Sweden. One was a large accident and emergency care hospital (1999-2000) and the other was a middle range accident and emergency care hospital (2009). The majority of patients were elderly orthopaedic patients (60 years or more). The strategy for selecting orthopaedic theatres was that the context abides in choices of upholding care giving to frail patients due to their age and physical condition.

Participants

The strategy of studying the phenomenon was by scrutinising intraoperative nurses' experiences. The inclusion criteria for the nurses were more than three years of experiences within the intraoperative area and a willingness to participate in the study. Twelve nurses whose age ranged from 35 to 55 years were interviewed. All were female and employed full-time. Their length of time employed ranged from 9 to 30 years.

Ethical considerations

All the nurses were informed that participation was voluntary and that they were free to terminate the interview at any time (written and verbal notification). The purpose of the study was explained and that the study would maintain the anonymity of all participants. The participants were asked to select a time and place for the interviews. All participants had the opportunity to ask questions and to contact researcher before and after the interview. Permission for the study was granted by the Research Ethics Committee at Karolinska Institute in Stockholm (no. 96:197).

Data collection

Fourteen hours of narrations were collected by tape-recorded qualitative interviews (Giorgi & Giorgi 2003). The interviews took place in a private room outside the surgical department. The researcher began by requesting, 'Please narrate an event where you have experienced a difficult care situation'. The nurses spoke freely, and supportive questions were only asked when clarification was required. Questions were directed by phrases such as: How can I understand that?; Tell me more about that; You mentioned something before about ...; and What do you mean by that?. All of the nurses narrated more than two situations that detailed the care difficulties of being exposed to difficult situations and ways of handling these situations. The interviews lasted for approximately one hour. The researcher transcribed the tapes verbatim. The text was rechecked and corrected in connection with the tapes for accuracy. The data was gathered on two occasions 1999-2000 and 2009. The additional interview in 2009 was included since new demands concerning efficiency and reporting incidences were raised in the context within this period of time, which in turn revealed a need of more variations of the nurses' reasoning.

Analysis

The descriptive phenomenological analysis, developed by Giorgi (2000) was used. The purpose was to describe the essence of the phenomenon of being exposed to difficult situations and ways of handling these situations. Analysis revealed different aspects (constituents) of the phenomenon. Tape recordings and transcribed verbatim texts were used simultaneously during the analysis. To identify the constituents, key phases utilised in data analysis were: reading the narratives, division of meaning into units, and transforming the units into defined constituents. All data were evaluated and discussed regularly by the authors, all of whom have prior experience in phenomenological research, have attended seminars focused on qualitative research in order to disengage from prior assumptions, and to reduce the risk of being selective.

Results

Unforeseen events

Unforeseen event were common features in difficult situations and appeared in all narrations. They were experienced as obstacles that placed pressure and demands on the nurses and affected the nurses' opportunity to take action. It meant that the nurses had difficulty in planning for and dealing with the actual situations. In connection with patients, the nurses described the events as threatening when they related this to the patient's illness or to the surgical and anesthesia management. This made the nurses unsure as to whether they managed to have the situation under control under such circumstances. For example one nurse said:

Unforeseen events occurred in situations when the surgery or anaesthesia management had to be changed due to complications. For example this was when a nurse could not handle the new equipment:

Governing circumstances that could not always be foreseen arose in situations when nurses could not please the patients due to the surgical circumstances that limited and dictated the patients' situation. For example:

A contradictory view of value

A contradictory view of value was the overriding problem in one narration and a contributing feature in many others. Routines and views which differed from their own made the nurses feel that they were unjustly treated. The nurses took on a protective attitude when their legal and professional codes did not correspond with other members of staff. In these situations, the nurses acted according to their legal duties as well as to their values and professional duties when carrying out commitments to their patients. The nurses did this to protect the patient when they felt that the patient's well-being was threatened. These situations were described as 'filled with conflict,' because the nurses protected the patients by defending them from other members of staff, within their own organisation. One nurse quoted herself and a physician in the following dialogue:

Difficult situations and conflicts also arose when nurses and surgeons took different measures when treating the patient. For example this occurred in situations when the surgeons were fully occupied with their own commitment to surgery. This, in turn, forced the nurses to watch over the patient and make sure that the patient was properly prepared for surgery. The nurses described situations where they felt that they had to protect the patient, and were aggravated by a contradictory view within the team, for example:

Situations involving incompatible loyalties were difficult if nurses were forced to make a choice between loyalties, and the patient was trapped 'in between' the conflicting parties. Conflicts arose when the nurses felt obliged to meet the needs of the ward, while they felt forced to neglect what they actually believed was best for the patient. One example of this relates to the conflicting views about the time used for anaesthesia care when preparing the patient for surgery.

The following situation involved an elderly patient with very weak and fragile skin:

Difficult situations arose when the patient's requirements did not fit into the prevailing norms of care. The nurses experienced that they had to defend the interests of the patient by guarding his or her dignity. For example, they had to protect the patient and check that the patient was not left naked during preparation for surgery and when doors were opened and closed.

Evoked unpleasant memories

For the nurses, past memories from former difficult situations were evoked when placed in new similar situations. Many of the nurses described their memories as if they had occurred very recently, even when the difficult care situation belonged to the distant past. Evoked memories reminded the nurses of past experiences and caused the nurses to feel afraid and made them change their behaviours. This was because they were unsure of how they would react personally in similar situations. For instance one nurse described that former unpleasant memories had influenced her behaviour and that she now hesitated to open a door when on call, since she was afraid of what was going on and of what was going to be expected of her. She described how she once had taken care of seriously ill patients suffering from burn injuries:

Methodological considerations

The goal for qualitative research is to explore information the essence of the phenomenon in order to describe it. The importance of reaching good participants, i.e. persons willing and able to tell about their experiences is emphasised in qualitative research (Giorgi 2000, Giorgi & Giorgi 2003). In this study the interviewed participants were experienced nurses within the context of intraoperative care. They were comfortable in telling of the difficult events they had experienced during intraoperative care that had occurred in the past. However, one threat in this study was that the nurses may reconstruct the past within a framework they have learned later. The use of quotations for comparison with the proposed described results aims to evaluate the authenticity of claimed data (Fossey et al 2002, Horsburgh 2003). The data were gathered on two occasions 1999-2000 and 2009 to get a broader view of being exposed to difficult intraoperative care situations and the ways of handling these situations. An effort was made to reveal preconceived notions by holding regular research seminars regarding the results in comparison within the natural transcribed narrations.

Discussion

The results reveal that difficult intraoperative care situations were influenced by the course of events, the persons involved, the commitments to patients, as well as by the contextual circumstances. In addition the issue of evoked memories also contributed to the situation. It must be emphasised that the patient's advanced age was not a reason that contributed to the difficult intraoperative care situations. Rather, it was the patients' vulnerability that contributed to the difficulties.

Unforeseen events led to uncertain care situations that placed pressure and demands on the nurses since they were almost impossible to plan for in advance. This meant that the nurses sometimes felt that it was difficult to know whether they managed to have the situation under control.

A conflicting value played a part in many of the described difficult situations and was the overriding feature in one narration. It is argued (Norvedt 2001, Torjuul & Sorlie 2006) that poor nurse-physician relationship was related to the disparity between the philosophy of nursing and the philosophy of medical science. A contradictory view of value was a contributing feature in intraoperative care situations. The nurses experienced a conflict when their value did not correspond with that of the surgeon or the organisation, which in this study might be the reason for nurses' poor relationships with the surgeon and or the organisation (Enns & Gregory 2007).

The results showed that nurses relate their values to their experienced commitments to the patients (Rudolfsson et al 2007). For example in some described difficult situations, the nurses described that they did not separate the physical and human aspects in intraoperative care, while the surgeon was experienced as being focused on the patients' physical well being and the surgery. When the nurses did not share the same values as team members, then the nurses tended to become defensive of their patient, because they believed that the situation threatened the patient's well being. Since the data emerged from the nurses' described experiences the results did not show whether the experience of conflicting values was true to the others in the team or organisation. These results are supported by others (Kennedy 2004, Almerud et al 2008) who also indicate that upholding a caring duty gives rise to a conflict that might not always be possible to avoid due to the different values in the team. Through the results we can understand that these conflict situations will occur but do we have to accept them?

Evoked memories were aroused in difficult care events that the nurses never could forget, and which made them reconsider things in new intraoperative care situations. Evoked memories were described as so 'vivid' that the person perceived them as real, and this influenced the nurses actions during the actual care situation. One consequence was painful memories. Other consequences were dissatisfaction and frustration with their working situation (Ekstedt & Fagerberg 2005). It seems reasonable that temporality is of importance and can be related to difficult situations; it plays an important role when looking at how to understand painful emotions and evoked memories in this way. This might be understood in the light of Merleau-Ponty (1995) who claimed that the present could be seen as a dynamic field including past, present, and future horizons. This implies that previously experienced care events are evoked in present care situations. This means that evoked memories must be considered and regarded as a contributing factor, not only in difficult situations, but also in everyday intraoperative care.

Difficult situations are an inevitable part of intraoperative care in which nurses have to face a number of conflicting issues. With this in mind, the challenge for nurses in intraoperative care is to gain a better understanding of the nature of intraoperative difficulties and how nurses handle these situations. The challenge is to understand that intraoperative care duties and commitments are creating difficulties and conflicts dilemmas resulting from unforeseen circumstances, different perspectives and values in the intraoperative environment. We should also consider that evoked memories are painful and a contributing factor to challenging situations.

References

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Ekstedt M, Fagerberg I 2005 Lived experiences of the time preceding burnout Journal of Advanced Nursing 49 (1) 59-67

Enns C, Gregory D 2007 Lamentation and loss: expressions of caring by contemporary surgical nurses Review Journal of Advanced Nursing 58 (4) 39-47

Fossey E, Harvey C, McDermott F, Davidson L2002 Understanding and evaluating qualitative research Australian New Zealand Psychiatry 36 (6) 717-32

Giorgi A (1994) The phenomenological psychology of learning and the verbal learningtradition phenomenology and psychological research Pittsburgh PA, Duquesne University Press

Giorgi A 2000 Concerning the application of phenomenology to caring research Scandinavian Journal Caring Sciences (14) 11-15

Giorgi AP, Giorgi BM 2003 The descriptive phenomenological psychological method In: Camic P, Rohdes JE, Vardley L (ed) Qualitative research in Psychology Washington DC, Psychological Association

Horsburgh D 2003 Evaluation of qualitative research Journal of Clinical Nursing 12 (2) 307-12

Husserl E 1989 Fenomenologins ide (Swedish) Ideas general introduction to pure phenomenology German original, originally published 1913 Uddevalla, Daidalos

Kennedy W 2004 Beneficence and autonomy in nursing: A moral dilemma Journal of Perioperative Practice 14 (11) 500-6

Larsson Mauleon A, Ekman S-L 2002 Newly graduated nurse anesthetists' experiences and views on anesthesia nursing - a phenomenographic study American Association of Nurse Anaesthetists Journal 70 (4) 281-7

Larsson Mauleon A 2005 Care for the elderly - A challenge in the anaesthesia context Dissertation Stockholm, Neurotec Department Division of Gerontological Caring Science Karolinska Institutet

Larsson Mauleon A, Palo-Bengtsson l, Ekman SL 2005 Anaesthesia of older patients as experienced by nurse anaesthetists Nursing Ethics 12 (3) 263-72

Merleau-Ponty M 1995 Temporality Merleau-Ponty M In (ed) Phenomenology of perception London, Routledge

Nortvedt P 2001 Needs, closeness and responsibilities. An inquiry into some rival moral considerations in nursing care Nursing Philosophy 2 (2) 112-21

Rudolfsson G, von Post I, Eriksson K 2007 The development of caring in the perioperative culture: nurse leaders' perspective on the struggle to retain sight of the patient Nursing Administration Quarterly 31 (4) 312-24

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by Annika Larsson Mauleon and Sirkka-Liisa Ekman

Correspondence address: Dr Annika Larsson Mauleon, Senior Lecturer, School of Health and Caring Sciences, Linnaeus University, S-351 95 Vaxjo, Sweden. Email: Annika.larsson_mauleon@lnu.se

About the authors

Annika Larsson Mauleon

RNT, RNAN, PhD

Dr, Senior Lecturer, School of Health and Caring Sciences, Linnaeus University, Vaxjo, Sweden

Sirkka-Lisa Ekman

RN, PhD, Professor

Professor Emerita, Senior Researcher, Dept of Neurobiology, Care Science and Society, Division of Nursing, Karolinska Institutet, Stockholm, Sweden

No competing interests declared

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Provenance and Peer review: Unsolicited article; Peer reviewed, Accepted for publication April 2012.
There was an old man that died - he was on the operating table when it
  happened (pause). I did not know if (pause) the old man having hip
  surgery was suffering from dementia (pause). Yes, I just had to take
  his blood pressure on one arm, since his other arm was amputated
  (pause) and then I was uncertain to what he was doing (pause). Was he
  suffering from heart trouble? Could it be that he was suffering from
  dementia? Also, was this why he was fiddling around with the arm that
  was ok? I was not able to take his blood pressure since the assessment
  I made was incomplete, because he kept bending his arm like this (she
  shows how). I could not determine if his blood pressure was low or
  (pause). I started to think does he understand? He does not
  understand. Well, is he suffering from dementia, or is he just
  fiddling around because he is getting ill?


He started to vomit and we were not able to intubate him. However,
  luckily we had a specific type of tube so my colleague ran to fetch it
   - I was not familiar with it. So I stepped back, he had to try to do
   it, and we succeeded. Then we inflated the cuff and first when we
  inflated, it was not in the trachea it was in the (pause). Then we
  had to do it all over again, and this time we succeeded in inflating
  air into his lungs. By this time, he was quite blue, but he recovered
  and I am quite sure that he had not aspirated, since he was lying in a
  Trendelenburg position on the operating table.


He (the patient) was suffering from back pain and the only thing that
  could have help him would be to place him on his back again, but
  this wish was impossible for me to fulfil, since he had to lie on his
  side and not on his back during his operation.


They lose respect for the patient and lose sight of the patient,
  seeing them only as a tool and they express this by saying things
  like: this is something I have to do research on, and when it comes
  to blood samples they say: just give me a blood sample - I only need
  a blood sample-Have you asked the patient? No there is no need. Oh,
  yes you must! But it is only a sample and you are taking blood
  samples anyway ...


The patient was awake, 1 provided the surgeon with information but he
  paid no attention to it, even when I explained that the patient was
  not yet ready for surgery, the surgeon still insisted on proceeding
  anyway.


The surgical nurse and 1 had to defend our decision, because the
  staff on the ward expected greater efficiency, even if this might
  lead to injury for the patient. We had been placed in an impossible
  situation. First of all, I had to defend the extra time used, even
  though it was our duty to see to it that no harm came to the patient
  and furthermore, I had to defend myself against charges of being
  inefficient and taking too long.


It happened sometime at the beginning of the eighties, and the smell
  and the awful picture is still there in my mind (pause) when (pause)
  if the same thing happened again (pause) and I knew about this
  beforehand ... What I went through then, really makes me hesitate
  before I go into a room (pause) I don't know if I would go into that
  room again, since there was so little I could do to help. They might
  as well just send the attendant to hold their hands; yes whatever
  (pause) you could not do anything for them.
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