The results of the analysis led to two main findings. The first main finding concerned OR nurses’ interaction between skills and understanding, and the second concerned OR nurses’ interaction between nursing care and technology. In the Results section, each citation of an observation or interview statement has been assigned a reference number for one of the 24 participants, who practiced as either the circulating nurse (CN) or surgical nurse (SN).
OR nurses’ interaction between skills and understanding
The first theme is entitled “technical skills” and concerns the different ways in which the technical assignments and developments were handled. The second theme is entitled “understanding of the individual patient” and concerns the different ways in which the patients were viewed. Table 1 shows how the relationships between the main finding (interaction between skills and understanding) and the subthemes were developed.
Technical skills were expressed in two ways: technical flair and a lack of technical skills.
Technical flair was considered to be present when nurses demonstrated skill in carrying out procedures and operating instruments regardless of the amount, size, construction, or variety of different types of machinery and equipment. Technical flair also involved the ability to easily acquire new knowledge and skills in using instruments and machinery, including the consequences of their use in a specific patient situation. Technical skills were reflected in the following observation: The SN [participant] unpacks and prepares for the operation and says to the CN, “Look at the scope—it has been assembled before autoclaving. It is not supposed to be assembled. It has to be separated in its many parts, springs, and screws before being autoclaved, and then the parts have to be assembled during preparation for the operation.” The SN acquires a new scope, easily assembles it, and says, “I think I am what you would call practical. I have a flair for technical things and electronics. It is easy for me and it interests me a lot” (21).
A lack of technical skill was characterized by the ability to assist in routine operations and apply already-known instruments, equipment, and machinery without problems. However, such nurses were unable to acquire knowledge and skills in using new instruments or establish routines involving complex technical procedures and computer-based equipment. This lack of skill had negative consequences as shown by the following interview response: “I don’t have technical flair. It is not easy for me and it doesn’t interest me. I fall short as soon as I have to work with a computer. One day, I made a mistake when a patient was connected to the navigation system [complex computer-based surgical equipment]. I touched ‘something’ and the patient had to undergo the surgery without the advanced technique” (1).
Technophobia was also viewed as a lack of technical skills. Technophobia was characterized by a lack of skills in certain procedures, potentially leaving the nurse feeling fearful and clumsy. This was expressed in the following statement during an operation: “I don’t feel good about mixing the cement. I am afraid that I might screw things up. That [the procedure] takes up so much [energy]. It is annoying to think about during the whole operation. I feel like a clown” (17).
Understanding of the individual patient
The nurses’ understanding of the individual patient was expressed in two different ways: the patient was viewed as either a human being or an object. Viewing the patient as a human being was shown by the way the nurses considered a patient’s situation during an operation: A 65-year-old woman is lying on the operating table after an ostomy operation. The surgeon has left the operating room. When removing the sterile cover, the CN [participant] notices that the ostomy is “uneven.” She encourages the SN to contact the surgeon. The surgeon agrees that the ostomy does not have the desired shape. He cuts the lowest suture, pulls the bowel further up, and places a new suture. Everyone is satisfied with the shape of the ostomy (23).
This participant was asked to elaborate on the above-described episode and said, “It is a trauma in itself to have a life-threatening disease and an ostomy. If the patient, on top of this, will have problems adhering the plate and the ostomy bag because we haven’t done our job properly…well, that just aggravates the situation. I have worked with ostomy patients and I could see that the ostomy was not okay” (23). In this episode, the CN applied her experience-based knowledge for the benefit of the patient. She expressed her understanding of the patient as an ill and vulnerable human being.
There were also nurses who viewed patients as objects. This was observed in a situation in which the SN did not allow the CN to speak up for a patient: A 45-year-old woman with cancer is undergoing surgery for a pathological fracture. The CN notices that the surgeon is uncertain about the instrumentation used to measure the size of the prosthesis. The surgeon asks the SN for a prosthesis of a certain size. The CN reacts by saying, “But your measurement was larger than this” [implying that the surgeon asked for the incorrect prosthesis]. The SN reacts by saying to the CN, “Hey!” [implying that she was interfering with something with which she was not supposed to interfere] (17). The prosthesis was subsequently discovered to be too large, and the patient required further surgery. According to the field notes, the SN was struck by passivity. Moreover, she prevented the CN from getting involved in the situation. In this example, the approach was characterized by a lack of interest in the patient as a human being; the patient was instead seen as an object.
OR nurses’ interaction between nursing care and technology
In the second main finding, OR nurses’ interaction between nursing care and technology, the coherence between the themes and subthemes contributed to the development of three levels of interaction: the interaction, declining interaction, and failing interaction levels (Table 2). The different ways in which the technical assignments and developments were handled and the different ways in which the patients were viewed contributed to the development of all three levels of interaction.
The interaction level was characterized by the interaction between the presence of technical flair and viewing the patient as a human being. This was expressed in the following way: The SN [participant] is assisting during an operation of a 72-year-old woman. The SN says, “I haven’t done this [specific operation] for a long time.” The SN gets five large boxes and separates instruments from a depot, takes the instruments to the operating room, and unpacks and prepares the instruments for the operation. She now places her hand on the patient’s shoulder after the patient has been sedated and assists in connecting her to the respirator. Later during the operation, the SN says, “She [the patient] is such a fine little lady.” With eyes on the surgical field and without speaking, the surgeon reaches a hand toward the SN, who passes a specific type of suture to the surgeon. The SN looks at the surgical field and says, “Wait. Is that the right suture for that place? If not, you’ll need a different one.” She then passes another type of suture to the surgeon (23).
In this episode, technical flair was evidenced by the SN’s confidence in using the equipment and proficient grasp of the situation despite the fact that it had been a while since she had assisted in this type of operation. The underlying understanding of the patient as a human being was expressed during the SN’s participation in the patient’s sedation, in which she placed her hand on the patient’s shoulder while assisting the anesthetic nurse. The SN referred to the patient in a respectful manner by using the expression “such a fine little lady,” and it is evident that she understands, sees, and meets the patient as a human being.
Declining interaction level
The declining interaction level was characterized in two ways: as an interaction between the presence of technical flair and viewing the patient as an object and as an interaction between a lack of technical skills and viewing the patient as a human being.
The interaction between the presence of technical flair and viewing the patient as an object was expressed when a participant spoke about a colleague: “She [a colleague] is technically very skilled. She can manage everything when it comes to technology and IT systems. Therefore, she is our expert, but only when it comes to technique. She has no interest in the patients. She cannot talk to [understand] them [the patients]” (4).
The participant who spoke about the colleague was later asked to elaborate on this statement and answered, “Yes, you have a point there” (3). This colleague was perceived as a skilled technician with technical flair. Her lack of interest in vulnerable patients, however, is an example of viewing the patient as an object.
The interaction between a lack of technical skills and viewing the patient viewed as a human being is shown in the following scenario: The SN [participant] is about to assist in a very complicated operation. She says, “I haven’t assisted in such an operation in 100 years.” The CN assists the SN with the preparation. After unpacking the equipment for the operation, the CN is about to leave the room. Very promptly, the SN says, “No, you can’t go.” The SN was later asked to elaborate on this episode and stated, “When I am insecure about the techniques, I get very affected by the way the surgeon enters the room and whether I can sense that he seems insecure. Today, when we were using new equipment, there had to be a technically minded colleague next to the surgeon to assist him. And while my colleague is technically minded, I am caring-minded. I am very considerate of the sedated and defenseless patient. I see him as a human being” (4). In this example, the technically unskilled nurse was insecure and using new equipment. The nurse acknowledges that she was insecure and expressed the need to have a technically skilled nurse present in the OR. The expressions “No, you can’t go” and “I get very affected” reflect the presence of technophobia in this technically unskilled nurse. In this scenario, it seemed as though the lack of technical skills was legitimized by viewing the patient as a human being.
Failing interaction level
The failing interaction level was characterized by the interaction between a lack of technical skills and viewing the patient as an object. This was demonstrated in a scenario involving the above-described 45-year-old woman with cancer who underwent surgery for a pathological fracture (see earlier theme, “Understanding of the individual patient”). In contrast to the CN, the SN did not interfere with the surgeon and his novice use of the instrumentation while measuring the prosthesis size. Furthermore, the SN prevented her colleague from providing the novice surgeon with important knowledge by saying, “Hey!” [implying that she was not supposed to interfere] (17). At the end of the operation, the surgeon said to the SN, “I have not been satisfied with your assistance.” The SN replied, “Well, it is not my fault that you chose a prosthesis that was too big. You are supposed to know how this should be done” (17). Before the operation, this particular participant said, “I don’t bother about the patient contact. I have often felt that I am unable to do anything for them [patients]” (17). According to the field notes, the SN exhibited passivity and was unable to share her (limited) technical, practical, and experience-based knowledge. Moreover, she prevented the CN from getting involved in the situation. In this example, the lack of technical skill was combined with a lack of interest in the patient as a human being; the patient was only an object.