During data analysis, 3 main themes and 12 sub-themes were extracted, which were presented in Table 2 as follows: Adherence to professional commitments, preserving patient dignity and respect for colleagues.
Description of the main themes and sub-themes from the experiences of operating room nurses from ethical codes:
Theme 1: Adherence to professional commitments
As providers of physical, social, and psychological care to patients, operating room nurses must comply with a set of professional and ethical standards. Because in the operating room, nurses are faced with complex ethical and professional issues that can be very challenging in their interactions with patients. Adherence to professional commitments provides this ethical framework for nurses to practice.
1.1. Striving to promote professional and personal competence
The nature of patient care in the operating room is complex and takes place in a unique, high-tech environment. Therefore, operating room nurses must constantly improve their scientific and practical information and skills about equipment and communication with the patient to provide principled and ethical care for the patient.
In this regard, a participant stated:
"Honestly, once it happened to me during the surgery, I wanted to work with the C-ARM, but I did not know. It made the surgeon angry, the operation lasted longer, and once or twice we had to expose the patient to high-dose radiation. After that day, I tried to have information for the smallest device in the operating room, and I also participate in training courses that are held so that I am always updated" (P9).
1.2. Commitment to honesty
Depending on the working conditions of the operating room, patients are present in this environment unaccompanied and lose their consciousness during the operation. In this situation, operating room nurses should be supportive of patients and always put honesty in the treatment of patients and their families.
One of the interviewees stated that:
"Some time ago, we had a case of hysterectomy, in which one of the ovaries was mistakenly removed during the removal of the uterus, and then the patient was told there was cyst also in the ovary" (P3).
1.3. Commitment to justice
In the operating room, as in other wards of the hospital, there is always a conflict of interest, prejudice, and unfair distribution of care resources as a challenge, especially since the patient's companions are not present, so operating room nurses always must strive for justice and fairness in care.
A contributor said:
"I remember we had a patient here who came from prison for surgery. Unfortunately, our anesthesia Nurse did not treat the patient well. He did not change the tubes of the anesthesia machine and the mask to be sterile because the patient was an imprisoned person. However, in another shift, when we worked together and the patient was one of the officials of the hospital, he worked very carefully and was extremely respectful and polite" (P1).
1.4. Commitment to keeping secrets and information of anesthetized patients
In the operating room, patients' secrets and information are provided to the surgical team due to receiving anesthesia drugs and removing conventional veils. Therefore, to preserve patients' dignity and respect their rights, the surgical team must be diligent in keeping these secrets.
One of the nurses said:
"The patient becomes delusional when he is anesthetized with ketamine. I have seen that the colleagues ask the patient some irrelevant questions or some points are written in the patient’s file that does not need to be mentioned, but the colleagues recount them in the operating room and thus the patient’s secrets are revealed “(P7).
1.5. Punctuality in operating room admissions
In surgical teams, health professionals are highly interdependent and work under time pressure. The timely presence of the surgical team and the patient in the operating room is an ethical issue because the treatment staff and the patient are mutually respected and prevent anxiety and worry in the patient and waste of time.
A participant said this:
"I have seen many times that the elective patients are picked up from the ward much earlier than the time of their surgery and the patient stays in the reception for a long time. Personnel traffic, the presence of various patients and waiting are annoying for the patient, making him agitated, and his blood pressure rises. I warned the colleagues about this and told them that whenever the room was ready and the surgeon was present, the patient should be handed over so that the patient experience the shortest time between his presence in the operating room and the anesthesia" (P10).
1.6. Responsibility
Responsibility is an inner sense of obligation and commitment to the correct performance of tasks and is one of the basic concepts in caring for patients in the operating room. Absence or deficiency in this causes distrust, worry, and harm to patients.
One participant highlighted this:
"Once the circular nurse in our room gave the sample of a patient to a student for registration. Unfortunately, the student did not do this correctly and the patient's sample was lost and the purpose of that surgery was only to take a sample. Well, it was the responsibility of the circular nurse to register the sample. However, he failed and did not take it himself “(P4).
1.7. Observing the correct principles of sterilization and aseptic
Nosocomial infections are one of the problems of the last century and are also considered as important complications after surgery. The most important people in preventing and controlling this complication are the members of the surgical team who can prevent the occurrence of this complication by observing the sterile principles regarding tools and medicines and proper hand washing during and after surgery.
One of the interviewees stated that:
"Once, we were in a room where laparotomy was performed. I remember it was the end stages of the operation that the scrub nurse once said the label was not sterile. That means the operation had been performed with contaminated equipment up to that point, while it had to be checked properly before the surgery begins “(P7).
Theme 2: preserving patient dignity
Operating room nurses meet with extremely vulnerable patients, as they delegate their authority to the surgical team in this environment and literally put their lives in the hands of the surgical team, and their reputation may be compromised. Accordingly, the protection of patient dignity should be a major concern for all health professionals, especially operating room nurses who are involved in patient care.
2.1. Respect the privacy of patients undergoing surgery
Privacy and human dignity in the care of patients undergoing surgery in the operating room where the usual privacy is lost and the patient is unconscious are essential and ethical that nurses should strive to comply with.
In this regard, a participant stated:
"In the genital surgery of a woman we had a few days ago, I felt the patient very uncomfortable because of the presence of the male students in the room. So I asked them to go out of the room and lock the door so that the patient would be comfortable" (P1).
2.2. Emotional and psychological support of patients undergoing surgery
The presence of the patient in the operating room is always associated with stress and many worries and questions, and all these factors affect the anesthesia and surgery process of the patient. It is the duty of an ethically committed nurse to understand the patient's concerns and to be kind to the patient and respond to their needs.
One of the nurses noted:
"Once our patient was a sick child, about 12 years old, when we saw him he hides under the blanket and his hand was shaking. I saw our colleague sitting next to him, holding his hand, caressing him, talking to him, and making him talk about his fear and worries about being in the operating room. Finally, before the anesthesia, the patient became very calm and relaxed" (P8).
2.3. Respect for patient autonomy
In the operating room, nurses and physicians must always be committed to respecting patients' decisions and their autonomy to choose surgery and anesthesia as far as is beneficial to the patient. Patients' decision to choose a surgeon and anesthesiologist should also be considered; Because in this environment, patients consider nurses and doctors as their advocators and put their health in their hands. One participant highlighted this:
"One of the patients was once told that your cholecystectomy would be performed laparoscopically, but when he came to the operating room, he was told that his surgery would be done openly. Although the patient did not like it; But the surgeon did it openly to educate the residents, and he satisfied the patient and did not care about his request" (P2).
Theme3: respect for colleagues
The operating room is an environment with many challenges and stresses. The quality and efficiency of surgical methods and patient safety, in addition to nurses' scientific skills, depend on high-quality communication, knowledge sharing, support for colleagues, and respect for them, which ultimately leads to the provision of optimal patient care.
3.1. Having a respectful relationship with colleagues
Nurses' commitment to ethics and respect for privacy, the position and personality of colleagues and disputes and free discussions with other colleagues, will enhance the sense of empathy and ultimately cooperation skills and will create a sense of calm in the workplace for operating room nurses.
One of the interviewees stated that:
"Personally, I feel useful and motivated when I am in a surgery group with colleagues with less experience and age than myself, that as someone who has more work experience, they pay attention to my opinions and respect me. And I perform my work with a better spirit"(P6).
3.2. Having a teamwork spirit in the operating room
The basis of work in the operating room is teamwork. The surgical team consists of different professions with different tasks that 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 the result of the work, so having a spirit of cooperation in these situations is very important.
A contributor said:
"Once we were having surgery, when the circular nurse went to fetch serum, and suddenly an emergency occurred. I shouted several times and asked for help, but none of my colleagues came to help. Even our anesthesia Nurse in the room did not try to help us. Here. We are a team and we must help each other to save the life of the patient" (P3).