Unveiling The Experiences of Operation Room Nurses on Ethical Issues: A phenomenological study in Adama Hospital Medical College, Ethiopia, 2022

doi:10.21203/rs.3.rs-4853425/v1

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Research Article

Unveiling The Experiences of Operation Room Nurses on Ethical Issues: A phenomenological study in Adama Hospital Medical College, Ethiopia, 2022

https://doi.org/10.21203/rs.3.rs-4853425/v1

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Background

Operating room nurses face frequent ethical issues and as key members of health care team must go beyond mere awareness of ethical principles to make ethically sound decisions in complex and challenging environment. Immediate resolving of these issues helps mitigate moral distress and its associated symptoms, such as anxiety and decreased job satisfaction, while enhancing patient care. A deeper understanding of ethical issues in the OR will help tailor interventions and policies to address real-world challenges, improve patient care, and better support healthcare professionals.

Objective

This study explored the lived experiences of operating room nurses with ethical issues at Adama Hospital Medical College in Adama, Ethiopia, in 2022.

Method

A qualitative study using the hermeneutic phenomenological method was conducted at Adama Hospital Medical College from March 15, 2022 to April 15, 2022. Eighteen nurses were selected as participants using maximum variation purposive sampling. The data was collected through semi-structured in-depth interviews. The data was then imported into Atlas Ti 8 software to be coded and categorized. To ensure trustworthiness, the basic principles were applied. Data analysis was conducted based on the Van Manen method and the results were summarized using thematic analysis.

Results

The study reveals two main themes and eight sub-themes regarding ethical issues faced by operating room nurses. The main themes were issues related with safeguarding patient dignity and professional commitments, while sub-themes include breaches of dignity, untruthful communication, overcrowded ORs, patient expectations, lack of informed consent, and breach of sterilization standards.

Conclusion

Upholding ethical principles and standards are critical for improving patient care and fostering positive relationships. Concepts like devotion to professional commitment, patient dignity, and collegial respect are crucial for participants. Addressing ethical concerns and ensuring compliance will enhance healthcare delivery in perioperative settings.

Adama Hospital Medical College

Ethical Issues

Ethiopia

Lived Experiences

OR Nurses

Phenomenology

The operating room (OR) is a hospital unit with advanced technology, requiring a multidisciplinary team to effectively address life-threatening situations, thus interpersonal conflicts are common (1). Again, it is the place where harmful risks encounter patients, and patients are unconscious due to anesthesia, making them dependent on all life activities. Thus, Operation Theatre Nurses (OTNs) play a crucial role as patient advocates (2). In addition to these feature, resource allocation is another ethical issues that confronts OR nurses in the health care setting. Ethical issues are complex problems that can be new situations, everyday issues, or dilemmas that are difficult to resolve and necessitate a moral solution, and thus must be decided among several alternatives (3).

Common ethical issues in OR include professional commitments, patient dignity, disrespect, unauthorized observers, dishonesty, ignoring patient expectations, suspicious drug usage, sterilization standards, operating on wrong patients, informed consent hesitation, resource misuse, and incorrect material registration are just a few of the ethical issues that OTNs face in their clinical practices (4–6).

Issues in ethics can lead moral distress, psychological and physical symptoms such as anxiety, despair, worthlessness, resentment and anguish, decreased job satisfaction and even improper or inadequate nursing care (7). Despite being avoidable, immoral behaviors in healthcare often occur in the operating room (OR), where instruments are retained within patients, necessitating continuous improvement in professional skills and moral competence for OTNs (8).

Studies revealed that Nurses working in OR double duties for ethical issues encounter them. A Swedish study revealed that OTNs face two moral dilemmas in patient care: possessing professional skills for procedures and maintaining professional relationships with patients and colleague (5). Studies in Turkey and Iran reveal that OTNs in theater complexes face moral challenges like respecting values, committing to organizational pledges, and adhering to professional and ethical principles (4, 9). Perioperative nursing care in Ethiopia faces challenges due to resource distribution, staff shortages, work load, and lack of ethical codes, affecting decision-making processes among OTNs (1, 6, 10).

OTNs should follow their country's code of ethics for nurses, which is a written list of the profession's values and standards of conduct in resolving ethical issues (11). Therefore, the features of the OR, hospital-related, patient related and staff-related issues OTNs experienced in their daily living for patient care during perioperative nursing (2, 4). Beneficence, nonmaleficence, justice, and autonomy are the universal ethical principles underlying nursing practice to handle ethical issues (11).

Few strategies are used to resolve ethical issues. Among these strategies, the World Health Organization, the International Council of Nurses (ICN), and the American Nurses Association (ANA) have developed and implemented professional codes of ethics (12–14). Adherence to professional ethics in nursing professions fosters a sense of reliance, safety, and peace in patients, reduces hospitalization time, fosters proper interactions between nurse-patient and nurse-colleagues, and ultimately reduces hospital stay costs (15–18).

However, codes of ethics in healthcare settings are primarily used for patient-related matters and should be updated to better serve the evolving nursing context (19–21). The Ethiopian Nurses Association's code of ethics for registered nurses is being revised but is not yet in clinical use (21). The International Council of Nursing (ICN) code of ethics states that many countries lack ethical codes for nursing specialties like OR (11). Thus, In the absence of such a tool, nurses are left confused about ethical issues and uncertain about their decisions, leading to patient dissatisfaction (16).

Again Operating room nurses, as key members of healthcare teams, frequently encounter ethical issues. Merely being aware of ethical principles is insufficient in complex and challenging OR environments; nurses must be sensitive and adept at making ethically sound decisions. Gaining a deeper understanding of these issues helps nurses make wiser decisions and can mitigate the moral distress, psychological and physical symptoms—such as anxiety, despair, worthlessness, resentment, and anguish associated with ethical dilemmas. These issues can also lead to decreased job satisfaction and inadequate nursing care. Therefore, this study aimed to explore the ethical experiences of operating room nurses at Adama Hospital Medical College, Adama, Oromia, Ethiopia, in 2022.

Study Setting and period

The study was conducted at Adama Hospital Medical College (AHMC), from March 15 to April 15, 2022. Adama, located in central Ethiopia, is situated at an elevation of 1712 meters and is 99km south east of Addis Ababa (22). AHMC, the largest public hospital in Ethiopia's Oromia regional state, serves over 7 million people and receives referrals from various regions. It is the only public hospital among five in Adama city, with a large operation room units, making it the most suitable for purposive selection. 90 department specific OR nurses comprised within th hospital as per the administrative records report (23).

Study approach

The study employed a phenomenological design grounded in Heidegger's philosophy (24) and hermeneutic phenomenology (25).

Populations

All operating Room nurses working in AHMC were our source population while those with rich experience of the subject and ability to express and fulfill inclusion criteria during study period were our study population.

Inclusion and exclusion criteria

To participate in the study, participants needed to have at least two years of work experience in the operating room, significant experience with the subject, and the ability and willingness to express themselves and engage in the study. Perioperative nurses on sick leave, annual leave, or maternity leave were excluded from the study

Sample Size Determination and Sampling Techniques

Eighteen experienced operation room nurses were recruited. The sample size was determined based on information needs, with saturation of information as a guiding principle, and sampling was conducted until no new information was obtained (26). To recruit participants, the study used maximum variation purposive sampling method by considering gender, years of experience, and working unit. The study included 10 women and 8 men, as shown in (Table 1). Oral and written consent was obtained. The majority of the participants were operating room nurses.

Table 1

Socio-demographic characteristics of study participants in AHMC, Adama, Ethiopia, 2022
Participants	Age	Sex	Level of Education	Total Working experience
P1	35	F	BSc	14
P2	39	M	BSc	15
P3	49	F	BSc	20
P4	50	F	MSc	23
P5	34	M	MSc	12
P6	29	M	BSc	7
P7	32	F	BSc	13
P8	27	F	MSc	11
P9	48	M	MSc	20
P10	32	F	Bsc	10
P11	49	F	MSc	22
P12	40	F	Bsc	19
P13	32	M	Bsc	12
P14	29	F	Bsc	13
P15	34	M	Bsc	14
P16	38	M	MSc	14
P17	23	F	Diploma	5
P18	25	M	BSc	5

Data collection tools and methods

A semi-structured interview guide was used to conduct an in-depth interview. The tool was created using similar research and some guides that were modified to fit the study's objects (2, 5, 20, 27). All interviews were conducted by first author. Memo was used to record facial expression of participants and newly found themes. To facilitate interviewing, the tool was first developed in English and then translated into the local language "Afan Oromo." Probing questions were asked to make the interview clearer and deeper. The goal of the study was stated prior to the start of the interview, and participants provided informed consent to record the interviews. A pretest was conducted with two operating room nurses at Bishoftu Referral Hospital, meeting inclusion criteria. Interviews were conducted between 1:30 − 2:15 hours, with a mean duration of 1:45 hours. Participants were thanked for their cooperation and time for participating in the study.

Rigor

A pilot study was conducted to ensure data quality, with the principal investigator handling interview questions, data collection, checking, and translation. A memo on participants' facial expressions and a convenient interview environment were also crucial. To ensure the rigor of the study, four main criteria were employed; credibility, confirmability, dependability, and transferability (28). Investigators conducted member checks on participants during the data collection and analysis process to ensure credibility. To ensure the accuracy and clarity of participants' experiences at each stage, data or results were returned to them, and changes were made as necessary. Furthermore, long-term and ongoing engagement with data, as well as participant diversity in terms of demographic characteristics (e.g., gender, age, and work experience) was made which contributed to the findings' credibility and transferability. The study was meticulously documented, with an audit trail created to record unique topics, explain code merging, and clarify theme meaning. The researchers were asked to reflect on their values and interests to identify biases, and participant words were used in the study findings.

Data Analysis

The data were analyzed using Van Manen's approach by the principal investigator and immediately following the first interview and simultaneous data collection (25). The study involved conducting interviews and creating a code book using Atlas ti - software. The code book was updated to include new codes discovered during data collection. Data analysis was conducted concurrently with data collection, with the principal investigators transcribed interviews in Afan Oromo and translated them into English. The researchers independently identified potential themes, codes, and quotes, and then pooled observations. Preliminary code lists were created, and related codes were generated by categories. Six steps were followed during analysis: familiarizing with the data, generating initial code, searching for themes, reviewing themes, defining and naming themes, and producing a report.

Standard definition of terms

Ethics

is the set of moral principles that guide individuals' behavior, encompassing both theoretical and applied categories. Theoretical ethics explores the meaning and objectives of morality and responsibility, while applied ethics aids in making the right and wrong decisions, dividing morality into theoretical and applied categories (4, 13).

Professional ethics

Is a new branch of applied ethics that addresses various professional ethical issues through specific principles, ensuring high-quality care for medical practitioners and nurses based on professional and ethical standards (1, 3).

Ethical issues

Are complex issues that are difficult to resolve. These issues could be new issues, daily issues, or situations that require a choice between several options (2, 3).

Code of ethics

Is a formal statement of a group's ideas and values, serving as a guide for professional actions and public commitment. These codes are typically higher than legal standards and must never be lower than the profession's legal standards. Perioperative nurses must adhere to their respective countries' Code of Ethics.

Socio-demographic characteristics of study participants

A total of 18 operating room nurses (10 women and 8 men) with a mean age of 34.325 years, a mean total work experience of 14.125 years and a mean work experience in OR of 5.675 years participated in this study as shown in (Table 1) below.

Emerged Themes

Analysis of the interviews data initially led to construction of 1,129 codes. But, after repeated data analysis, subsequent deletion of duplicate codes and merging similar items, two main themes and eight sub-themes for regarding common ethical issues raised in OR were emerged (Table 2).

Table 2

Extracted themes and sub-themes regarding common ethical issues in making ethically sound decision in AHMC, Adama, Ethiopia, 2022.
Identified Themes regarding Ethical issues
Themes	Sub-themes
Issues related with safeguarding patient dignity	Traffic and crowdedness in narrow OR
	Communicating with patients in an untrustworthy manner
	Ignoring patients' expectations
	Issue of informed consent
	Omission to follow sterilization standards and aseptic techniques
Issues related with professional commitments	Issue of personal & professional competence
	Issue of responsibility
	Issue of justice

Identified themes regarding ethical issues encountered

Two themes were constructed regarding common ethical issues encounter nurses in OR. The first theme, issues related with safeguarding patient dignity was composed of five subthemes. All of these subthemes were so prominent, and thus are described below.

Issues related with safeguarding patient dignity

1. Traffic and crowdedness in narrow OR

Most participants reported that observers in operating rooms often perform training and education without patients' consent in our hospital, which poses threats to infection and violates the principle of privacy, despite being treated as normal. An OR nurse with 10 years of work experience stressed that, "More than 20 people including routine surgical staffs attained narrow operating room for training without permission of patient, which makes OR overcrowded and source of infection. This issue also violates the patient's privacy principle.” (P5)

Participants share their experiences by suggesting way to overcome the issue. A participant of 35 years old with 6 years of work experience confirms that, “Over traffic in perioperative settings can cause stress and psychological safety issues for patients, and negatively impact team performance. Maintaining a quiet environment, especially during preoperative is crucial for the theatre team to ensure patient safety and prevent harm to the patient.” (P1)

The majority of participants agree that patients' privacy is crucial especially in perioperative settings, as they are highly susceptible to loss their privacy due to their unconscious status as a result of anesthesia. A participant with 6 years of work experience in OR share his experience “A few days ago, myomectomy procedure was performed with spinal anesthesia, allowing the patient to remain fully conscious. During catheterization, a woman felt uncomfortable due to a male resident ready to catheterize her. So I asked him to give the procedure our sister and go out, until the procedure was complete, ensuring her comfort. I do that because the focus was on patient privacy, rapport, and fostering positive relationships between the care giver and patient.” (P3)

2. Issue of truth telling

The participants of the study reported that communicating patients in an untruthful manner is the other ethical issue seen in perioperative setting. A participant with 23 years of work experience highlighted said, "Some of our employees speak to patients in an untrustworthy manner. One must respect the promise made to his or her patient as an individual, regardless of social status or background, and should always tell the truth. This attitude should be extended to their family caregivers as well as the surgical team.” (P4)

Another participant with 12 years of experience stressed by sharing his experience that, "Some of our employees engage in unethical behavior with patients. One must always tell the truth and respect the promise made to his or her patient as an individual, regardless of social status or background. This attitude should be extended to both the patient's family caregivers and the surgical team.” (P5)

The study found that honesty and truthfulness are the most effective strategies for addressing ethical issues in operating theatre settings, where operation teams collaborate to improve patient wellbeing. With these regard, one of the participants with 12 in OT years of work experience suggested by sharing his experience that, "Once upon a time, I gave a surgeon a small artery clamp for the purpose of free tie, and the instrument became lost inside the patient's abdomen, potentially causing severe complications for the patient. Finally, during sign out for counting, I couldn't find the correct instrument, and I was very stressed, but I said the count was correct because time was running out and residents were beginning to close the patient's abdomen, and I was afraid that if I told the surgeon, I would get in trouble. But, because the patient could have a post-operative infection due to a foreign body left in the abdomen or another issue, I quickly told the truth, and they discovered it quickly. Thanks to Allah, the patient's safety was ensured. Honesty among the perioperative team and in working with patients and their families is required for eternity to gain the trust and satisfaction of patients and colleagues." (P3)

3. Ignoring patients' expectations

Participants also stated that ignoring patients’ expectation is one of the most ethical issue encountered in perioperative setting. They reported that in the operating room sometimes our staffs omit patients’ decisions and the right of their treatment option.

A participant with 5 years of experience in OR stated by sharing his experience that, “I remember that once upon a time, we had a patient who in the past undergone Laparatomy. At that time her skin was sutured with a stapler and end up in many scars. For second time myoma was relapsed and again she come for surgery and she stressed to suture with material that end up her skin with disgusting scar. In contrast the same thing has happened because surgical team was harried to finish the case and go out. Due to this, the patient was very upset and had many scars left. Look! How ignoring patients expectation harms performance outcome and patients psychology.” (P13)

The most frequent events reported by the participants were that nurses ignored patients’ expectation by ignoring their needs or shouting at them. A participant shared her experience: “Many explanations for why the nurses ignored patients’ expectation can be so harsh. Of course they are tired and angry because the …. may have brought the patient too late.” (P2)

4. Issue of informed consent

Again participants of study reported that one of ethical problems/issues happen in perioperative setting is informed consent. They reported that patients’ informed consent is not fully performed during patients undergoing surgery and they are included in the research without their permissions. In this regard an OR nurse with 10 years of work experience stressed that, "Typically, patients are brought to the operating room without having signed a consent form. Their surgical information is also taken without their permission. Again I said! One of the most common issues is that surgical procedures are performed on patients without their permission.” (P10)

Participants described situations in which health care providers failed to respect patients' rights to know about their illness, to choose treatment options, and to refuse treatment. The participants were stressed because their informed consent was not followed. One of the participants stated, "We have seen the practice of obtaining consent from patients for major procedures, but we have not seen the practice of informing patients in detail about their treatment. As a result, they sign stating that they are unfamiliar with the procedure in detail. On the other hand, they believed that consent was simply a formality for obtaining signatures for procedures, and that the patient and family were not properly informed." (P18)

Another participant shared their experience by stating: “When…… a patient who developed pneumothorax after tracheostomy, the patient's family argued that they were not adequately informed and given treatment options…………. (P6).

Another participant share his experience by stating: “The necessary intervention without the client/patient’s consent only as an exception and in case of an emergency, when immediate therapeutic action is required to save the client/patient’s life” (P17)

5. Omission to follow sterilization standards and aseptic techniques

Another most commonly encountered ethical issue in OR is failing to follow proper sterilization and aseptic technique as majority of participants of this study’s experienced. In this regard one of OR nurse with work experience of 10 years said that "Most of the time, nurses in this OR are responsible for following sterilization of instruments and observing aseptic technique. Although it is the responsibility of the entire surgical team, operating room nurses can play an important role in preventing and controlling post-operative complications by adhering to the principles of aseptic and sterile regarding hand scrub equipment used in surgery, skin preparation (prep), and surgical drape. But, some of our staffs are negligent in this regard and commits malpractice.” (P5)

Aseptic technique observance in the operating room is a fundamental factor in providing indirect care for patients under surgical operation. "I opened a surgery set and found a hair in it. Under such conditions, I give back the set to CSR, and never use these sets for the operation." (P7)

Issues related with professional commitments

Sub-themes emerged under this theme are issues of commitment for personal and professional competence, issue of responsibility and issue of justice.

1. Issue of personal & professional competence

The participants mentioned that among ethical issues frequently occurred in perioperative setting is inability to pro-actively aimed for the growth and development of themselves and other team members with knowledge, skill and attitude which hinder the enhancement of the personal and professional competence. A participant with nine work experience highlighted: "The majority of our staff, including myself, are not prepared to be efficient and successful at our task and improve certain character traits; we only do the task for the sake of our lively hood. Sorry to say, not only accomplishments at work, but also a virtuous personality. Overall, we are not aiming for excellence.”(P6)

An OR Nurse with 13 years of work experience also confirms the above idea by stressing that, "As far as I can tell, most of the time, especially among nurses, they are passive in their pursuit of scientific knowledge. Even if OR activities are an excellent example of effective teamwork for sharing whatever you require to ensure the best possible outcome, and do everything possible during surgery to ensure that the patient is transferred to the recovery room without complications that need enriching yourself in terms of knowledge, skill, and attitude, I have observed a passive reaction in our team to striving for personal and professional excellence.” (P7)

Participants in the study suggested that maintaining personal and professional competence can help overcome ethical issues in perioperative settings, given the complexity and uniqueness of patient care. They suggested that, OTN’s should continuously update their empirical and esthetical information and practice to give principled and ethical patient care. In this regard, An OTN with 6 years of work experience suggested that, “As I told you earlier, when I tried to scrub the BPH case I failed to practice it well and the urethral blockage happens twice and it made the surgeon angry, the operation lasted longer which exposed the patient to extra anesthesia time. After that day, I tried to have information for the case in the operating room, and I also participated in training courses that are held so that I am always updated.” (P1)

2. Issue of responsibility

The majority of participants reported that bearing responsibility is sometimes ethical issue encountered nurses in perioperative setting. They reported that most of surgical team in our setup shows little sense of commitment to conducting the right job description and not be punctual. In this regard one of OR Nurse with 5 years of work experience reported that, "Most of our employees fail to discharge their responsibilities in terms of keeping patient charts, being on time, leaving work within recommended time frames, and labeling and recording patient samples, which directly or indirectly harms patient outcomes. Receiving quality care, on the other hand, is the right of all patients, while making it the responsibility of all nurses, and failing to follow this principle causes patients' distrust of nurses, worries, and harms patients.” (P18)

Again participant with 13 years of work experience stressed that, "Sometimes, some staffs do not arrive on time, even if the surgery is scheduled to begin early in the morning to ensure patient safety." However, due to their tardiness, patients may face surgery delays and cancellation after fasting for an extended period of time. This demonstrates a failure to accept personal responsibility.” (P16)

Participants of this study suggested that staffs in perioperative setting should bear a sense of commitment to carry out the right job description. They suggested that receiving quality care is the right of all patients and discharging it is the responsibility of all nurses which helps to overcome challenges that hinder making ethically sound decision on ethical issues.

In this regard, one of operating OTN with 5 years of working experience suggested by sharing his experience that, “Some time ago our staff circulating a case in our room gave the sample of a patient to a student to label and record on perioperative nursing registration. As a chance, the student did not do this correctly hence the patient’s biopsy was lost, and the purpose of that surgery was only for biopsy. Well, it was the responsibility of our staff circulating the case to label and record it on perioperative nursing record. But, the nurse action was being futile and breach discharging responsibility.” (P16)

The participants this study also suggested that, monitoring of principles of sterilization and aseptic technique is also the responsibility of surgical teams. If a principle of sterilization and aseptic techniques was not monitored well, surgical site infection is the most common complication after surgery which may sometimes forces patients reopening and may predisposes patient for long-term hospitalization.

In this regard one of OTN suggested that, “By appropriately observing the principles of aseptic and sterile techniques such as surgical hand scrub, equipment processing, cleansing surgical site and assisting surgical drape, OTNs’ should take part in a vital position in preventing and controlling surgical site infection and other complications due to breach of this principle.” (P18)

3. Issue of justice

Most of time the issue of justice and fairness encounter in health care setting in terms of unfair distribution of care resources as suggested by participants of the study. They stated that these issues may lead to prejudice and unfair distribution of care resources, since the patient’s relatives are not present in the operating room to monitor how care is provided to their patients, it is the duty of a morally committed nurse to treat all patients fairly without discrimination. A contributor with 6 years of work experience said by sharing his experience that, "Giving service in a discriminating manner is becoming a habit in this era, which is a bottleneck issue in the health care setting. Last year, I had a female patient come in from rural for emergency surgery. Unfortunately, our staff did not treat the patient properly. He did not change the sterile mask for the patient or even the tubes of the anesthesia machine because the patient's personal hygiene was poor. In contrast, on another round when we worked together, he carefully completed his task for a relative of one of the hospital's officials and was extremely respectful and polite.” (P1).

The study found that fairness and justice are crucial for addressing ethical issues in healthcare settings, particularly in perioperative settings where OTNs encounter diverse patients with differing religious beliefs, social status, economic status, and language. The majority of participants believe that differences in care giving practices could lead to discrimination and unfair distribution of healthcare resources, unless a principle of fairness is implemented. An OTN with 10 years of work experience in OT suggested that “The reality that the patient’s accompanying person are not present in the OR complex to observe how care is provided to the patient, it is the duty of a morally committed OTN’s to treat all patients fairly without bias.” (P2)

This study was intended to explore the leaved experiences of operation room nurses to ethical issues at Adama Hospital Medical College. Semi-structured interviews were performed, and data analysis revealed two main themes; Issues related with safeguarding patient dignity and Issues related with professional commitments.

The first main theme of this study regarding ethical issues mostly encountered in perioperative setting was issues related with safeguarding patient dignity. Sub-themes included under these main themes were ignoring patients' expectations, issue of informed consent, omission to follow sterilization standards and aseptic techniques, over traffic and crowdedness in narrow operating room and issue of truth telling.

Regarding issues of ignoring patient expectation and violation of informed consent, findings of the study was supported by the studies conducted in Norway (27), Ireland (29), Turkey (30) and Iran (31), which reported, ignore of patients expectation by misuse of scarce resources and charging for unused materials, and issues of informed consent and privacy. This implicates that in referral hospitals as overloaded patients invited in seeking higher care and thus the need for sharing space and resource competition increases and by passing consent in hurry manner during emergency referrals and issue of privacy were natural phenomenon. As a result breach to safeguarding patient dignity might happen and these are threats to sense of security, strengthens and self-esteem, and discourage psychological support, results stress and negative consequences. However, the result of this study contradicts with studies conducted in Finland and Sweden (5, 6). This might be in our study setup shortage of skilled human power and advanced surgical as well as our culture of treating patients in perioperative setting were source for ethical issues.

In aspect of traffic and crowdedness in narrow OR, omission to follow sterilization standards and aseptic techniques and issue of truth telling the result of the study was in line with the studies conducted in Turkey and two in Iran (4, 20, 32), which reported tolerating visitors in OR, violation to follow sterilization standards and aseptic principles and issue of veracity. This implicates that being of teaching hospitals invites different professionals in the care of patients in the process of teaching and thus the need for sharing space and resource competition increases. As a result breach to safeguarding patient dignity might happen and these are threats to infection and the principle of safety. However, the finding of the study contradicts with the studies conducted in Norway (27), Ireland (29), Turkey (30), Malawi (33) and Iran (34), in which those studies conducted in mentioned countries revealed participants moral competence; kindness, compassion, responsibility, discipline, accountability, communication, honesty, and respect for values, dignity, and human rights both in controlling traffic flow in OR and protection of sterilization standards and aseptic principles. Sterile technique is an essential principle of patient safety which reduces the risk of microbial transmission to patients during surgery. Participants of the study suggested that being honesty, respecting patients’ autonomy and paying attention to their dignity, accepting responsibilities to follow sterilization standards and aseptic techniques and controlling traffic flow, are key ethical skills for operating room nurses for patients safety, that create a sense of security, strengthens their self-esteem, foster physical and psychological support, faster recovery of patients, prevents stress and negative consequences.

The American Nurses Association (ANA) (12), Association of Operating Room Registered Nurses (AORNA) (35) and International Counsel of Nurses (ICN) (11) Code of Ethics also suggested limiting traffic flow and adherence to aseptic principles and patient safety concerns in the OR are considered as responsibility of surgical team members, including nurses and must be committed to the proper observance. In addition medical and nursing ethics requires surgical team who must be polite to patients, maintain patients’ privacy, and respect their beliefs and values.

The second main theme of this study was issues related with professional commitments. The sub-themes include issue of personal & professional competence, issue of responsibility, and issue of justice. Finding of this study was contradicts with the study conducted in Canada (36), London (37), Sweden, German (38), Croatia (39) and Iran (2), where these studies participants suggests the promotion of professional commitments and striving to improve scientific knowledge, be honesty, kindness, generosity, punctuality, equality, fairness, justice, and courage, keep secrets, proper interaction with the patient, equitable distribution of limited resources, maintaining trust and accepting responsibility for performing tasks properly and maintaining patient safety, humility in dealing with patients, respect for patients’ right to make decisions are examples of ethical responsibilities of operating room nurses. In addition, providing professional services by nurses without a sense of professional commitment is difficult with a negative impact on the quality of care. The possible reason for this disparity might be the difference in socio-cultural and socio-economic status and study setup.

Devotion to professional commitments such as up-dating one’s professional and personal competence, dedication to truthfulness, fairness, and punctuality and bearing responsibility for your action were the suggested methods to overcome ethical issues faced operation room nurses of these study participants. Regarding the necessity of up-dating one’s professional and personal competence to overcome ethical issues the result of this study was in line with the findings of two studies conducted in Iran (20, 35), where as regarding to dedication to truthfulness, fairness, and punctuality and bearing responsibility for your action the result of the study was similar with International guidelines such as American Nurses Association (ANA) (12), AORNA (35) and ICN (11). The implication for this is that devotion to professional commitments to continuously update their empirical and esthetical information and practice to give principled and ethical patient care, being honest and truth telling, punctuality, acting as a team to attain a particular goal, for restoring or improving patients’ wellbeing, fairness and justice is the root for overcoming challenges in solving ethical issues in health care setting.

Limitations of the study

The finding represents the perspectives of OR nurses on common ethical issues, potentially overlooking important insights from other health professionals, patients, and their families. Nurses were chosen from various operating rooms within the Adama Hospital Medical College hospital to address the limitation of a reflection of the experiences of a small group of operating room nurses from one hospital.

The findings of this study demonstrated the lived experience of operating room nurses to common ethical issues raised in operation during their clinical care. Traffic and crowdedness in narrow OR Communicating with patients in an untrustworthy manner, Ignoring patients' expectations, Omission to follow sterilization standards and aseptic techniques, Issue of personal & professional competence, Issue of responsibility and justice are main ethical issues faced operation room nurses during clinical care. Concepts such as devotion to professional commitments, safeguarding patient dignity, having respectful rapport with colleagues were crucial for participants to overcome challenges. Identification of ethical principles and standards, and adherence of nurses to it, supports of stake holders, establishment of effect ethical committee will enhance the quality of nurses’ interactions with patients and colleagues, leading to improved quality of surgical patient care.

AHMC: Adama Hospital Medical College, ANA: American Nurses Association, ENA: Ethiopian Nurses Association, ICN: International Council of Nurses, IRB: Institutional Review Board, OR: Operating room, OTNs: Operation theatre Nurses, AORN: Operating Room Registered Nurses Association, WHO: World health organization

Ethics approval and consent to participants

The research obtained ethical approval from the Institutional Review Board (IRB) at Addis Ababa University's College of Health Sciences, School of Nursing and Midwifery, under protocol No: 47/22/SNM. Following this, an official approval letter from the Department of Nursing, along with a support letter and a copy of the ethical clearance, was submitted to Adama Hospital Medical College (AHMC) for data collection. All necessary permissions were secured from AHMC. Participants' anonymity was preserved, and their names were not disclosed. They were briefed on the study's purpose, benefits, and risks, and written consent for participation and audio recording was obtained from all participants prior to the start of the study.

Consent for publication: Not applicable

Availability of data and materials: Data are available from the corresponding author upon reasonable request.

Competing interests

This manuscript maintains no competing financial interest declaration from any person or organization, or non-financial competing interests such as political, personal, religious, ideological, academic, intellectual, commercial, or any other.

Funding: In preparation of this research article our source of fund was Addis Ababa University

Authors’ contributions

Yohannes Midekso Beriso: Conceptualization, Methodology Software, Formal analysis, Investigation, Resources, Data curation and Writing original draft.

Wudma Alemu: Conceptualization, Methodology, Formal analysis, Investigation.

Tefera Mulugeta: Conceptualization, Methodology, Software, Validation, Formal analysis, Investigation, Data curation, and Writing original draft, Writing - review & editing.

All authors have read and approved the manuscript.

Acknowledgment

We are deeply thankful to Addis Ababa University for funding the study. We extend our gratitude to Adama Hospital Medical College for their cooperation and to the participants for their invaluable contributions. Our appreciation also goes to all the data collectors who were involved throughout the process

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No competing interests reported.

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Unveiling The Experiences of Operation Room Nurses on Ethical Issues: A phenomenological study in Adama Hospital Medical College, Ethiopia, 2022

Status:

Version 1

Abstract

Background

Objective

Method

Results

Conclusion

Background

METHODS

Study Setting and period

Study approach

Populations

Inclusion and exclusion criteria

Sample Size Determination and Sampling Techniques

Data collection tools and methods

Rigor

Data Analysis

Standard definition of terms

RESULTS

Socio-demographic characteristics of study participants

Emerged Themes

Identified themes regarding ethical issues encountered

1. Traffic and crowdedness in narrow OR

2. Issue of truth telling

3. Ignoring patients' expectations

4. Issue of informed consent

5. Omission to follow sterilization standards and aseptic techniques

Issues related with professional commitments

1. Issue of personal & professional competence

2. Issue of responsibility

3. Issue of justice

DISCUSION

Limitations of the study

Conclusion

Abbreviations

Declarations

Ethics approval and consent to participants

Acknowledgment

References

Additional Declarations

Status:

Version 1