Volume 30 Issue 1 Article 2

3-1-2017

Exploring experienced nurses’ views, attitudes and expectations of graduate nurses in the operating theatre

Michelle Freeling [email protected]

Steve Parker [email protected]

Katrina Breaden [email protected]

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Recommended Citation Freeling, Michelle; Parker, Steve; and Breaden, Katrina (2017) "Exploring experienced nurses’ views, attitudes and expectations of graduate nurses in the operating theatre," Journal of Perioperative Nursing: Vol. 30 : Iss. 1 , Article 2. Available at: https://doi.org/10.26550/2209-1092.1012 https://www.journal.acorn.org.au/jpn/vol30/iss1/2

This Article is brought to you for free and open access by Journal of Perioperative Nursing. It has been accepted for inclusion in Journal of Perioperative Nursing by an authorized editor of Journal of Perioperative Nursing. Peer-reviewed article

Author Michelle Freeling Exploring experienced BN (Hons), RN School of Nursing and Midwifery nurses’ views, attitudes and The Flinders University of South Australia

Dr Steve Parker expectations of graduate nurses PhD, BEd, DipT (Nurse Ed), RN, RPN Associate Dean (Teaching & Learning) in the operating theatre School of Nursing and Midwifery The Flinders University of South Australia While the new graduate nurse journey has been well documented, little research exists from the perspective of the experienced Dr Katrina Breaden nurse, particularly in the perioperative environment. Barriers to PhD, MN, Grad Cert Ed (Higher Education), RN graduate nurse support need to be understood, as job satisfaction, Lecturer in Nursing nurse wellbeing and quality of patient care can be negatively School of Nursing and Midwifery affected. The Flinders University of South Australia Background clinical skills in a technically complex Corresponding author environment13, and nurses are rarely Throughout the history of nursing, Michelle Freeling offered meaningful perioperative the relationships between BN (Hons), RN training in undergraduate education experienced nurses and nurses School of Nursing and Midwifery programs14. These challenging undergoing training have been The Flinders University of South Australia characteristics of perioperative widely discussed. There is a nursing may cause new graduate plethora of research which examines nurses in the operating theatre to the graduate nurse journey and feel isolated and discouraged13. subsequent feelings and attitudes towards workplace integration1–7. Additionally, negative staff attitudes However, little research exists have been highlighted as one of regarding the view of the experienced the most powerful barriers to registered nurse concerning graduate graduate nurse support10, further nurses. Experienced registered compounding the challenges of the nurses significantly contribute to the perioperative graduate nurse journey. development of the graduate nurse, It has been noted that a negative and it is widely recognised that approach from senior nurses towards experienced registered nurses acting graduate nurses creates a barrier as preceptors is essential to graduate for optimal skill utilisation by the nurse development8–10. graduate15. Nursing culture has been perceived, both historically Perioperative nursing, defined as and contemporarily, as negative16–18 providing care for patients in the and many graduate nurses find it period prior, during and following challenging to become accepted in surgery or interventional procedures11, the culture of the unit19. The unique presents further challenges for challenges of perioperative nursing novices. The intrinsic stress of and the new graduate nurse journey, undertaking surgical procedures, coupled with the present climate of the absence of experienced staff, budgetary constraints in health care, the seclusion and constraint of the mean that investigating barriers in operating room and the high patient nursing is vital. acuity contribute to the challenging nature of the perioperative A literature review conducted as environment for graduate nurses12. part of this study revealed a lack of Perioperative nursing requires the research investigating experienced ability to perform an abundance of nurses’ views, attitudes and

Journal of Perioperative Nursing in Australia Volume 30 Number 1 Autumn 2017 acorn.org.au 23 expectations of graduate nurses in nurses a voice and allow readers of hospital in Adelaide, South Australia. any setting19. A total of ten studies this study a glimpse of theatre life The nurses had five, nine and more were reviewed15,18,19,21–27 and four main that describes the nurses’ world than twenty years’ experience themes were identified: within this particular context. respectively. All participants had experience teaching and working with 1. experienced nurses believe Methods graduate nurses in the perioperative graduate nurses are inadequately setting. The in-depth method of prepared for practice Aim and design interviewing deemed necessary 2. graduates need to improve The aim of this study was to explore by a hermeneutic methodology practical nursing skills experienced nurses’ views about, allows meaning to be explored and attitudes towards and expectations 3. experienced nurses have negative details of participants’ real-world of graduate nurses in the operating attitudes towards graduates experiences to be considered. theatre. Data collection was 4. experienced nurses believe undertaken using face-to-face, Data analysis graduate nurses lack the unstructured, in-depth interviews. An The primary researcher immediately confidence necessary to practice interpretive hermeneutic approach transcribed verbatim each interview competently. was used, allowing interpretation of after it occurred. The researcher This literature review demonstrated the data and eliciting meaning from listened to the recorded interview a significant lack of research on the participants’ stories. several times while reading the transcript. Central concerns, this topic and a need for further Settings and participants investigation. To enable graduates important themes or meanings to fulfil their potential, the attitudes, Participants were recruited from the unfolded for particular participants beliefs and expectations of perioperative department of a busy and were highlighted during this 28 experienced registered nurses and metropolitan teaching hospital. A step by the researcher . The graduate nurses must be explored convenience sample of nurses with researcher read and analysed the with regards to graduate nurses more than three years’ experience transcript again, this time with the entering the workforce. Only then in the operating theatre who were intention of deriving themes from can these attitudes and feelings currently working or had previously the data. Summaries of central be addressed and methods put in worked directly with graduate themes were developed based on the place to facilitate good relationships nurses were invited to participate. researchers’ initial interpretations. between graduate nurses and These criteria ensured participants During this process, the transcripts experienced registered nurses. This were experienced and competent were simultaneously examined with understanding may ultimately allow perioperative nurses who were the emerging interpretation. NVivo graduate nurses to utilise their full capable of reflecting on their overall software was used to manage and range of skills, practice confidently views about, attitudes towards and code the data. and comfortably and become a expectations of graduate nurses. Findings and discussion valuable part of the health care team. Data collection Application of the data analysis The above considerations culminated Ethics approval was given by the in the research question: what are techniques applied to the interview appropriate Human Research Ethics data resulted in six predominant experienced nurses’ views, attitudes Committee (506.14) and the site- and expectations of graduate nurses themes, and concepts within these specific ethics committee. Informed themes (Table 1). Some of the issues in the operating theatre? The consent was gained before the objective of this research is to unlock that arose are briefly discussed interviews. Participants consisted below; quotations (using participant the experiences and opinions of of a convenience sample of three experienced operating theatre nurses numbers to identify each) are used perioperative nurses and were to illustrate the findings. regarding graduate nurses and, in recruited for a 45-minute, in-depth doing so, explore the relationship interview with the aim of exploring The importance of mentoring between experienced and graduate their views about, attitudes towards In this study, mentoring emerged as nurses as well as revealing what and expectations of graduate nurses experienced operating theatre nurses a significant subconcept within the in the operating theatre of a large concept of education and theme of underwent as graduate nurses. This metropolitan tertiary teaching research question aims to give people. Participants described their

24 Journal of Perioperative Nursing in Australia Volume 30 Number 1 Autumn 2017 acorn.org.au Themes challenge to graduate nurses and (in order of unfamiliarity emerged as a significant prevalence) Concept Subconcept concept within the theatre theme. Experienced nurses conveyed the 1. People 1.1 Personalities atypical nature of operating theatre 1.2 Education 1.2.1 Learning nursing, and that graduate nurses 1.2.2 Attitudes were initially unfamiliar with the nursing skills required: 1.2.3 Workload Ward nursing is more comfortable 1.2.4 Continuity for graduates because that’s 1.2.5 Mentoring where their three years of clinical 1.3 Management placements were. You have to be a 2. Theatre 2.1 Patient-centered care lot more flexible [in the operating theatre] than on the ward (N1). 2.2 Roles 2.3 Unfamiliarity Experienced nurses conveyed that different skills and different flexibility 3. Structure 3.1 Specialties are necessary for theatre nursing. 3.2 Allocations You know, we have so many 4. Culture 4.1 Generations intricacies of which way to hand 5. Graduates 5.1 Thriving an instrument, for example – 5.2 Experience upside down, left to right, forward, backwards – and if you do it 5.3 Overconfidence incorrectly … You’re always going 5.4 The basics to at the beginning but at some 6. Stress point there’s an expectation you’ll pick it up. And surgeons definitely Table 1: Themes, concepts and subconcepts let you know if you’re not doing it right, either in a nice way or a experiences of receiving mentoring at the moment. And, you know, mean way (N1). as graduate nurses and highlighted from the bigger picture I think Due to the absence of perioperative the importance of guidance. it’s obviously time and money nursing instruction in most Graduates may thrive if a senior constraints. Public health is under undergraduate programs, the core nurse notices them and chooses stress. Everything is bare bones. processes and atmosphere in the to form a supportive, mentoring And so we are losing good people operating theatre is foreign to 32 relationship. The participants because of it, because they’re not most graduate nurses . Another declared mentoring an essential being supported and mentored and participant discussed the importance part of an effective relationship nurtured (N1). of emphasising patient-centred care between experienced nurses and in the operating theatre: As mentoring promotes a supportive graduate nurses in the operating theatre learning environment30,31, this In theatre when you first start as a theatre. Similarly, Lydon and Burke29 lack is worrying. Education regarding graduate it is not exactly patient- found that a supportive preceptor the ramifications of neglecting centred. You’re not there hands enhanced learning whereas an a graduate nurse’s learning on with the patient taking blood unsupportive preceptor impeded opportunities, the potential presence pressure, asking them how their learning. In this study, participants of horizontal violence and failure pain is, because you’re opening uncovered a current lack of nurturing to integrate into the perioperative a sterile packet for someone and mentoring in their workplace, team should be given to all relevant wearing a gown behind a trolley. which is, unfortunately, inhibiting individuals in the workplace. At the beginning typically you’re graduate nurse success in this so overwhelmed, you’re not even environment: Unfamiliar environment thinking about the patient… (N1). I was nurtured so well; I think The ‘foreign’ nature of the Due to the unfamiliar nature of that’s something that’s lacking operating theatre presents a unique theatre nursing, participants

Journal of Perioperative Nursing in Australia Volume 30 Number 1 Autumn 2017 acorn.org.au 25 asserted that previous theatre really struggling but that’s the environment is a significant experience was beneficial to nurses only time it’s extended, if they’re cause of horizontal violence, a beginning a perioperative graduate struggling, and it’s affecting the contentious issue in nursing today. year. Unfortunately, perioperative relationships. People are deskilling The negative views of graduate nursing is often under-utilised for quicker because they’re churned nurses held by experienced nurses undergraduate clinical placement significantly affect their investment through like a production line (N1). experience33. Baumberger-Henry19 and effort regarding the provision found that material required to A better understanding of underlying of mentoring and education. This work competently in a specialised pathology, rationales behind surgical intra-professional tension is of area is often not taught as part of techniques and nursing methods substantial concern as disruptive undergraduate education. However, may be developed through longer nurse relationships may affect a perioperative placement (with rotations. This may then have a optimal graduate nurse training, instructional guidance from a positive impact on graduate nurse inhibit communication within the placement coordinator) may allow performance in future rotations. health care team and ultimately the student to develop a greater Similarly, Pupkiewicz, Kitson affect the retention of graduate understanding of surgical ward and Perry36 reported a need for nurses37. Further research is needed nursing than surgical ward nursing graduate nurses to stay in one to investigate relationships between experience alone34. Reallocating a rotation until they achieve clinical perioperative nurses of different portion of time and resources from competence. Graduate nurses may generations. surgical nursing to perioperative feel overwhelmed if they change nursing may ease the difficulty that specialties too soon, due to the Occupational stress 36 universities are having in securing increase in volume of information . Stress – a significant issue in placements and would improve Overall, longer surgical rotations perioperative nursing – was an recruitment to perioperative for graduate nurses will increase underlying issue for all participants. 34 nursing . trust between team members, allow One participant discussed a better understanding of specific occupational stress: Length of time in rotations procedures and prevent the volume The operating theatre environment The theme of ‘structure’ was the of information from becoming third in prevalence and included overwhelming. can become quite stressful if graduate nurses don’t know the two concepts – specialties and Generational differences allocations. This study uncovered the severity of the situation and then detrimental effect on theatre teams Tension between older and younger things can escalate to the point of shorter specialty rotations during nurses arose as a significant source where they can’t manage…you the graduate nurse year. It became of distress for participants in need to know when to ask for help apparent that experienced nurses are this study making ‘generations’ a (N3). hesitant to invest time and energy significant concept under the theme in graduate nurses’ education if of ‘Culture’. Many nurses continued Stress is also experienced if trust, they are aware the graduate nurse to treat the theatre environment positive working relationships and will soon be moving to another as in the past – where surgeons familiarity between members of the specialty. Participants described the were allocated one scrub nurse and theatre team are absent. Another frustration of continually teaching surgical specialties had exclusive participant stated: graduate nurses. According to teams: The reason a theatre works is the Young35, perioperative nurses are A lot of the nurses will treat it like relationship and the trust you have overworked and understaffed so [between the] scrub and scout, training a high volume of new nurses ‘the old days’ where they would between the surgeon and nurses as well as meeting the daily demands have one scrub nurse or they try to of theatre nursing increases the keep the specialties very exclusive… and the team. If it’s a team they pressure nurses face. Indeed, in this Although we’ve got all the skills [surgeons] don’t know, it’s instantly study, minimal surgical rotations in the world and we’re extremely stressful (N1). of three months were described as competent, they still won’t relax A recent review of the occupational weakening the relationships within and they still won’t be accepting of stress of scrub/scout practitioners theatre teams. you. It’s because of the attitudes revealed that occupational stress in We’re struggling with that at the that the older nursing generation the operating theatre impacts on moment, because our current are perpetuating… (N1). perioperative nurses’ health and behaviours. Jacob38 discovered factors nurses are doing three-month The friction between the older that increase the occupational rotations – sometimes six if they’re and younger nurses in the theatre

26 Journal of Perioperative Nursing in Australia Volume 30 Number 1 Autumn 2017 acorn.org.au stress experienced by scrub/scout In neurosurgery I remember being graduate nurses in the perioperative nurses include the atypical nature told [by a senior nurse] to give environment and explore if formal of theatre nursing work, lack of these new forceps to the surgeon, communication and assertiveness resources, work-related stress and who was notorious for being training would enable graduate surgeon-perpetuated . horrible to staff. And she’s, like, nurses to cope with abusive Occupational stress can increase situations. ‘he’ll be really happy, we specially perioperative nurses’ engagement ordered these’. I handed them to with unhealthy coping behaviours Limitations such as smoking, overeating and him at the beginning of the case, This study was undertaken as part increased alcohol consumption39, 40. he threw them across the room, of the researchers’ honours year so Further, occupational stress may lead looked at me and said ‘don’t ever time restraints were a significant to fatigue, reduced concentration hand them to me again’ (N1). constraint. As this study documents and increased sick leave, which Behaviours such as verbal , the opinions and experiences of may affect patient safety38. The throwing surgical instruments and three nurses, it is crucial to avoid findings in this study further extend belittling staff, and the reputation generalising these findings to this work by directly identifying of particular surgeons for exhibiting all nurses. This study should be factors that influence stress in the negative behaviours compounded repeated with more participants to perioperative environment. Stress nurses’ occupational stress. allow data saturation to be reached. resulted from numerous and, often, Factors that put nurses at risk of However, the participants’ words cumulative factors, including bullying experiencing abuse from surgeons are still worthy of consideration and behaviours, increased workload, include personality differences, some interesting themes are put generational differences, concerns closeness of working relationships, forth in this paper. Also, participants with confidence and the unfamiliarity stressful patient care situations were only recruited from one of the perioperative setting. 42 and unequal power relationships . institution and a multisite study Bullying behaviours Graduate nurses are particularly would reduce the effect of specific vulnerable to abuse, as they may local factors particular to one Although not identified as a major not understand the surgeon’s setting45. theme, is not routine or preferences41. Abuse uncommon in the perioperative exacerbates the stress and confusion Conclusions environment and contributes to already experienced when new to This study has investigated nurses’ occupational stress. Horizontal the perioperative environment and views about, attitudes towards and violence (nurse-to-nurse violence) results in adverse psychological, expectations of graduate nurses and surgeon-perpetuated, or physical and social effects. surgeon-to-nurse, violence were in the operating theatre of a busy Workplace violence poses a serious established as significant issues in metropolitan hospital. This issue is threat to the health and wellbeing this study. Surgeon-perpetuated significant as graduate nurses face of nurses, and the World Health violence may be psychological many challenges when entering Organization (WHO) has therefore or physical. the workforce and there is little stated that elimination of these includes belittling, yelling, research exploring experienced behaviours is a high priority43. A condescension and ignoring. registered nurses’ views about, victim of workplace violence may includes shoving, attitudes towards and expectations experience insomnia, low self-esteem, hitting, throwing instruments and of graduate nurses in the operating 41 low work morale, disconnection kicking . In a study exploring the theatre. As negative staff attitudes from others, depression, and incidence and impact of physician have been highlighted as one of the increased sick leave44. Graduate on perioperative most powerful barriers to graduate 42 nurses may experience burnout nurses, Cook et al. reported that 91 nurse support, considering the and disempowerment because of per cent of nurse participants had origin of these attitudes along bullying, which may lead to leaving experienced some verbal abuse from with the expectations and views of the profession altogether37. As physicians in the past year. Similarly, experienced registered nurses is the retention of new graduates is participants in the current study essential. essential for a sustainable nursing identified that surgeon-perpetuated The participants’ views about, workforce, it is critical to address violence detrimentally affected attitudes towards and expectations horizontal violence and create their experiences in the operating of graduate nurses in the operating positive working environments. theatre. One participant tells of her theatre were explored in this study Further research is needed to experience: and the process of undertaking this investigate the effects of inter- study was a worthwhile journey of and intra-professional abuse on discovery. Recommendations for

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