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Lillemor Lindwall and Irne von Post
Key words:

caring science; culture; ethics; hermeneutics; perioperative nursing care

This study focuses on investigating habits in perioperative nursing culture, which

are often simply accepted and not normally considered or discussed. A hermeneutical
approach was chosen as the means of understanding perioperative nurses experiences
of and reflections on operating theatre culture. Focus group discussions were used to
collect data, which was analysed using hermeneutical text analysis. The results revealed
three main categories of habits present in perioperative nursing culture: habits that
promote ethical values (by temporary friendship with patients, showing respect for each
other, and spending time on reflection on ethics and caring); habits that hinder progress
(by seeing the patient as a surgical case, not acknowledging colleagues, and not talking about ethics); and habits that set the cultural tone (the hidden power structure and
achieving more in less time).

Background and purpose

This study focuses on habits within a perioperative nursing culture that are often simply accepted and not normally considered or discussed. Perioperative nursing involves
the caring process and perioperative dialogue (meaning perioperative nurses pre-,
intra- and postoperative dialogues with patients), as well as the surgical treatment
1 and alleviate suffering. Perioperative nursing
techniques that serve life and health
1 3 According to
should be perceived as a profession founded on caring and ethics.
Eriksson, 4 a human being is seen as an entity, consisting of body, soul and spirit, and
the body is seen as a vessel for health and suffering, an abode for human dignity and
vulnerability. 1
Habits and ethics belong together because of the moral virtue that arises through
5 (p. 49) none of
habit, which is implied in the word ethics. According to Aristotle
the moral virtues are present in us by nature, but we naturally respect them and
they are perfected through habit. However, habits are created by human beings
living in a particular culture. Habits and culture belong together. According to
Taylor, 6 culture encompasses experiences, moral concepts, ideas of right and wrong
and the habits a person develops as a member of society. A habit is something that
Address for correspondence: Lillemor Lindwall, Department of Caring and Public Health
Sciences, Mlardalen University, SE- 721 23 Vsters, Sweden. Fax: 46 21 1017633; E-mail:

Nursing Ethics 2008 15 (5)

2008 SAGE Publications 10.1177/0969733008092875

Habits in perioperative nursing culture


is performed often or regularly within a culture, but can also be an ethical act that is
considered to be bad that someone performs repeatedly and finds difficult to stop.
Culture as a concept is described as spiritual and material culture and is charac7 A perioperative nursterized by the habits and acts that affect culture as a whole.
ing culture can be understood as having both spiritual and material aspects.
Spiritual culture is seen as the humanistic side of a culture, formed by ideals,
8 and based on cultural elements.
upbringing, morals, traditions and education,
Nurses habits in a perioperative nursing culture are formed by education and basic
10 Perioperative material culture is characterized
values, as well as ethos and ethics.
by advanced, high-tech equipment in the operating theatre, which has been created
to serve life and health, meet the demands of specialist medical requirements
11 The habits found in this culture result from the
and facilitate nurses work.
demands for asepsis and safety, but also for productivity. According to Nightingale,
nurses habits and behaviour have an effect on patients experiences of well-being.
The habits that form operating theatre culture are dominated by the biomedical
9 and on
model. 13 Widespread research has been conducted on transcultural nursing
14 but we have found no research focuspatient autonomy in intercultural nursing,
ing on habits in a perioperative nursing culture, and this therefore became the aim
of our present study.

8 was chosen to describe habits in perioperative nursing
A hermeneutical approach
culture in an attempt to understand them in a new way. The research process
was influenced by the researchers theoretical caring perspective with regard to
ontological questions and epistemological interest. Because of the explorative character of the research question, focus group discussions were used to collect data.
The focus group text was analysed using hermeneutical text analysis.


Participants and data collection

Focus groups can be defined as meetings for in-depth, open-ended discussion in
which 412 participants explore a specific set of issues on a pre-defined and limited
topic. 15 This method is a useful means of examining not only what people think but
also how they think and why they think that way. Focus group discussion can reach
depths that other methods cannot reach, revealing dimensions of understanding that
often remain untapped by more conventional collection techniques.
In choosing members for focus groups, our aim was that they should represent both
nurse anaesthetists and theatre nurses, and also work in various operating theatres in
Sweden. An important criterion for selection was that participants should have work
experience in perioperative nursing.
A total of 30 nurses participated, all of them registered nurses with specialist education and training as either nurse anaesthetists (
n 15) or theatre nurses ( n 15), and
aged between 32 and 61 years. Their work experience varied from two to 18 years. They
worked in 10 different operating theatres (surgical, orthopaedic and gynaecological) and
were divided into six focus groups comprising five nurses each. The focus group discussions were conducted in meeting rooms located within the respective hospitals.
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L Lindwall and I von Post

The focus groups discussions lasted for approximately one hour each, and were
overseen by a group leader. The theme question concentrated on nurses experiences
of habits in perioperative nursing culture. The aim was to create an open atmosphere
and stimulate the group to exchange their experiences of and views on the topical
themes. 15,17 The ethical responsibility of the group leader was to ensure that they did
not affect the dynamics and dialogue between group members. The discussions were
audio-taped and transcribed verbatim.
The study was approved by the Ethics Committee of Mlardalen University
(2005/263). Participation was voluntary. This was important because of the requirement for the perioperative nurses to be willing to talk freely about their experiences.

Hermeneutical text analysis

The texts obtained from the focus group field notes were subjected to hermeneutical
text analysis 16 with the aim of understanding the nurses experiences. Hermeneutics
aims to gain understanding through interpretation and forms an important part of
18 Gadamer 8 focused on the concepts of prejudgement,
basic human science research.
pre-understanding and fusions of horizon, and emphasized that those who express
themselves and those who understand are connected by a common human consciousness that makes understanding possible.
Before reading the text, we decided not to question its credibility. The text was to
be allowed to express itself, making its claim to have something to say about habits
in perioperative nursing culture.
In the first stage of interpretation we started with a naive reading to acquire a general idea of the habits prevalent in the culture, to enable us to become acquainted with
the text and to permit spontaneous interpretation of what the whole text was saying.
1 6 that is,
The interpretation was influenced by our professional pre-understanding,
4 and on our knowledge, experience, duties and
based on our caring science perspective
commitment as nurse anaesthetists. Reading with an open mind, we constantly asked
questions of the text: Are these the habits found in a perioperative culture? and the
text answered: Yes, habits could take this form. Our professional pre-understanding
made the text understandable.
In the second stage, the text was carefully read so that it could present itself in
all its otherness. 8 We had to try out our professional pre-understanding in relation
to the unfamiliar text and ask new questions, such as: How do nurses experience
the habits present in perioperative culture? This question arose when we transcended
8 states that a dialogue with
the horizon of the text as well as our own. Gadamer
a text leads to a fusion of horizons; that is, the reality of the text becomes a part of
the reader. As a result, during this stage of the analysis the text acquires new
In the third stage, new questions arose from the text, which in turn produced new
answers. The following question was generated by our new understanding: What do
perioperative nurses perceive as habits within the culture of the operating theatre?
The text was studied further in order to find answers to our question. We looked
16 moving back and forth
for quotations with common and distinguishing qualities,
through the text and organizing significant expressions into three main categories:
habits that promote ethical values; habits that hinder progress; and habits that set
the tone. Two or three subcategories were revealed for each main category (Table 1).

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Habits in perioperative nursing culture

Table 1


Habits in perioperative nursing culture

Main category Subcategory

Habits that promote ethical values A temporary friendship with patients
Showing respect for each other
Time for reflection about ethics and caring
Habits that hinder progress Seeing the patient as a surgical case
Not acknowledging one another
Not talking about ethics and caring
Habits that set the tone The hidden power structure
Achieving more in less time

In the fourth stage the text was again treated in its entirety in order to arrive at
a higher abstract level than had been achieved in earlier interpretations.
Eight subcategories emerged from the understanding. These are described below
and illustrated by direct quotations.

Habits that promote ethical values
A temporary friendship with patients
A temporary friendship is formed with patients as a habit and an ethical act in which
nurses promise to be there when patients need them and to be someone patients
will recognize in the operating theatre. Nurses assume responsibility for ensuring
that patients need never feel alone or abandoned on the operating bed.
Caring, for me, is like a temporary friendship, in which, during our time together,
I guide the patient through the operation process.

Nurses offer patients a temporary friendship in which there is humour, warmth

and closeness. They promise to guide patients through the operation and take it
upon themselves to ensure that such friendship closes in a dignified way.
There exists a feeling of welcome in the culture. Children become kings and queens
for the day; we adjust to the childrens needs and their level of knowledge.

This habit presents the welcoming nature of the culture, allowing patients their
dignity. Friendship creates a pleasant atmosphere and allows patients to be the king
or queen in the operating room, making them feel they are the most important person there, and that everyone will do their best for them.
Showing respect for each other
The habit of showing respect for colleagues creates an atmosphere of well-being,
warmth, calm and harmony around patients. Nurses show respect for each other

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L Lindwall and I von Post

and others professional tasks; no professional task is considered less important than
another because everyone must participate in protecting patients dignity and
ensuring that the care provided is seen as both safe and professional in its nature.
The mutual respect shown for each other allows nurses to see patients as entities of
body, soul and spirit.
A caring atmosphere is one where everyone is pleasant to each other and where everyone is happy at their place of work. Nurses look at patients when they talk to them.
They talk quietly and in gentle terms about what will happen in the operating theatre.
They show that this patient is their main concern.

The habit of showing respect for one another creates an atmosphere of respect for
individuals as human beings. Nurse managers allow nurses to agree with patients
wishes, such as: Be with me throughout the operation. This ethic is kept alive and
immediate to allow continuance of mutual respect.
Caring is given an increased value, both by senior staff and within the profession as a
whole, so that nurses are clearly seen as professionals. They are then proud of their
work and of the profession to which they belong.

The habit of showing respect for one another leads to people caring for each other
and seeing each other as unique individuals, and everyone feeling that they are all
part of a professional team. Nurses are then generous and tolerant towards one
another, and are noticed, listened to and appreciated by ward supervisors and colleagues alike. They are proud of the fact that they are nurses who can influence their
work situation and use their knowledge effectively. They feel able to discuss with
each other their experiences related to patients situations.
Time for reflection about ethics and caring
The habit of finding time to reflect on ethical questions and on what is and what is
not part of a caring culture creates a tolerant atmosphere. Nurses need to discuss
with each other the quality of the care provided, their professional code of ethics,
ethical dilemmas and conflict within the caring process, but also the overall aims
and basic values of the operating room.
Nurses are prepared to take responsibility for caring and promoting discussion on the
professional code of ethics and ensuring that the ethics of daily nursing are always a
current issue. Time must be allowed for, and value placed on, preparing for each new

Being given time to reflect on ethical questions creates a warm atmosphere within
a perioperative nursing culture, allowing time for learning and discussion of such
subjects as a vision for the future of the operating theatre, what is considered ethically defensible, and what protects and what infringes patients dignity. Time for
ethical reflection presupposes that patients can share their thoughts with nurses
before, during and after the operation. The essence of this habit is that it enables an
ethic and a set of values that help carers to decide on their ethical standpoint.

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Habits that hinder progress

Seeing the patient as a surgical case
The habit of regarding patients simply as surgical cases or diagnoses is often prevalent in perioperative culture. Patients are reduced to being seen as objects and
devalued as fellow human beings. Staff members will not always respect the dignity
of people regarded as surgical cases and will often treat them in a nonchalant manner. They may talk to each other using their own jargon, and discuss patients in the
operating theatre by talking over their heads. Staff indulge in joking and laughing with
each other without including patients in the conversation, which patients will often
find insulting. Nurses are not always near at hand when patients seek eye contact.
Being handled like just another operating case. Too much focus on the task and the staff
talk over the head of the patient or discuss other patients cases.

The habit of treating patients as operation cases will often include being insensitive to the fact that patients may have to wait before being taken into the operating
theatre, or have to wait for the arrival of the surgeon, perhaps for a long time, giving the impression that something has gone wrong. If promises made during the
planning of an operation are broken it is not surprising that patients may feel alone
and abandoned, despite all the people around them.
When routines fail the patient is left waiting unnecessarily. Nurses lose their focus on
the patient when things have to be rescheduled. Patients may receive information from
several different people. I dont think they are able to take it all in.

Neither time nor space is created for personal discussion if patients are receiving
information from several people. Patients sense of dignity is offended when all
around them are rushing about and working at such a tempo that patients are somehow left behind. Such habits hinder progress in working routines and create ill feeling and ethical conflict, especially for nurses who would rather regard patients as
human beings comprising body, soul and spirit.
Not acknowledging one another
Nurses not acknowledging one another and not regarding others as colleagues
is a habit that will hinder co-operation at work, create unhealthy competition, and disrupt and cause jealous guarding of ones own preserve at work. Colleagues are seen
to be acting dishonestly and people no longer trust each other. It becomes difficult to
know what holds good and which skills and competencies need to be applied.
It is not a healthy state of affairs when people do not acknowledge one another, do not
appreciate each others different professional skills, regardless of whether one is a nurse
anaesthetist or a theatre nurse.

This habit gains momentum when senior staff members do not show interest in
suggestions put forward by nurses. The atmosphere is permeated by feelings of insecurity when department heads belittle nurses competence, and when nurses are not

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given the opportunity to use their professional scientific nursing knowledge. A lack
of interest on the part of senior staff for new proposals means that there will be no
room for new habits to develop within the culture and staff will lose their interest
in the work of daily nursing.
Not talking about ethics and caring
In a perioperative nursing culture there are many excellent nurses who cannot find
the words to talk about their daily caring work. They are unable to express how they
help patients to feel good in the operating theatre. They see the patients, they understand patients needs and wishes, but lack the words to describe what they see.
Everyone subconsciously cares deeply for the patient but somehow this is not expressed
verbally. Unfortunately there are many very good nurses who cannot express their
thoughts about nursing in words.

The habit of being unable to express ones thoughts or to talk about ones work
as a nurse means that good nurses remain unnoticed. They may quietly strive not
to disclose patients identity in sensitive situations, but they cannot find the right
words to discuss their approach.

Habits that set the tone

The hidden power structure
A hidden power structure traditionally constitutes a habit that allows the medical
profession to set the tone within perioperative culture. They decide the norms and
values, and it is their judgement on people that dominates the culture. Physicians
presume to decide who are the good nurses.
It is the doctors who decide things. It is their judgement that applies when deciding
who the good nurses are.

The medical profession practices both hidden and open exercise of power. There
are physicians who have learned that the work atmosphere is better if all nursing
specialties are invited to participate when decisions are to be made. However, this
is not a common habit.
The surgeons are in a position of considerable power, but they have learned that the
working atmosphere becomes much easier if the staff are consulted when a decision has
to be made.

Weak management will allow informal bosses to hold sway under the surface.
Habit allows such dominating people to steer things unseen. Sometimes it is just one
person who assumes this power in the operating theatre and sometimes it is groups
among the staff who want to take charge.
Weak senior staff with strong informal bosses who direct things based on their ignorance of nursing practice. Little emperors are to be found in all branches of the hospital.
Their influence is dependent on the strength of leadership demonstrated by senior staff.

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The hidden power structure creates a feeling of insecurity among colleagues. The
power of little emperors is governed by the level of leadership shown by senior
staff. The more restricted the working routine for individuals, the greater their desire
to be elevated, to assume power, and to direct and organize others. The habit of
this hidden power structure creates a conflict of values among nurses.
Achieving more in less time
Achieving more in less time is a habit that has developed in recent years as a result
of increased demands for productivity. This demand often comes from senior staff
who do not fully understand nurse anaesthetists or theatre nurses responsibilities
with regard to patients. The pressure to achieve more in less time makes work feel
more stressful and more routine. The nurses feel they are bad nurses, abandoned
and alone with their responsibilities, when they do not have time to get to know
patients well enough.
Nurses have to take on varying degrees of responsibility depending on the availability
of doctors and their competence, and they are pressurized to achieve more in less time.
Decisions that have been taken within the team are sometimes changed by others who
are not directly involved. This adversely affects job satisfaction and demands a lot of
energy from the team with these responsibilities.

A culture aimed at getting more out of less time prevents professional development. The tone of the culture forces nurses to stop thinking in order to survive the
stress, and leaves them in a state where they give up any hope of being able to be
there for patients. This frame of mind, centred on increased productivity, will not
always be in line with the ethical values of carers.

The results of this study have revealed three categories of habits in perioperative
nursing culture: habits that promote ethical values, hinder progress, and set the tone.
These habits, when so readily accepted, can be understood as a form of tacit knowledge because they are just there. The results show that nurses acquire habits through
6 and
being members of a perioperative nursing culture or of a particular social group,
that the prevailing culture has formed them and taken control of them. Kuhn
believes that habits, in the same way as knowledge, are acquired through culture and
cannot be clearly defined, but our results show that they can be described. It appears
that habits have a certain similarity to tacit knowledge, they are hidden away, they
are just there, and they become part of the culture through their practice by nurses
2 0 people are only indiand because they are not clearly defined. According to Polanyi,
rectly or subconsciously aware of tacit knowledge. Habits that conform with tacit
knowledge are not always given expression, articulated or reflected upon. If habits
2 0 claims, that tacit knoware unexpressed, do they exist at all? Or is it, as Polanyi
ledge is never articulated because it cannot be described, because it must remain hidden away or because we have never bothered to try to describe it? The results of this
study show that there are nurses who never talk about caring and ethics, seeing their
work as something self-evident, and something one gets on with and does not talk
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L Lindwall and I von Post

about. By not talking about their work, that knowledge is not reflected upon. It is
documented or passed on in articulated form, but remains just a habit, something
that is incompletely defined. Are all people within a certain culture aware of these
habits but do not, however, question their existence because they have always been
there and because they are never discussed? These are questions that this research
leaves unanswered, but they should be given more attention than has been possible
in this study. We hope to have shown that it is possible to describe these habits and
2 1 no habit passes completely unnoticed,
to give them a voice. According to Molander,
but affects even those who are not a part of that habit, because this is something
must be acquired, not as a spectator but as a participant. Habits, like traditions, are
passed on without being subjected to dissection because they can be understood as
part of unreflected practice. Yet that which remains undiscussed can sometimes be
put into words, be subject to critical reflection and, under the right conditions, be
improved and reintroduced back into a culture.

Habits as ethical acts in perioperative nursing culture

To have a temporary friendship with patients is the result of mutual goodwill in
5 An ethical habit
which the act of a good friend helps fellow human beings in need.
is created by nurses, forming a common bond in which they and patients are partners in their common world. Through friendship a sense of hospitality is created
gives joy and strength, and engenders what is good in life for fellow human beings.
Being in a temporary friendship can be perceived as nurses making time for
patients. 23 When this occurs, nurses gain strength and a sense of joy through that
25 When nurses must achieve
work 24 and feel that they are developing professionally.
26 which in turn cremore in less time, they cannot do all that is possible for patients,
ates a conflict of values for them.
There are, however, other nurses who consider patients only as surgical cases and
a diagnosis. This habit does not allow patients to be seen as fellow human beings,
people with whom nurses would want to share a common world. When nurses stop
4 this creates an
seeing patients as human beings, and entities of body, soul and spirit,
unethical habit resulting in patients becoming exposed to unnecessary suffering.
7 and nurses who are prevented from providing
habit creates an ethical dilemma,
proper care experience conflicting values, and are in conflict with themselves.
Nurses not acknowledging one another is a habit that creates a bad atmosphere
and lays foundations for a culture in which the spirit is inhospitable and restrictive.
According to Aristotle, 5 if one wants to be a good and happy person one must be
brought up in a culture that fosters good habits, and not just have the knowledge
of what is right. One necessary precondition, if the culture is to present fertile
ground for habits that promote ethical values, is that nurses must show respect for
each other and have a good sense of judgement. A responsible leader shows respect
for colleagues and would want the perioperative nursing culture to be a place where
19 believes that, hidden in the habits of a culethical habits can be developed. Kuhn
ture lie the fundamental convictions concerning the world and people, and also
accepted theories and the basic premises for research.
When the habit of showing respect for each other is predominant, nurses feel
5 sees pride as a virtue, a trait of character, a middle
proud to be nurses. Aristotle
course between conceit and excess of pride. Pride is a matter of great honour in

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Habits in perioperative nursing culture


which people appreciate their worth as human beings, but some exaggerate this.
People are seen as proud when they hold themselves in high regard; this opinion is
5 exhorts striking the right middle way between despisclearly warranted. Aristotle
ing or thinking too highly of oneself and others. Another important habit that can
be developed to the benefit of patients and nurses is that of regularly taking time to
reflect on ethics and caring. This means that nurses and leaders acknowledge each
other through mutual reflection, agree on common goals, and create a set of basic
4 ethics will provide the foundation on which the
values. According to Eriksson,
habits of a culture will be based.
Among the habits that set the tone in a perioperative nursing culture is a hidden
power structure, which allows informal leaders and little despots to exaggerate
allow their conceit or desire for power to take over. In Aristotles opinion, people
who go too far are conceited and do not know themselves or the effect of their
actions. When a hidden power structure predominates, an unhealthy atmosphere is
created in which not all nurses are allowed to take their place in the group and to
express their views; people are no longer aware of the rules that apply. If a hidden
power structure is allowed to predominate, this could be a sign of weak leadership
because informal leaders are allowed to decide matters. An informal leader is normally someone who seeks to gain power over others within a culture. Moral knowledge is more than just having power over someone because it requires reflection
8 believes that
and the ability to weigh one alternative against another. Gadamer
moral knowledge is affected by a concrete situation and that it demands a sensitivity and awareness for a unique set of circumstances.

When considering the implications of the findings, it is important to recognize that
this study was carried out by using focus groups consisting of only a limited number of perioperative nurses. The findings cannot therefore be generalized, but they
could still serve to contribute to an area in perioperative nursing culture that has not
been widely researched.
The perioperative nurses taking part in the focus discussion groups were volunteers with varying degrees of experience in perioperative nursing care. Group interaction analysis 17 showed considerable consensus about the way in which the nurses
discussed habits in the operating theatre. They enjoyed sharing different points of
view, but also interrupted and sometimes finished each other s sentences. No
was made to validate any facts that were stated in the discussions. The focus group
discussions therefore represented the reflections and experiences of the nurses present. Despite the limitations of the study, the findings do have relevance to a perioperative nursing culture. The hermeneutical approach made it possible to deepen
our understanding of the habits that exist and see how they affect carers in a specific context. However, since both authors were the researchers, they could help
other to see what might have been missed individually, and the reliability of the
study was enhanced by the fact that each of us conducted our own independent
interpretation of the text, before meeting together to agree unanimously on a final
interpretation and identify the categories that resulted from the study. In this way it
was possible to achieve joint co-examiner reliability.
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L Lindwall and I von Post

The findings of this research draw attention to the habits that exist in a perioperative nursing culture. According to the results, further research needs to be
to focus on other habits that did not come to the surface in this study. The results
also make us conscious of the fact that senior staff must be aware that they are
responsible for the habits that prevail, how those habits are developed, and how
set the tone in a perioperative nursing culture. These habits are regarded by the
people concerned as being self-evident and instinctive, thus they should be the subject of further careful research.

It is important to understand the habits evident in operating theatre cultures, in
which nursing theory and habit become united. Caring science has a duty to acquire
knowledge of caring, its ethos and ethics, the work of relieving human suffering,
and how to create a caring atmosphere in order to promote health and well-being.
Habits should be centred on the essence of caring,
caritas, and the habits of a perioperative nursing culture should spring from the ethos of perioperative caring and
its dignity. 1,2 The results make us aware that there is a need to identify the good and
bad habits found in a perioperative culture and to extract the bad habits from it.

The authors would like to thank all the participants for their contribution to this
Lillemor Lindwall, Mlardalen University, Vsters, Sweden.
Irne von Post, bo Academy University, Vasa, Finland.




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