limitations and delimitations in the research process perioperative nursing

LIMITATIONS AND DELIMITATIONS IN THE RESEARCH PROCESS

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Perioperative nursing in public university hospitals: an ethnography

• Erik Elgaard Sørensen 1 , 2 ,
• Ida Østrup Olsen 3 ,
• Marianne Tewes 4 &
• Lisbeth Uhrenfeldt 5  

BMC Nursing volume  13 , Article number:  45 ( 2014 ) Cite this article

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In recent years, perioperative nursing has received ongoing attention as part of an interprofessional collaboration. Perioperative nursing is constantly faced with new challenges and opportunities that necessitate continual updates of nursing knowledge and technical skills. In light of the longstanding relationship between nursing and technology, it is interesting that few studies with this focus have been performed. Therefore, our research question was: What is the content of perioperative nursing and how do nurses facilitate the interaction between nursing care and technology in highly specialized operating rooms in public university hospitals?

An ethnography involving participant observations and interviews was conducted during a 9-month study period. The participants comprised 24 nurses from 9 different operating wards at 2 university hospitals in different regions of Denmark.

Patients were addressed as either human beings or objects. Likewise, the participants’ technical skills were observed and described as either technical flair or a lack of technical skills/technophobia. The different ways in which the technical skills were handled and the different ways in which the patients were viewed contributed to the development of three levels of interaction between technology and nursing care: the interaction, declining interaction, and failing interaction levels.

Nursing practice at the interaction level is characterized by flexibility and excellence, while practice at the declining interaction level is characterized by inflexibility and rigidity. Nursing practice at the failing interaction level is characterized by staff members working in isolation with limited collaboration with other staff members in operating rooms. Considering that the declining and failing interaction levels are characterized by inflexibility, rigidity, and isolation in nursing practice, nurses at these two levels must develop and improve their qualifications to reach a level of flexible, excellent interaction. Nurse leaders must therefore refocus their skills on proficiency in perioperative nursing.

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Perioperative nursing has been explored from different angles for more than a decade [ 1 ]-[ 3 ]. The interaction between nursing care and technology has been discussed in particular detail [ 2 ],[ 4 ]. This discussion has raised a number of questions about the tendency to view nursing in operating rooms (ORs) as invisible to the patient and as surgical interventions without nursing activities [ 5 ],[ 6 ].

Perioperative nursing as an act of technology includes the knowledge and skills to work proficiently with instruments, equipment, and machinery [ 7 ]-[ 9 ]. Numerous advances in technology such as robots, digital displays, artificial organs, magnetic sensors, and communications technology [ 7 ],[ 10 ] require that nurses also become educated in information technology (IT) [ 8 ]. In ORs, the team members work and activities are structured around the management of the “operating list” [ 11 ].

The surgical event is viewed as a social and technical process [ 12 ] that involves the entire team, including the surgical nurse, circulating nurse, anesthesia provider, surgical technician, and surgeon. Furthermore, the content of perioperative nursing is viewed as a number of activities that often occur simultaneously. The use of specific instrumentation and procedures illustrates the central nature of the actions in ORs, where the dominant goal is to conduct a successful operation for the treatment of a specific disease or injury [ 6 ] with a focus on patient safety and prevention of surgical infection [ 13 ],[ 14 ].

From a patient perspective, technology can be quite frightening, despite the fact that nurses find all aspects of perioperative nursing and the large display of technology familiar [ 15 ]. According to Sweeny [ 8 ], the use of technology and related transitions can reduce human contact. A recent review highlighted the transitions that increased patients’ anxiety [ 16 ], adding importance to the implementation of individualized nursing care in the perioperative setting.

However, the involvement of such care (e.g., when using the term “advocacy”) in perioperative nursing in the OR is unclear. A descriptive study of OR nurses’ perceptions of the implications the concept “advocacy” included interrelated and overlapping themes such as protection, communication/vocalizing, doing, comfort, and caring [ 17 ]. When Westerling and Bergbom [ 18 ] evaluated effective perioperative nursing care from the patient’s perspective, they found that the value of being acknowledged as an individual carried particular importance to the patients, and that the ability of patients to share their perioperative experience with familiar nurses made the patients feel calm, safe, and secure. This perspective was first identified by Rudolfsson et al . [ 19 ] and later actualized by Rudolfsson [ 4 ] in their elaboration of a model illustrating the perioperative dialogue/ethos, showing that the patients felt that it was safe to hand over the responsibility to the nurse when they felt acknowledged, listened to, and met with empathy. Likewise, another study demonstrated the creation of continuity through preoperative dialogue, its manifestation in intraoperative dialogue, and its closure in postoperative dialogue [ 20 ]. Although the interaction between nursing care and technology has been taken for granted by many OR nurses [ 6 ], the interaction has also been viewed as a challenge [ 21 ]-[ 24 ] because perioperative nursing has been, and remains, inextricably linked to the development of technology with the risk of eroding the quality of care [ 6 ]. Therefore, perioperative nursing is constantly faced with new challenges and opportunities that necessitate continual updates of nursing knowledge and technical skills [ 3 ],[ 25 ]. In light of the longstanding relationship between nursing and technology, it is interesting that only few studies with this focus have been performed [ 21 ]-[ 24 ]. Furthermore, these studies are >10 years old.

With this background, the purpose of the present study was to investigate the actual content of perioperative nursing in highly specialized ORs in public university hospitals. The research question was: What is the content of perioperative nursing and how do nurses facilitate interactions between nursing care and technology in highly specialized ORs in public university hospitals?

This ethnography was based on participant observations and interviews inspired by practical ethnographic principles [ 26 ]-[ 28 ]. We directly observed OR nurses in the field and interviewed them about their experience to capture the concrete, everyday practice in ORs and understand the content of perioperative nursing. The participants comprised 24 registered female nurses selected from 8 surgical specialties at 3 urban geographical locations in 2 public university hospitals to ensure diverse and nuanced data. The surgical specialties included orthopedic, thoracic, gastrointestinal, breast, ear-nose-throat, neurosurgical, urological, and gynecological surgery. The participants’ ages ranged from 31 to 63 years. They had from 3 to 24 years of nursing experience in ORs. A minimum of 3 years of clinical nursing experience was required for enrollment in this study to ensure a strong nursing identity and clinical knowledge [ 29 ],[ 30 ].

Data were collected through field observations of each participant for a period of 3 to 5 days for 5 to 8 hours per day depending on the participant’s daily work in the OR. This time period was based on both experience from another field study and the aim of achieving empirical saturation [ 31 ]. This saturation was achieved when the nuances in the nurses’ experiences decreased though changes in settings and geography.

During the field observations, the authors (E.E.S. and I.Ø.O.) produced handwritten field notes [ 27 ]. Each participant observation was followed by an ethnographically inspired interview [ 26 ]. The interviews were based on semistructured interview guides individually created based on the previous field observations. One interview question was: “You told me you had technical flair. Could you please tell me more about this flair?” The interviews were intended to contribute to a deeper understanding of the context-bound events from the participant observations [ 28 ]. The overall study period included 122 operations performed during 9 months, amounting to 273 hours in 44 days and 6 nights. This strategy allowed for repetitions over time and set aside the “tip-of-the-iceberg” assumption [ 27 ].

Data analysis and preunderstanding

The authors (E.E.S. and I.Ø.O.) transcribed all field observations, notes, and interviews into verbatim text. This text was later subjected to a hermeneutic back-and-forth process [ 32 ] in a stabilization analysis phase and an adaptation analysis phase (E.E.S., I.Ø.O., and L.U.) according to Hammersley and Atkinson’s guidelines [28:333–367].

The stabilization phase involved preparation of data for analysis, systematization, and pattern identification using the qualitative analysis program NVivo9 [ 33 ] to develop the content of perioperative nursing (first part of the research question). This led to the formation of two themes: “Technical skills” and “Understanding of the individual patient.” These themes were developed into subthemes (Table  1 ), and the themes and their subthemes were grouped within the first main finding: OR nurses ’ interaction between skills and understanding .

In the adaptation phase, the analysis focused on gaining an understanding of the interaction between nursing care and technology in perioperative nursing (second part of the research question). Themes and subthemes of nursing care and technology were coded and collected based on mutual links and internal relationships and structures [28:241]. The coherence between the themes and subthemes contributed to the development of three levels of interaction: the “interaction level,” “declining interaction level,” and “failing interaction level” (Table  2 ). These three levels were grouped in the second main finding: OR nurses ’ interaction between nursing care and technology .

Recent theory-, experience-, and research-based work [ 31 ],[ 34 ],[ 35 ] from public urban university hospitals with a practice-theory termed “interactional nursing practice” [ 36 ],[ 37 ] has inspired our data analysis with a theoretical preunderstanding during all steps in the data analysis. The theoretical and practice perspectives of this practice theory are closely interwoven. This preunderstanding challenged and problematized the normative nature of perioperative nursing during the field observations and interviews [ 37 ]. Therefore, the observations and interviews allowed for investigation of three possible modes of action. The first is the cognitive - instrumental mode of action , which contributes to problem-solving and result-oriented activity representing technical activities. The aesthetic - expressive mode of action concerned nurses’ self-knowledge and understanding of the individual patient’s situation based on dialogue and communication. The third mode of action, the moral - practical mode of action , handles discussions and actions in relation to the patient’s overall situation. These three different modes of action were only separated for theoretical reasons in the present study; in nursing care, they are part of a whole. Their separation in nursing practice may result in narrow-minded moralism and dogmatism [ 36 ],[ 37 ].

Ethical considerations

The North Denmark Regional Research council approved the study protocol before study start (Data Protection Agency, journal no. 2008-58-0028). The study adhered to the ethical guidelines for nursing research in the Nordic countries with regard to participant information, including declarations of consent and anonymity [ 38 ]. The nursing directors at the two university hospitals were gatekeepers [28: 49]. The leaders, OR nurses, anesthesia providers, and surgeons met the researchers (E.E.S. and I.Ø.O.) during the information sessions and were informed about the investigation. Knowledge transfer was secured by a Danish publication [ 35 ]. All 24 participants provided written informed consent, and none withdrew during the study. Direct encounters between the researchers and awake patients were avoided by standing behind apparatuses or screens. When this was impossible, the researchers introduced themselves to the patients.

The results of the analysis led to two main findings. The first main finding concerned OR nurses ’ interaction between skills and understanding , and the second concerned OR nurses ’ interaction between nursing care and technology . In the Results section, each citation of an observation or interview statement has been assigned a reference number for one of the 24 participants, who practiced as either the circulating nurse (CN) or surgical nurse (SN).

OR nurses’ interaction between skills and understanding

The first theme is entitled “technical skills” and concerns the different ways in which the technical assignments and developments were handled. The second theme is entitled “understanding of the individual patient” and concerns the different ways in which the patients were viewed. Table  1 shows how the relationships between the main finding (interaction between skills and understanding) and the subthemes were developed.

Technical skills

Technical skills were expressed in two ways: technical flair and a lack of technical skills.

Technical flair was considered to be present when nurses demonstrated skill in carrying out procedures and operating instruments regardless of the amount, size, construction, or variety of different types of machinery and equipment. Technical flair also involved the ability to easily acquire new knowledge and skills in using instruments and machinery, including the consequences of their use in a specific patient situation. Technical skills were reflected in the following observation: The SN [ participant ] unpacks and prepares for the operation and says to the CN , “ Look at the scope — it has been assembled before autoclaving. It is not supposed to be assembled. It has to be separated in its many parts , springs , and screws before being autoclaved , and then the parts have to be assembled during preparation for the operation .” The SN acquires a new scope , easily assembles it , and says , “ I think I am what you would call practical. I have a flair for technical things and electronics. It is easy for me and it interests me a lot ” (21).

A lack of technical skill was characterized by the ability to assist in routine operations and apply already-known instruments, equipment, and machinery without problems. However, such nurses were unable to acquire knowledge and skills in using new instruments or establish routines involving complex technical procedures and computer-based equipment. This lack of skill had negative consequences as shown by the following interview response: “ I don ’ t have technical flair. It is not easy for me and it doesn ’ t interest me. I fall short as soon as I have to work with a computer. One day , I made a mistake when a patient was connected to the navigation system [ complex computer - based surgical equipment ]. I touched ‘ something ’ and the patient had to undergo the surgery without the advanced technique ” (1).

Technophobia was also viewed as a lack of technical skills. Technophobia was characterized by a lack of skills in certain procedures, potentially leaving the nurse feeling fearful and clumsy. This was expressed in the following statement during an operation: “ I don ’ t feel good about mixing the cement. I am afraid that I might screw things up. That [ the procedure ] takes up so much [ energy ]. It is annoying to think about during the whole operation. I feel like a clown ” (17).

Understanding of the individual patient

The nurses’ understanding of the individual patient was expressed in two different ways: the patient was viewed as either a human being or an object. Viewing the patient as a human being was shown by the way the nurses considered a patient’s situation during an operation: A 65 - year - old woman is lying on the operating table after an ostomy operation. The surgeon has left the operating room. When removing the sterile cover , the CN [ participant ] notices that the ostomy is “ uneven .” She encourages the SN to contact the surgeon. The surgeon agrees that the ostomy does not have the desired shape. He cuts the lowest suture , pulls the bowel further up , and places a new suture. Everyone is satisfied with the shape of the ostomy (23).

This participant was asked to elaborate on the above-described episode and said, “ It is a trauma in itself to have a life - threatening disease and an ostomy. If the patient , on top of this , will have problems adhering the plate and the ostomy bag because we haven ’ t done our job properly … well , that just aggravates the situation. I have worked with ostomy patients and I could see that the ostomy was not okay ” (23). In this episode, the CN applied her experience-based knowledge for the benefit of the patient. She expressed her understanding of the patient as an ill and vulnerable human being.

There were also nurses who viewed patients as objects. This was observed in a situation in which the SN did not allow the CN to speak up for a patient: A 45 - year - old woman with cancer is undergoing surgery for a pathological fracture. The CN notices that the surgeon is uncertain about the instrumentation used to measure the size of the prosthesis. The surgeon asks the SN for a prosthesis of a certain size. The CN reacts by saying , “ But your measurement was larger than this ” [ implying that the surgeon asked for the incorrect prosthesis ]. The SN reacts by saying to the CN , “ Hey !” [ implying that she was interfering with something with which she was not supposed to interfere ] (17). The prosthesis was subsequently discovered to be too large, and the patient required further surgery. According to the field notes, the SN was struck by passivity. Moreover, she prevented the CN from getting involved in the situation. In this example, the approach was characterized by a lack of interest in the patient as a human being; the patient was instead seen as an object.

OR nurses’ interaction between nursing care and technology

In the second main finding, OR nurses ’ interaction between nursing care and technology , the coherence between the themes and subthemes contributed to the development of three levels of interaction: the interaction, declining interaction, and failing interaction levels (Table  2 ). The different ways in which the technical assignments and developments were handled and the different ways in which the patients were viewed contributed to the development of all three levels of interaction.

Interaction level

The interaction level was characterized by the interaction between the presence of technical flair and viewing the patient as a human being. This was expressed in the following way: The SN [ participant ] is assisting during an operation of a 72 - year - old woman. The SN says , “ I haven ’ t done this [ specific operation ] for a long time .” The SN gets five large boxes and separates instruments from a depot , takes the instruments to the operating room , and unpacks and prepares the instruments for the operation. She now places her hand on the patient ’ s shoulder after the patient has been sedated and assists in connecting her to the respirator. Later during the operation , the SN says , “ She [ the patient ] is such a fine little lady .” With eyes on the surgical field and without speaking , the surgeon reaches a hand toward the SN , who passes a specific type of suture to the surgeon. The SN looks at the surgical field and says , “ Wait. Is that the right suture for that place ? If not , you ’ ll need a different one .” She then passes another type of suture to the surgeon (23).

In this episode, technical flair was evidenced by the SN’s confidence in using the equipment and proficient grasp of the situation despite the fact that it had been a while since she had assisted in this type of operation. The underlying understanding of the patient as a human being was expressed during the SN’s participation in the patient’s sedation, in which she placed her hand on the patient’s shoulder while assisting the anesthetic nurse. The SN referred to the patient in a respectful manner by using the expression “such a fine little lady,” and it is evident that she understands, sees, and meets the patient as a human being.

Declining interaction level

The declining interaction level was characterized in two ways: as an interaction between the presence of technical flair and viewing the patient as an object and as an interaction between a lack of technical skills and viewing the patient as a human being.

The interaction between the presence of technical flair and viewing the patient as an object was expressed when a participant spoke about a colleague: “ She [ a colleague ] is technically very skilled. She can manage everything when it comes to technology and IT systems. Therefore , she is our expert , but only when it comes to technique. She has no interest in the patients. She cannot talk to [ understand ] them [ the patients ]” (4).

The participant who spoke about the colleague was later asked to elaborate on this statement and answered, “ Yes , you have a point there ” (3). This colleague was perceived as a skilled technician with technical flair. Her lack of interest in vulnerable patients, however, is an example of viewing the patient as an object.

The interaction between a lack of technical skills and viewing the patient viewed as a human being is shown in the following scenario: The SN [ participant ] is about to assist in a very complicated operation. She says , “ I haven ’ t assisted in such an operation in 100 years .” The CN assists the SN with the preparation. After unpacking the equipment for the operation , the CN is about to leave the room. Very promptly , the SN says , “ No , you can ’ t go .” The SN was later asked to elaborate on this episode and stated , “ When I am insecure about the techniques , I get very affected by the way the surgeon enters the room and whether I can sense that he seems insecure. Today , when we were using new equipment , there had to be a technically minded colleague next to the surgeon to assist him. And while my colleague is technically minded , I am caring - minded. I am very considerate of the sedated and defenseless patient. I see him as a human being ” (4). In this example, the technically unskilled nurse was insecure and using new equipment. The nurse acknowledges that she was insecure and expressed the need to have a technically skilled nurse present in the OR. The expressions “ No , you can ’ t go ” and “ I get very affected ” reflect the presence of technophobia in this technically unskilled nurse. In this scenario, it seemed as though the lack of technical skills was legitimized by viewing the patient as a human being.

Failing interaction level

The failing interaction level was characterized by the interaction between a lack of technical skills and viewing the patient as an object. This was demonstrated in a scenario involving the above-described 45-year-old woman with cancer who underwent surgery for a pathological fracture (see earlier theme, “Understanding of the individual patient”). In contrast to the CN, the SN did not interfere with the surgeon and his novice use of the instrumentation while measuring the prosthesis size. Furthermore, the SN prevented her colleague from providing the novice surgeon with important knowledge by saying, “ Hey !” [ implying that she was not supposed to interfere ] (17). At the end of the operation, the surgeon said to the SN, “ I have not been satisfied with your assistance .” The SN replied, “ Well , it is not my fault that you chose a prosthesis that was too big. You are supposed to know how this should be done ” (17). Before the operation, this particular participant said, “ I don ’ t bother about the patient contact. I have often felt that I am unable to do anything for them [ patients ]” (17). According to the field notes, the SN exhibited passivity and was unable to share her (limited) technical, practical, and experience-based knowledge. Moreover, she prevented the CN from getting involved in the situation. In this example, the lack of technical skill was combined with a lack of interest in the patient as a human being; the patient was only an object.

The purpose of this descriptive study was to investigate the content of perioperative nursing in highly specialized ORs in public university hospitals and elucidate perioperative nurses’ interactions between nursing care and technology. The findings suggest three different levels in which perioperative nurses navigate between nursing care and technology. Thus, this study supports earlier research regarding nurses’ ability to combine technical and relational skills [ 6 ],[ 21 ]-[ 24 ]. Bull and FitzGerald [ 6 ] reported similar findings from an ethnographic study in Australia. They stated that the necessity of combining technological proficiency and caring in the OR was taken for granted by nurses. However, our study suggests that this is not always the case when the interaction between nursing care and technology is declining or failing.

Research-based knowledge is needed to inform leaders and nurses about the technological and nursing tasks involved in perioperative nursing [ 39 ],[ 40 ] and to apply this knowledge to patient safety [ 16 ]. According to Scheel [ 36 ], the cognitive-instrumental mode of action in this study is presented by the nurses’ different levels of technological skills, which range from technical flair to a lack of technical skills. The aesthetic-expressive mode of action is observed by the way Informant 23 referred to the patient in a respectful manner. The opposite occurred when Informant 17 stated that she did not care about patient contact. The third mode of action, the moral-practical mode, is represented by Informant 23, who applied her experiential knowledge about ostomy care. This was what the patient and the actual situation demanded from the nurse. The opposite occurred when Informant 17 prevented a colleague from speaking up for the benefit of the patient.

These three different modes of action require unification [ 36 ]. At the interaction level , the interactions among the three modes of action are always part of the current patient–nurse interaction. At the declining interaction level , the cognitive-instrumental or aesthetic-expressive mode of action is particularly prioritized depending on the individual nurse. Thus, the three modes of action do not always interact at this level. This leads to the risk of inadequate nursing care unless the OR is staffed with nurses with different skills who can ensure an interaction among the three modes of action. The failing interaction level was characterized by a lack of interaction among the three modes of action. According to Scheel’s [ 36 ] terminology, this is not nursing. This interpretation was confirmed by Bull and FitzGerald [ 6 ] who concluded that the combination of technological proficiency and patient-focused ethics of care defines whether nurses’ actions in the OR can be characterized as “nursing” ( interaction level ) rather than “technical” tasks ( failing interaction level ). In other words, there is a risk that technology undermines care. However, the present study also showed that nurses at the declining interaction level prioritize nursing care, perhaps because of their lack of technical flair. Interestingly, however, most studies on perioperative nursing have focused on nursing care in contrast to OR nurses’ technical skills [ 2 ],[ 4 ],[ 41 ],[ 42 ]. Barnard [ 21 ] and Sandelowski [ 23 ] are well known for their theoretical studies on nursing and technology. Similarly, Barnard and Gerber (1999) investigated nurses’ understanding of technology through interviews. Nevertheless, the study was based on ethnographic principles and thus revealed new dimensions in technical skills. Some nurses possessed technical flair, while others were technically unskilled. This raises new questions and concerns about nurses’ varying technical skills and may thus inspire further research and discussion.

In this study, nurses at the interaction level combined nursing care and technology with self-reflection and a great understanding of the interdisciplinary team. Nursing practice was characterized by flexibility and excellence because the same nurse interacted with all three modes of action [ 37 ] in that she managed all tasks in the OR. Nurses at the declining interaction level prioritized either the technical or the nursing care dimension, and self-reflection was directed toward elements of the tasks in the OR. A match between two different nurses in the OR is required to ensure interaction among all three modes of action. This limits the implementation of perioperative nursing because the nurses cannot perform all of the tasks in the OR. Nurses at the failing interaction level lacked self-reflection and showed no interest in the patient. New technological challenges were limited by the nurses’ lack of technical skills. Nursing practice was characterized by inflexibility and rigidity because the nurses worked in isolation with limited collaboration with the other staff members. This interpretation was confirmed by Coe and Gould [ 43 ] and Finn [ 44 ], who claimed that well-functioning interdisciplinary teamwork is described as excellent. Thus, the present study’s findings regarding flexible versus inflexible nursing practice add to the discussion on generalist versus specialist nurses [ 45 ], as well as to the discussion on seeing the big picture in nursing, which indicates a desire to provide good care to both patients and staff [ 46 ]. An individual who fails to see the big picture might act rigidly, rather than appropriately, resulting in blind action due to mechanical and automatic thinking.

The findings in this study suggest three different levels at which perioperative nursing care and technology interact in highly specialized ORs in public university hospitals. This categorization of perioperative nursing into levels is not new. In a quantitative, descriptive, correlational study of perioperative nurses’ ability to think critically, Fesler-Birch [ 3 ] calculated the average level of critical thinking to be 2.12 on a scale of 1 to 4, in which 1 indicates no critical thinking and 4 indicates complex critical thinking. Because critical thinking may be central to nurses’ ability to meet patients’ expectations regarding care and skill, this average level of 2.12 can be costly from a patient perspective, in that as intraoperative problems arise, quick clinical judgment decision making may weaken. Fesler-Birch’s study cannot be compared to the present study in that the two were based on different methodologies. However, a number of new questions are raised when comparing one study to the other. For example, could a correlation exist between perioperative nursing at the failing interaction level, which is characterized by nurses’ lack of self-reflection, and level 1 critical thinking, which is characterized by the absence of critical thinking? On the contrary, could a correlation exist between perioperative nursing at the interaction level, which is characterized by nurses’ self-reflection, and level 4 critical thinking, which is characterized as complex? If so, both the failing interaction level and level 1 critical thinking can be costly from a patient perspective. Although there is no solid basis for this conclusion, these questions may inspire further research and discussion.

Limitations of this study

In this study, the content of perioperative nursing was analyzed based on data from highly specialized ORs in two public university hospitals, and the results were interpreted as main findings, themes, and subthemes. Because of the particular sample and special health care context, the findings may be dismissed as unique with no scientific value. However, there are aspects of the universal within the unique [ 47 ],[ 48 ]. Accordingly, the main findings of this study might be applicable by perioperative nurses at other hospitals. A few limitations are noteworthy. For example, the fieldwork was performed in daytime and in the evening, and the night hours were limited. Therefore, the study did not address the content of perioperative nursing and what characterizes this practice in relation to emergency surgery in night hours The study context focused on perioperative nursing in highly specialized ORs in public university hospitals, which are characteristically populated by seriously ill and vulnerable patients undergoing complex surgical procedures. Because the study context did not focus on the research question as related to less severely ill patients and short-term surgical procedures, this should also be seen as a limitation.

Field relationships between informants and researchers are central to any ethnographic study [ 49 ]. A typical question raised is how to account for bias associated with the fact that the participants knew that they were being observed. According to Hammersley and Atkinson [ 28 ], the underlying belief is that human behavior cannot be studied in isolation or independently from the context in which it occurs. Contextualizing the data enables the researcher to place it within a broader perspective and capture a more holistic view. This involves extensive fieldwork in naturalistic settings for prolonged time periods in which the researcher has direct, personal, face-to-face contact with informants [ 49 ]. In the present study, we observed individual nurses for 3 to 5 days for 5 to 8 hours per day. Pretending to be a completely different person than who you are is impossible for such a long period of time [ 34 ]. Therefore, we were able to capture more than just a snapshot of the nurses’ activity and were able to observe routine, repeated, and patterned social practices and processes.

Conclusions

Perioperative nursing in highly specialized ORs in public university hospitals is performed at three different levels depending on the interaction between nursing care and technology. This leads to different characteristics of practice: Practice at the interaction level is characterized by flexibility and excellence because nurses exhibit interaction among (a) technological activities based on technical flair, (b) an understanding of the individual patient and self-reflection based on dialogue and communication, and (c) acting in relation to the patients’ overall situation. Nurses at the interaction level perform all tasks in the OR. Practice at the declining interaction level is characterized by less flexibility because nurses prioritize either (a) technological and instrumental activities based on technical flair or (b) nursing care based on an understanding of the individual patient. Nurses at the declining interaction level are unable to perform all tasks in the OR. Finally, practice at the failing interaction level is characterized by inflexibility and rigor because nurses’ self-reflection and interest in the patient are lacking. New technological challenges are limited by nurses’ lack of technical skills or technophobia. Nurses at the failing interaction level work in isolation with limited collaboration with other staff in the OR.

The findings of this study are useful in organizational, clinical, and educational settings in updating policies for perioperative nursing and enlarging perioperative nurses’ understanding of the relationship between nursing care and technology. Considering that practice at the declining interaction level and failing interaction level is characterized by inflexibility and isolation, nurses at these two levels must develop their competency to the flexible and excellent interaction level . An important task for nurse leaders with respect to recruiting and retention is to be aware of the need for proficiency in this field. The present findings also have some potential in relation to other areas where technology is increasing in the nursing field; e.g., the use of telehealth and technology to support older people in their homes as well as other highly technical areas such as high-dependency units and intensive (coronary) care.

Our discussion is an example of how to use nursing theory in research and expressions such as nursing care and technology, which might lead to constrained nursing practices if misunderstood. Further empirical studies are required to challenge our conclusion that nurses perform perioperative nursing in highly specialized operating departments at three different levels depending on the interaction between nursing care and technology.

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Acknowledgements

The authors thank Connie Skrubbeltrang for assisting with the literature search and Line Jensen for assisting with language revision.

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EES and MT developed the idea for the study. EES, IØO, and LU performed the data collection and analysis. EES and LU performed the literature review. EES and LU critically reviewed the Background, Methods, Results, and Discussion sections. EES drafted the manuscript. All authors have read and approved the final manuscript.

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Sørensen, E.E., Olsen, I.Ø., Tewes, M. et al. Perioperative nursing in public university hospitals: an ethnography. BMC Nurs 13 , 45 (2014). https://doi.org/10.1186/s12912-014-0045-7

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LIMITATIONS AND DELIMITATIONS IN THE RESEARCH PROCESS

Dimitrios theofanidis, antigoni fountouki.

Saturday, September 1, 2018

Publication year:

• Theofanidis Dimitrios , PhD, MSc, Assistant Professor, Nursing department, Clinical Professor, Alexandreio Educational Institute of Thessaloniki, Greece
• Fountouki Antigoni , PhD(c), MSc, Clinical Lecturer, Nursing department, Clinical Professor, Alexandreio Educational Institute of Thessaloniki, Greece

Keywords index:

• Study Limitations
• Methodology
• Nursing Research

Pages: 155-163

DOI: 10.5281/zenodo.2552022

Introduction: Many authors tempt to balance the recognition of shortcomings and study limitations with the risk of having their paper rejected. Yet, before any attempt to run a study, a researcher needs to recognise the meaning and operational definitions of the terms ‘limitations’ and ‘delimitations’ in biomedical research. Aim: to define, review and elaborate how limitations and delimitations are currently acknowledged in the nursing and biomedical literature and their implications in health care studies. Methods: A critical literature review was undertaken, focusing on papers debating the core essence of research limitations and associated concepts. Initial searches yielded >300 papers of which only 25 were appropriate for this paper’s needs. Results: It is evident that any research attempt inevitably carries limitations and delimitations regarding its underlying theories, study design, replication potential, shortcomings in data collection and questionnaire design, insufficient subgroups or data for robust statistical analysis, narrow time span for data collection, lack of consideration for seasonal differences and missing data, causal relationships, measurement errors, study setting, population or sample, ethical parameters, data collection/analysis, result interpretations and corresponding conclusions. Delimitations require challenging the assumptions of the researchers and openly exposing shortcomings that might have been better tackled. Some authors cite study limitations solely because it is required by journal policy. Under these circumstances, the weakest limitation may be put forward in an attempt to ‘safeguard’ the study’s chance of being published. Researchers need to be aware of the wide range of limitations and delimitations and address them early in the research process Conclusions: Constructive rethinking and restructuring of the global nursing and biomedical research agenda is necessary to upgrade the profession and reassure the public. Thus, authors should openly and extensively report their research limitations, delimitations and assumptions in order to improve the quality of their findings and the interpretation of the evidence presented. On the contrary, when any of these key elements are neglected, overlooked or hushed, the study kudos is jeopardised.

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Moral Breakdowns and Ethical Dilemmas of Perioperative Nurses during COVID-19: COREQ-Compliant Study

Amalia sillero sillero.

1 ESIMar (Mar Nursing School), Parc de Salut Mar, Universitat Pompeu Fabra Affiliated, 08003 Barcelona, Spain; se.ude.ramise@orellisa (A.S.S.); se.ude.ramise@pligm (M.G.P.); se.ude.ramise@sasordape (E.P.); se.ude.ramise@asnie (E.I.C.); se.ude.ramise@vrevoclac (C.A.V.d.W.)

2 SDHEd (Social Determinants and Health Education Research Group), IMIM (Hospital del Mar Medical Research Institute), 08003 Barcelona, Spain

Raquel Ayuso Margañon

Maria gil poisa.

3 Nursing Care Research, IIBSANT PAU, Hospital Santa Creu i Sant Pau, 08025 Barcelona, Spain; moc.liubzaid@suen

Eva Padrosa

Esther insa calderón, elena marques-sule.

4 Physiotherapy in Motion, Multispeciality Research Group (PTinMOTION), Faculty of Physiotherapy, Department of Physiotherapy, University of Valencia, 46010 Valencia, Spain; [email protected]

Carlota Alcover Van de Walle

Associated data.

The datasets generated and/or analysed during the current study are not publicly available to guarantee anonymity but are available from the corresponding author upon reasonable request.

(1) Background: The COVID-19 pandemic has led to an increase in the complexity of caregiving, resulting in challenging situations for perioperative nurses. These situations have prompted nurses to assess their personal and professional lives. The aim of this study was to explore the experiences of perioperative nurses during the first wave of the COVID-19 pandemic, with a specific focus on analyzing moral breakdowns and ethical dilemmas triggered by this situation. (2) Methods: A qualitative design guided by a hermeneutical approach was employed. Semi-structured interviews were conducted with 24 perioperative nurses. The interviews were transcribed and thematically analysed following the Consolidated Criteria for Reporting Qualitative Research (COREQ) guidelines. (3) Results: The findings revealed three main categories and ten subcategories. These categories included the context in which moral breakdowns emerged, the ethical dilemmas triggered by these breakdowns, and the consequences of facing these dilemmas. (4) Conclusions: During the first wave of COVID-19, perioperative nurses encountered moral and ethical challenges, referred to as moral breakdowns, in critical settings. These challenges presented significant obstacles and negatively impacted professional responsibility and well-being. Future studies should focus on identifying ethical dilemmas during critical periods and developing strategies to enhance collaboration among colleagues and provide comprehensive support.

1. Introduction

Nurses frequently encounter moral and ethical decisions inherent in their clinical practice [ 1 , 2 ]. Several literature reviews highlight the importance of developing a comprehensive understanding of the nursing profession’s ethical dilemmas to enhance ethical competence [ 3 , 4 , 5 ]. The COVID-19 pandemic, though, introduced a new array of challenging and intricate ethical situations and discussions. For example, nurses have faced the ethical dilemma of caring for seriously ill patients who are in end-of-life situations and separated from their families [ 6 , 7 ]. These unprecedented circumstances have heightened the complexity of ethical decision-making and raised novel ethical concerns for healthcare professionals.

Despite nurses’ awareness of professional, ethical principles, applying these principles during the pandemic has posed significant challenges due to a need for more guidance and support from management [ 8 ]. As a result, nurses have experienced moral and emotional distress [ 9 , 10 ], including feelings of grief, anger, frustration, compromised moral integrity, and diminished self-esteem [ 11 , 12 , 13 ]. Professionally, they have encountered difficulties in interpersonal communication, lack of leadership, and desire to leave the profession [ 13 , 14 , 15 ].

The experiences of perioperative nurses during the pandemic are particularly intriguing. In addition to the challenges mentioned earlier, they have had to adapt to significant structural changes in surgical units, such as their conversion into COVID-19 care units [ 16 , 17 , 18 ] or being reassigned to intensive care units (ICUs) [ 19 ]. There is scarce available evidence regarding the specific experiences of perioperative nurses in these environments and, more importantly, how they may contribute to various ethical dilemmas and develop potential moral breakdowns among nurses.

While ethics and morality are often used interchangeably, they possess distinct nuances. This study will adopt Zigon’s theoretical framework [ 20 ] to explore the ethical dimensions of perioperative nursing experiences during the COVID-19 pandemic. At the same time, adopting the Evidence-Based Nursing Model provides a comprehensive approach to guide nursing practice in high-quality care.

According to Zigon, morality relates to non-reflexive norms and awareness of ethical dilemmas, encompassing freedom and moral choice. On the other hand, ethics is associated with cultivating virtues as part of personal growth, achieved through practice and engagement in specific activities [ 21 ], such as the professional realm. Significantly, both concepts coexist in the daily lives of nurses [ 22 ] as everyday life is not a static entity but rather a way of being immersed in tasks and activities anchored in the present moment [ 23 ]. In this state, individuals may lose self-perception, prioritizing the needs of others, accepting the norm of existence, and losing sight of their ultimate reality.

Nonetheless, Zigon asserts that certain events or situations disrupt this state and compel individuals to assess and consciously reflect on the most appropriate response. These instances, which prompt individuals to revisit themselves and challenge dominant conceptions, norms, or beliefs, are what Zigon terms “moral breakdowns”, marking the threshold at which he distinguishes morality from ethics [ 22 , 24 ]. Thus, morality represents an unconscious way of being shaped by embodied moral dispositions, beliefs, conceptions, hopes, expectations, and more [ 24 ]. Simultaneously, ethics corresponds to conscious questioning and initiating an ethical work process aimed at assimilating new provisions and returning to moral action in the social world. A moral breakdown propels individuals to engage in self-work, leading them to what Zigon refers to as an ethical moment, where possibilities unfold, enabling conscious choices [ 20 ].

Understanding the numerous ethical challenges that nurses encountered during the pandemic is essential for a comprehensive understanding of the profound and extensive impact of the pandemic on the nursing profession. This understanding is crucial in informing and enhancing the continuous emotional, psychological, and practice support provided to nurses during and even after the pandemic.

Drawing upon Zigon’s theoretical framework of ethics and morality, the primary objective of this study is to delve into perioperative nurses’ experiences during the initial wave of the COVID-19 pandemic. Our focus is directed explicitly towards investigating potential moral breakdowns and ethical dilemmas in this unusual situation. By conducting this exploration, we aim to foster a more profound comprehension of the distinctive ethical challenges perioperative nurses face in a global health crisis. Ultimately, the insights gained from this study will inform the development of strategies to support and enrich perioperative nurses’ well-being and professional practice.

2. Materials and Methods

2.1. study design and participants.

A qualitative design guided by a hermeneutical approach [ 25 ] was used to explore the experiences of perioperative nurses during the first wave of the COVID-19 pandemic through an analysis of their narratives. Participants were recruited on-site in a university hospital in Barcelona, Spain, from June to July 2020. Potential participants were informed of the purpose of the study and were invited to participate. The inclusion criterion was to have worked as a perioperative nurse during the first wave of the COVID-19 pandemic (14 March–1 June 2020). A total of 24 perioperative nurses were interviewed until data saturation was reached when interviews did not offer new information [ 26 ]. Interventional studies involving animals or humans, and other studies that require ethical approval, must list the authority that provided approval and the corresponding ethical approval code.

2.2. Data Collection

Face-to-face semi-structured interviews were conducted from June to July 2020. Prior to the start of the interview, participants were informed again about the study and the implications of participating, and they were given a written consent form. During the interview, a note-taker was present to keep track of the topics discussed. Interviews were audio-recorded for subsequent literal transcription. Interviews were transcribed and pseudo-anonymized. Interviews lasted between 40 and 60 min and covered aspects related to nurses’ experiences during the first wave of the pandemic, including topics such as their thoughts and feelings about treating COVID-19 patients or being assigned to different units, coping mechanisms, and recommendations for future solutions in public health crises. Background information was also collected, including gender, age, household composition, years of experience, working shift, type of contract, and if they had been sent to the reserve, reassigned to other units, treated COVID-19 patients, or had a COVID-19-related sick leave.

2.3. Data Analysis

An interpretative hermeneutical approach was used, following Crist and Tanner’s recommendations [ 25 ]. An abductive thematic analysis strategy was divided into five stages: identification of deductive categories and subcategories, familiarization with the data, identification of new categories and subcategories, review of deductive and inductive categories and subcategories, and naming of final categories and subcategories.

We started preliminary data analysis right after the first interviews were conducted to assess whether and when informational saturation was reached, and pre-defined deductive codes for thematic analysis were determined. After transcribing and pseudo-anonymizing all the interviews, three analysts independently coded the same randomly chosen transcripts. Forty-three data codes were found, distributed in ten code groups. Then, the three researchers met to discuss and resolve discrepancies related to the use of deductive categories and subcategories, as well as the generation of additional themes. These additional themes were either placed as subcategories into a deductive category or grouped as new categories. Once a category tree was agreed on, three researchers verified the coherence of categories and subcategories and checked for clear distinctions between them. Thereafter, three researchers systematically coded the rest of the transcripts and met weekly to refine categories and subcategories as the coding process moved forward [ 27 ]. The results of data analysis were discussed with the full research team to facilitate the interpretation and discussion of findings. All study authors hold a PhD degree and have extensive experience in qualitative research, including qualitative data analysis. Their expertise and qualifications enable them to perform the coding and analysis of the transcripts effectively. Analysis was conducted using ATLAS.tiWindow Software (23.0.8.0).

To ensure rigour throughout the research process, we followed multiple steps adapted from Lincoln and Guba’s criteria of evaluation (1985) [ 28 ]. Credibility, transferability, confirmability, and trustworthiness were guaranteed by integrating researcher triangulation, considering reflexivity in every stage of the research project, undertaking peer debriefing after each interview, managing data systematically, and exploring potential interpretations of findings. Peer checking of team members was also applied, along with participants’ feedback. The Consolidated Criteria for Reporting Qualitative Research (COREQ) were followed [ 29 ]. See the Checklist in the Supplementary Material for comprehensive information.

2.4. Ethical Considerations

Prior to implementation, the study was guaranteed ethics approval by an Official Ethics Review Board (IIBSP-COV-2020-58). Beyond that, we followed the standards established in the Declaration of Helsinki (2013): participants had access to an information sheet of the study and signed a written consent form prior to data collection [ 30 ]. Data were treated according to Regulation (EU) 2016/679 of the European Parliament and the Council of 27 April 2016 on the protection of natural persons with regard to the processing of personal data and on the free movement of such data and repealing Directive 95/46/EC (General Data Protection Regulation) [ 31 ].

Twenty-four nurses met the inclusion criteria, completed the study, and were included in the analyses. All nurses were women, their ages ranged from 28 to 60 years old, and they had been working as nurses between 3 and 40 years, the mean being 20 years of experience. Most of them worked day shifts (n = 17) and had permanent jobs (n = 20). During the first wave of the pandemic, the majority were sent to the reserve at some point (n = 17), meaning that they had to stay at home until they were called to the frontline, and half of them were reassigned to other units (n = 12). All of them but one treated COVID-19 patients. However, only 10 individuals went on sick leave due to COVID-19 during that period. The characteristics of the sample are presented in Table 1 .

Characteristics of the sample.

All data are expressed as mean(SD) or frequency(percentage), as appropriate. %: percentage; SD: Standard Deviation.

Three main themes were identified from the analysed narratives: (1) the context of moral breakdowns, (2) the ethical dilemmas triggered by moral breakdowns, and (3) the consequences of facing ethical dilemmas. The categories and subcategories are presented in Table 2 .

Categories and subcategories of narratives encountered by perioperative nurses.

3.1. Context in Which Moral Breakdowns Emerged

According to the narratives of perioperative nurses, the feeling of being in a collapse situation was key to their experience during the first wave of the pandemic. They reported experiencing quick, poorly informed, and disorganised changes in their units and, by extension, in their tasks and activities. For instance, some of them were called to the frontline to take care of COVID-19 patients, reassigned to other units, asked to adopt new professional roles and tasks, or challenged with multiple schedule changes. And they were not necessarily trained for these changes (Q1,2).

To add to this tension, they had to work under poor working conditions, dealing with a shortage of beds, equipment, medication, and professionals. In the interviews, it was salient that transforming resuscitation units into ICUs generated structural barriers to using the available resources, which impeded delivering patient care (Q3,4).

For many, this resulted in an emotional debacle. Nurses narrated how the situation became emotionally unbearable when they thought about their lack of knowledge to treat COVID-19 patients (Q5,6).

3.2. Ethical Dilemmas Triggered by Moral Breakdowns

All these factors combined were the perfect storm for moral breakdowns to burst. The interviews highlighted that perioperative nurses started to doubt the morality of how their profession was being performed due to the above-described context, and this triggered ethical moments in which they questioned not only their daily tasks and activities but also those of their peers and supervisors.

The first ethical dilemma was the quandary between professional responsibility versus the incapacity to provide quality care. Nurses reported not having time or resources to take care of patients in a holistic manner. Consequently, some interviewees felt they were hindering the principle of justice, as they could not treat patients equally. Moreover, perioperative nurses described how they did not feel prepared or trained to treat critical patients, which interfered with their sense of professional duty (Q7,8).

Also related to the morality of the nursing profession, nurses experienced ethical dilemmas when it came to respecting the right of patients to be accompanied by their families versus the restriction of visits in health institutions. These restrictions placed nurses in a situation in which they had to emotionally support patients knowing that what would help them the most would be to see their families, infringing the principles of autonomy and, as they wondered, even of beneficence (Q9).

A third dilemma perioperative nurses referred to was the choice between patient care versus self-care. As depicted in the interviews, nurses were confronted with wanting to care for COVID-19 patients and not wanting to become infected and infect their families. This was compounded by the fact that most nurses were not adequately provided with PPEs, as described by the quotes referred on Table 3 (Q10,11).

Results table and participants’ quotes.

Finally, breakdowns triggered by the pandemic opened the door to questioning the morality of peers, supervisors, and other health professionals. It is worth noting that these dilemmas might hold significant importance for both the informants and researchers. This is primarily due to their direct relevance in professional settings and the potential impact they can have on workplace relationships. Perioperative nurses that were sent to the frontline felt disappointed and sometimes distrusted the commitment to the profession of, on the one hand, colleagues that were sent to the reserve (Q12,13) and, on the other hand, supervisors who made those decisions (Q14). They also described feelings of skepticism related to the recruitment of nursing students while keeping experienced professionals in reserve (Q15). In that line, nurses that were sent to the reserve or kept their role in the perioperative service experienced guilt and regretted not being able to be there with their colleagues and patients (Q16) should the situation not have been dangerous for their families (Q17).

3.3. Consequences of Facing Ethical Dilemmas

The ethical dilemmas mentioned above entailed multiple consequences, being emotional reactions the most remarked on in the interviews (Q18,19). This topic emerged in the narratives of perioperative nurses on how they experienced feelings of despair, powerlessness, fear, and rage; these sometimes triggered emotional and mental health effects, including anxiety, depression, or sleep disorders.

Occasionally, facing these ethical dilemmas also led nurses to reconsider their profession, albeit with diverging outcomes. While some perioperative nurses questioned whether the profession was worth it (Q20), others re-awoke the significance of being a nurse and even considered changing from the surgical ward to other units (Q21).

Similarly, nurses narrated that working under such conditions strengthened interpersonal relationships within teams and identified interprofessional teamwork as one of the most helpful strategies to cope with difficulties (Q22), along with resilience (Q23,24). However, when it came to supervisors, nurses exposed multiple needs that had not been adequately addressed. In their narratives, they talked about feeling unsupported after their return, as if supervisors did not care about the emotional discomfort that the overall process of getting back to the surgical ward was causing them (Q25).

For many of the interviewed nurses, acknowledgement and support from their supervisors would have been key, not only for a safe return (Q26) but also for the management of future public health crises, coupled with better-articulated information flows and continuous training programs (Q27).

4. Discussion

This study aimed to explore the experiences of perioperative nurses during the initial wave of the COVID-19 pandemic, focusing on moral breakdowns and the subsequent ethical dilemmas they faced. The constant conflict between providing care under adverse conditions and maintaining quality care posed significant challenges, leading to moral and emotional distress among nurses [ 32 ]. This study is one of the first of its kind to examine the morality of the nursing profession within the context of a pandemic, specifically from the perspective of nurses who rapidly adapted to new roles, tasks, and activities.

The discussion highlights various ethical principles that were at stake during the pandemic, aligning with challenges identified in recent nursing studies. These principles include autonomy, justice, respect for patients and their families, caregiving quality, safety in the working environment, and health of both nurses and patients [ 33 , 34 , 35 , 36 , 37 , 38 , 39 , 40 ].

The COVID-19 pandemic brought about unprecedented changes in healthcare, including strict physical distancing measures. Overnight, healthcare professionals found themselves dealing with biosecurity imperatives such as locked doors, restricted areas, and visitor restrictions [ 7 ]. While the interviewed nurses acknowledged the importance of these measures in preventing COVID-19 infections and the severity of the disease, they disagreed with the extent of visitor restrictions and the resulting isolation of patients from their families [ 41 ], they disagreed with the extent to which visitor restrictions and patients died alone [ 33 , 36 ]. Nurses became intermediaries between patients and their families, adding to the emotional burden they carried [ 36 , 42 ]. This challenging situation not only impacted the emotional well-being of nurses but also generated ethical and moral conflicts, as they questioned the imposed measures [ 11 , 12 , 36 , 43 , 44 , 45 , 46 ].

During the pandemic, nurses faced the dilemma of balancing their professional responsibilities and values. The principles of nonmaleficence (do no harm) and beneficence (doing good) were in tension, as nurses had to prioritize patient safety despite their own well-being [ 36 , 47 , 48 ]. The core duty of nursing practice is to provide care, restore health, alleviate suffering, and respect the rights of every patient [ 49 ]. However, in this exceptional situation, nurses found themselves torn between their caregiving duty to patients and the need to prioritize self-care. It is important to note that nurses’ duty of caregiving is not absolute and can become a dilemma when it conflicts with their personal beliefs [ 32 ]. According to the International Code of Ethics for Nurses [ 49 ], nurses also have a commitment to promote their own health and safety. In this study, perioperative nurses sought to strike a balance between their responsibilities to patients and their own rights, all within the unique circumstances of the pandemic.

Perhaps the most disruptive ethical issues were the conflicts between the right to decide (the principle of autonomy) and patient safety, as well as the conflicts between the principles of beneficence and nonmaleficence [ 36 , 47 , 50 ]. Nurses faced ethical questions regarding their stressful and exhausting working conditions, such as the lack of protective equipment, limited knowledge and experience with COVID-19, and scarce protocols for the pandemic [ 36 , 51 , 52 ]. In this context, several questions arose, such as how to protect the principle of autonomy, to what extent medical committees should weigh patients’ rights against the working conditions of healthcare workers, and how nurses can ensure their own and their family’s safety [ 8 , 39 , 40 , 53 ]. One of the key solutions to these dilemmas lies in creating safe working conditions, which is essential for providing safe care to patients and preventing moral distress or harm among nurses [ 54 , 55 , 56 ]. We acknowledge that contextual factors and evolving circumstances can significantly influence the experiences and ethical challenges faced by perioperative nurses.

The principle of justice also played a role in the ethical challenges faced by nurses. Nursing leaders had to divide nursing personnel into different teams, such as first-line and reserve nurses, to reduce the risk of contagion. This change in professional roles caused feelings of unfairness among nurses, as some perceived they had assumed more risk than others [ 17 , 18 ]. Nurse leaders must apply the principle of justice by ensuring fair distribution of burdens and implementing adequate rotation among nurses to balance assignments and workloads, thereby reducing negative feelings [ 57 , 58 , 59 , 60 ].

Nurses relied on teamwork and peer support resilience to navigate these moral breakdowns. Nurse managers and leaders should continue to promote teamwork, recognize and reward strong teams, and foster an ethical work environment [ 47 ]. Resilience is crucial in managing ethical challenges, and nurses need to learn to adapt to new situations as a team [ 61 , 62 ]. Some participants in the study found these experiences to be opportunities for personal and professional growth, while others contemplated leaving the profession. Prolonged exposure to moral breakdowns can lead to compassion fatigue, highlighting the need for professional resilience and strategies to cope with stressful environments [ 63 , 64 ].

The studies by Jia et al. (2021) and Hossain and Clatty (2021) offer valuable insights into the ethical challenges and self-care strategies among nurses during the pandemic, albeit not specifically focused on perioperative nursing. Nonetheless, the findings from these studies can still provide relevant perspectives and contribute to our understanding of the broader ethical landscape in healthcare settings during this unprecedented time [ 42 , 64 ].

This pandemic presents an opportunity to learn and improve healthcare practices by establishing evidence-based strategies. Nursing managers should prioritize an ethical work environment and implement strategies to enhance nurses’ well-being, morale, and personal and professional development [ 65 ]. Ethics education and training should be provided to create greater awareness of ethical considerations and promote the application of professional values in daily practice [ 66 ].

4.1. Limitations and Strengths

This study acknowledges several limitations that should be highlighted. Firstly, the research sample was obtained from a single hospital in Spain, limiting the findings’ generalizability. Caution should be exercised when applying the results to a broader population.

Secondly, the study was conducted shortly after the peak of COVID-19 infections, and intense personal and professional emotional experiences may have influenced the participants’ responses during that time. Although the nurses had resumed their regular practice, some of them might still be in the process of reflecting on and comprehending their experiences.

Additionally, the study solely employed qualitative methods, and including quantitative research could have enriched the obtained data. Future studies could consider adopting a mixed-method approach combining quantitative and qualitative components to provide a more comprehensive understanding of the subject.

Despite the mentioned limitations, an essential strength of this study is its distinction as one of the few studies that have explored perioperative nurses’ experiences during the initial wave of COVID-19.

4.2. Implications of Findings

The findings of this study have significant implications for nurses and healthcare professionals. By being aware of the moral breakdowns and ethical dilemmas that may arise in the clinical environment during critical periods like the COVID-19 pandemic, nurses can better understand their ethical role as healthcare providers and maintain an ethical perspective in their daily clinical practice. It is crucial to prioritize ethics education and training in workplaces, and further research should assess how these moral breakdowns and ethical dilemmas impact the quality of patient care. Future studies should focus on identifying moral breakdowns and ethical dilemmas experienced by nurses during critical periods, with the ultimate goal of improving the overall well-being of healthcare professionals.

5. Conclusions

In this study, we investigated how perioperative nurses in the first wave of COVID-19 coped with, perceived, and were impacted by moral and ethical challenges, commonly referred to as moral breakdowns, which are often inevitable and prevalent in critical settings. These challenges posed significant hurdles that had to be addressed. It became crucial to prioritize the well-being of nurses on both personal and professional levels while simultaneously striving to enhance patient care. The participants in the study relied on their own resourcefulness to navigate the complexities of moral and ethical dilemmas.

The study revealed that the nature and duration of the response, as well as the severity, frequency, and duration of morally challenging situations, were perceived as having a detrimental effect on both professional responsibility and well-being. Crucially, the support that proved most beneficial was primarily centered around team support, emphasizing the importance of collaboration and solidarity among colleagues. Furthermore, management support after deployment was considered valuable, particularly when it demonstrated a comprehensive understanding of the working conditions and the shared experiences of the nursing staff.

Moreover, being well-informed and adequately prepared to confront diverse moral and ethical challenges within a demanding work environment can significantly contribute to stress management and the prevention of moral breakdowns. It is important to acknowledge that these problematic experiences, while exacting a personal toll, also engendered positive outcomes such as personal and professional growth and a transformed worldview.

The findings of this study have implications for organizations in developing support structures for nurses and other healthcare professionals, both before, during, and after their deployment. By recognizing the unique challenges faced by nurses and providing targeted support, healthcare organizations can foster an environment that promotes the well-being and resilience of their workforce. This study serves as a valuable resource to inform and shape organizational strategies and interventions aimed at supporting nurses and healthcare professionals in navigating moral and ethical challenges throughout their careers.

Supplementary Materials

The following supporting information can be downloaded at https://www.mdpi.com/article/10.3390/healthcare11131937/s1 . CoreQ Checklist.

Funding Statement

This research received no external funding.

Author Contributions

Conceptualization, A.S.S., N.B. and C.A.V.d.W.; methodology, E.P., A.S.S., C.A.V.d.W. and E.M.-S.; software, M.G.P., C.A.V.d.W. and R.A.M.; validation, A.S.S., E.P. and M.G.P.; formal analysis, E.P., M.G.P. and A.S.S.; investigation, A.S.S., R.A.M. and N.B.; resources, E.I.C., R.A.M. and E.M.-S.; data curation, C.A.V.d.W., M.G.P. and A.S.S.; writing—original draft preparation, E.I.C. and R.A.M.; writing—review and editing, E.M.-S., E.I.C., E.P., N.B. and A.S.S.; supervision, E.M.-S., C.A.V.d.W. and A.S.S.; project administration, E.I.C. and R.A.M. All authors have read and agreed to the published version of the manuscript.

Institutional Review Board Statement

The study was conducted in accordance with the Declaration of Helsinki and approved by the Research Ethics Committee of Hospital Santa Creu i Sant Pau Barcelona (IIBSP-COV-2020-58).

Informed Consent Statement

Informed consent was obtained from all subjects involved in the study.

Data Availability Statement

Conflicts of interest.

The authors declare no conflict of interest.

Disclaimer/Publisher’s Note: The statements, opinions and data contained in all publications are solely those of the individual author(s) and contributor(s) and not of MDPI and/or the editor(s). MDPI and/or the editor(s) disclaim responsibility for any injury to people or property resulting from any ideas, methods, instructions or products referred to in the content.

Research Limitations & Delimitations

What they are and how they’re different (with examples)

By: Derek Jansen (MBA) | Expert Reviewed By: David Phair (PhD) | September 2022

If you’re new to the world of research, you’ve probably heard the terms “ research limitations ” and “ research delimitations ” being thrown around, often quite loosely. In this post, we’ll unpack what both of these mean, how they’re similar and how they’re different – so that you can write up these sections the right way.

Overview: Limitations vs Delimitations

• Are they the same?
• What are research limitations
• What are research delimitations
• Limitations vs delimitations

First things first…

Let’s start with the most important takeaway point of this post – research limitations and research delimitations are not the same – but they are related to each other (we’ll unpack that a little later). So, if you hear someone using these two words interchangeably, be sure to share this post with them!

Research Limitations

Research limitations are, at the simplest level, the weaknesses of the study, based on factors that are often outside of your control as the researcher. These factors could include things like time , access to funding, equipment , data or participants . For example, if you weren’t able to access a random sample of participants for your study and had to adopt a convenience sampling strategy instead, that would impact the generalizability of your findings and therefore reflect a limitation of your study.

Research limitations can also emerge from the research design itself . For example, if you were undertaking a correlational study, you wouldn’t be able to infer causality (since correlation doesn’t mean certain causation). Similarly, if you utilised online surveys to collect data from your participants, you naturally wouldn’t be able to get the same degree of rich data that you would from in-person interviews .

Simply put, research limitations reflect the shortcomings of a study , based on practical (or theoretical) constraints that the researcher faced. These shortcomings limit what you can conclude from a study, but at the same time, present a foundation for future research . Importantly, all research has limitations , so there’s no need to hide anything here – as long as you discuss how the limitations might affect your findings, it’s all good.

Research Delimitations

Alright, now that we’ve unpacked the limitations, let’s move on to the delimitations .

Research delimitations are similar to limitations in that they also “ limit ” the study, but their focus is entirely different. Specifically, the delimitations of a study refer to the scope of the research aims and research questions . In other words, delimitations reflect the choices you, as the researcher, intentionally make in terms of what you will and won’t try to achieve with your study. In other words, what your research aims and research questions will and won’t include.

As we’ve spoken about many times before, it’s important to have a tight, narrow focus for your research, so that you can dive deeply into your topic, apply your energy to one specific area and develop meaningful insights. If you have an overly broad scope or unfocused topic, your research will often pull in multiple, even opposing directions, and you’ll just land up with a muddy mess of findings .

So, the delimitations section is where you’ll clearly state what your research aims and research questions will focus on – and just as importantly, what they will exclude . For example, you might investigate a widespread phenomenon, but choose to focus your study on a specific age group, ethnicity or gender. Similarly, your study may focus exclusively on one country, city or even organization. As long as the scope is well justified (in other words, it represents a novel, valuable research topic), this is perfectly acceptable – in fact, it’s essential. Remember, focus is your friend.

Need a helping hand?

Conclusion: Limitations vs Delimitations

Ok, so let’s recap.

Research limitations and research delimitations are related in that they both refer to “limits” within a study. But, they are distinctly different. Limitations reflect the shortcomings of your study, based on practical or theoretical constraints that you faced.

Contrasted to that, delimitations reflect the choices that you made in terms of the focus and scope of your research aims and research questions. If you want to learn more about research aims and questions, you can check out this video post , where we unpack those concepts in detail.

Psst... there’s more!

This post was based on one of our popular Research Bootcamps . If you're working on a research project, you'll definitely want to check this out ...

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18 Comments

Good clarification of ideas on how a researcher ought to do during Process of choice

Thank you so much for this very simple but explicit explanation on limitation and delimitation. It has so helped me to develop my masters proposal. hope to recieve more from your site as time progresses

Thank you for this explanation – very clear.

Thanks for the explanation, really got it well.

This website is really helpful for my masters proposal

Thank you very much for helping to explain these two terms

I spent almost the whole day trying to figure out the differences

when I came across your notes everything became very clear

thanks for the clearly outlined explanation on the two terms, limitation and delimitation.

Very helpful Many thanks 🙏

Excellent it resolved my conflict .

I would like you to assist me please. If in my Research, I interviewed some participants and I submitted Questionnaires to other participants to answered to the questions, in the same organization, Is this a Qualitative methodology , a Quantitative Methodology or is it a Mixture Methodology I have used in my research? Please help me

How do I cite this article in APA format

Really so great ,finally have understood it’s difference now

Getting more clear regarding Limitations and Delimitation and concepts

I really appreciate your apt and precise explanation of the two concepts namely ; Limitations and Delimitations.

This is a good sources of research information for learners.

thank you for this, very helpful to researchers

Very good explained

Great and clear explanation, after a long confusion period on the two words, i can now explain to someone with ease.

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The limitations of the study are those characteristics of design or methodology that impacted or influenced the interpretation of the findings from your research. Study limitations are the constraints placed on the ability to generalize from the results, to further describe applications to practice, and/or related to the utility of findings that are the result of the ways in which you initially chose to design the study or the method used to establish internal and external validity or the result of unanticipated challenges that emerged during the study.

Price, James H. and Judy Murnan. “Research Limitations and the Necessity of Reporting Them.” American Journal of Health Education 35 (2004): 66-67; Theofanidis, Dimitrios and Antigoni Fountouki. "Limitations and Delimitations in the Research Process." Perioperative Nursing 7 (September-December 2018): 155-163. .

Importance of...

Always acknowledge a study's limitations. It is far better that you identify and acknowledge your study’s limitations than to have them pointed out by your professor and have your grade lowered because you appeared to have ignored them or didn't realize they existed.

Keep in mind that acknowledgment of a study's limitations is an opportunity to make suggestions for further research. If you do connect your study's limitations to suggestions for further research, be sure to explain the ways in which these unanswered questions may become more focused because of your study.

Acknowledgment of a study's limitations also provides you with opportunities to demonstrate that you have thought critically about the research problem, understood the relevant literature published about it, and correctly assessed the methods chosen for studying the problem. A key objective of the research process is not only discovering new knowledge but also to confront assumptions and explore what we don't know.

Claiming limitations is a subjective process because you must evaluate the impact of those limitations . Don't just list key weaknesses and the magnitude of a study's limitations. To do so diminishes the validity of your research because it leaves the reader wondering whether, or in what ways, limitation(s) in your study may have impacted the results and conclusions. Limitations require a critical, overall appraisal and interpretation of their impact. You should answer the question: do these problems with errors, methods, validity, etc. eventually matter and, if so, to what extent?

Price, James H. and Judy Murnan. “Research Limitations and the Necessity of Reporting Them.” American Journal of Health Education 35 (2004): 66-67; Structure: How to Structure the Research Limitations Section of Your Dissertation. Dissertations and Theses: An Online Textbook. Laerd.com.

Descriptions of Possible Limitations

All studies have limitations . However, it is important that you restrict your discussion to limitations related to the research problem under investigation. For example, if a meta-analysis of existing literature is not a stated purpose of your research, it should not be discussed as a limitation. Do not apologize for not addressing issues that you did not promise to investigate in the introduction of your paper.

Here are examples of limitations related to methodology and the research process you may need to describe and discuss how they possibly impacted your results. Note that descriptions of limitations should be stated in the past tense because they were discovered after you completed your research.

Possible Methodological Limitations

• Sample size -- the number of the units of analysis you use in your study is dictated by the type of research problem you are investigating. Note that, if your sample size is too small, it will be difficult to find significant relationships from the data, as statistical tests normally require a larger sample size to ensure a representative distribution of the population and to be considered representative of groups of people to whom results will be generalized or transferred. Note that sample size is generally less relevant in qualitative research if explained in the context of the research problem.
• Lack of available and/or reliable data -- a lack of data or of reliable data will likely require you to limit the scope of your analysis, the size of your sample, or it can be a significant obstacle in finding a trend and a meaningful relationship. You need to not only describe these limitations but provide cogent reasons why you believe data is missing or is unreliable. However, don’t just throw up your hands in frustration; use this as an opportunity to describe a need for future research based on designing a different method for gathering data.
• Lack of prior research studies on the topic -- citing prior research studies forms the basis of your literature review and helps lay a foundation for understanding the research problem you are investigating. Depending on the currency or scope of your research topic, there may be little, if any, prior research on your topic. Before assuming this to be true, though, consult with a librarian! In cases when a librarian has confirmed that there is little or no prior research, you may be required to develop an entirely new research typology [for example, using an exploratory rather than an explanatory research design ]. Note again that discovering a limitation can serve as an important opportunity to identify new gaps in the literature and to describe the need for further research.
• Measure used to collect the data -- sometimes it is the case that, after completing your interpretation of the findings, you discover that the way in which you gathered data inhibited your ability to conduct a thorough analysis of the results. For example, you regret not including a specific question in a survey that, in retrospect, could have helped address a particular issue that emerged later in the study. Acknowledge the deficiency by stating a need for future researchers to revise the specific method for gathering data.
• Self-reported data -- whether you are relying on pre-existing data or you are conducting a qualitative research study and gathering the data yourself, self-reported data is limited by the fact that it rarely can be independently verified. In other words, you have to the accuracy of what people say, whether in interviews, focus groups, or on questionnaires, at face value. However, self-reported data can contain several potential sources of bias that you should be alert to and note as limitations. These biases become apparent if they are incongruent with data from other sources. These are: (1) selective memory [remembering or not remembering experiences or events that occurred at some point in the past]; (2) telescoping [recalling events that occurred at one time as if they occurred at another time]; (3) attribution [the act of attributing positive events and outcomes to one's own agency, but attributing negative events and outcomes to external forces]; and, (4) exaggeration [the act of representing outcomes or embellishing events as more significant than is actually suggested from other data].

Possible Limitations of the Researcher

• Access -- if your study depends on having access to people, organizations, data, or documents and, for whatever reason, access is denied or limited in some way, the reasons for this needs to be described. Also, include an explanation why being denied or limited access did not prevent you from following through on your study.
• Longitudinal effects -- unlike your professor, who can literally devote years [even a lifetime] to studying a single topic, the time available to investigate a research problem and to measure change or stability over time is constrained by the due date of your assignment. Be sure to choose a research problem that does not require an excessive amount of time to complete the literature review, apply the methodology, and gather and interpret the results. If you're unsure whether you can complete your research within the confines of the assignment's due date, talk to your professor.
• Cultural and other type of bias -- we all have biases, whether we are conscience of them or not. Bias is when a person, place, event, or thing is viewed or shown in a consistently inaccurate way. Bias is usually negative, though one can have a positive bias as well, especially if that bias reflects your reliance on research that only support your hypothesis. When proof-reading your paper, be especially critical in reviewing how you have stated a problem, selected the data to be studied, what may have been omitted, the manner in which you have ordered events, people, or places, how you have chosen to represent a person, place, or thing, to name a phenomenon, or to use possible words with a positive or negative connotation. NOTE :   If you detect bias in prior research, it must be acknowledged and you should explain what measures were taken to avoid perpetuating that bias. For example, if a previous study only used boys to examine how music education supports effective math skills, describe how your research expands the study to include girls.
• Fluency in a language -- if your research focuses , for example, on measuring the perceived value of after-school tutoring among Mexican-American ESL [English as a Second Language] students and you are not fluent in Spanish, you are limited in being able to read and interpret Spanish language research studies on the topic or to speak with these students in their primary language. This deficiency should be acknowledged.

Aguinis, Hermam and Jeffrey R. Edwards. “Methodological Wishes for the Next Decade and How to Make Wishes Come True.” Journal of Management Studies 51 (January 2014): 143-174; Brutus, Stéphane et al. "Self-Reported Limitations and Future Directions in Scholarly Reports: Analysis and Recommendations." Journal of Management 39 (January 2013): 48-75; Senunyeme, Emmanuel K. Business Research Methods. Powerpoint Presentation. Regent University of Science and Technology; ter Riet, Gerben et al. “All That Glitters Isn't Gold: A Survey on Acknowledgment of Limitations in Biomedical Studies.” PLOS One 8 (November 2013): 1-6.

Structure and Writing Style

Information about the limitations of your study are generally placed either at the beginning of the discussion section of your paper so the reader knows and understands the limitations before reading the rest of your analysis of the findings, or, the limitations are outlined at the conclusion of the discussion section as an acknowledgement of the need for further study. Statements about a study's limitations should not be buried in the body [middle] of the discussion section unless a limitation is specific to something covered in that part of the paper. If this is the case, though, the limitation should be reiterated at the conclusion of the section.

If you determine that your study is seriously flawed due to important limitations , such as, an inability to acquire critical data, consider reframing it as an exploratory study intended to lay the groundwork for a more complete research study in the future. Be sure, though, to specifically explain the ways that these flaws can be successfully overcome in a new study.

But, do not use this as an excuse for not developing a thorough research paper! Review the tab in this guide for developing a research topic . If serious limitations exist, it generally indicates a likelihood that your research problem is too narrowly defined or that the issue or event under study is too recent and, thus, very little research has been written about it. If serious limitations do emerge, consult with your professor about possible ways to overcome them or how to revise your study.

When discussing the limitations of your research, be sure to:

• Describe each limitation in detailed but concise terms;
• Explain why each limitation exists;
• Provide the reasons why each limitation could not be overcome using the method(s) chosen to acquire or gather the data [cite to other studies that had similar problems when possible];
• Assess the impact of each limitation in relation to the overall findings and conclusions of your study; and,
• If appropriate, describe how these limitations could point to the need for further research.

Remember that the method you chose may be the source of a significant limitation that has emerged during your interpretation of the results [for example, you didn't interview a group of people that you later wish you had]. If this is the case, don't panic. Acknowledge it, and explain how applying a different or more robust methodology might address the research problem more effectively in a future study. A underlying goal of scholarly research is not only to show what works, but to demonstrate what doesn't work or what needs further clarification.

Aguinis, Hermam and Jeffrey R. Edwards. “Methodological Wishes for the Next Decade and How to Make Wishes Come True.” Journal of Management Studies 51 (January 2014): 143-174; Brutus, Stéphane et al. "Self-Reported Limitations and Future Directions in Scholarly Reports: Analysis and Recommendations." Journal of Management 39 (January 2013): 48-75; Ioannidis, John P.A. "Limitations are not Properly Acknowledged in the Scientific Literature." Journal of Clinical Epidemiology 60 (2007): 324-329; Pasek, Josh. Writing the Empirical Social Science Research Paper: A Guide for the Perplexed. January 24, 2012. Academia.edu; Structure: How to Structure the Research Limitations Section of Your Dissertation. Dissertations and Theses: An Online Textbook. Laerd.com; What Is an Academic Paper? Institute for Writing Rhetoric. Dartmouth College; Writing the Experimental Report: Methods, Results, and Discussion. The Writing Lab and The OWL. Purdue University.

Writing Tip

Don't Inflate the Importance of Your Findings!

After all the hard work and long hours devoted to writing your research paper, it is easy to get carried away with attributing unwarranted importance to what you’ve done. We all want our academic work to be viewed as excellent and worthy of a good grade, but it is important that you understand and openly acknowledge the limitations of your study. Inflating the importance of your study's findings could be perceived by your readers as an attempt hide its flaws or encourage a biased interpretation of the results. A small measure of humility goes a long way!

Another Writing Tip

Negative Results are Not a Limitation!

Negative evidence refers to findings that unexpectedly challenge rather than support your hypothesis. If you didn't get the results you anticipated, it may mean your hypothesis was incorrect and needs to be reformulated. Or, perhaps you have stumbled onto something unexpected that warrants further study. Moreover, the absence of an effect may be very telling in many situations, particularly in experimental research designs. In any case, your results may very well be of importance to others even though they did not support your hypothesis. Do not fall into the trap of thinking that results contrary to what you expected is a limitation to your study. If you carried out the research well, they are simply your results and only require additional interpretation.

Lewis, George H. and Jonathan F. Lewis. “The Dog in the Night-Time: Negative Evidence in Social Research.” The British Journal of Sociology 31 (December 1980): 544-558.

Yet Another Writing Tip

Sample Size Limitations in Qualitative Research

Sample sizes are typically smaller in qualitative research because, as the study goes on, acquiring more data does not necessarily lead to more information. This is because one occurrence of a piece of data, or a code, is all that is necessary to ensure that it becomes part of the analysis framework. However, it remains true that sample sizes that are too small cannot adequately support claims of having achieved valid conclusions and sample sizes that are too large do not permit the deep, naturalistic, and inductive analysis that defines qualitative inquiry. Determining adequate sample size in qualitative research is ultimately a matter of judgment and experience in evaluating the quality of the information collected against the uses to which it will be applied and the particular research method and purposeful sampling strategy employed. If the sample size is found to be a limitation, it may reflect your judgment about the methodological technique chosen [e.g., single life history study versus focus group interviews] rather than the number of respondents used.

Boddy, Clive Roland. "Sample Size for Qualitative Research." Qualitative Market Research: An International Journal 19 (2016): 426-432; Huberman, A. Michael and Matthew B. Miles. "Data Management and Analysis Methods." In Handbook of Qualitative Research . Norman K. Denzin and Yvonna S. Lincoln, eds. (Thousand Oaks, CA: Sage, 1994), pp. 428-444; Blaikie, Norman. "Confounding Issues Related to Determining Sample Size in Qualitative Research." International Journal of Social Research Methodology 21 (2018): 635-641; Oppong, Steward Harrison. "The Problem of Sampling in qualitative Research." Asian Journal of Management Sciences and Education 2 (2013): 202-210.

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Research nurse and nurse researcher: differences and similarities

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• Vol. 7 No. 4 (2021): Volume 7 Issue 4 October - December 2021

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