Elsevier

Social Science & Medicine

Volume 62, Issue 6, March 2006, Pages 1541-1551
Social Science & Medicine

Governance in operating room nursing: Nurses’ knowledge of individual surgeons

https://doi.org/10.1016/j.socscimed.2005.08.007Get rights and content

Abstract

This paper explores governance and control in operating room nurses’ clinical practice. Traditionally, operating room nurses have been portrayed as “handmaidens” to the surgeons, a position which implies that nurses’ bodies and the knowledge they use in practice are sites of discursive control by others. This paper unsettles this understanding by showing how operating room nurses studied ethnographically in an Australian setting are both disciplined by and actively shape practice through knowing surgeons’ technical requirements for surgery, through inscribing them in discourses of time, and through having deep knowledge of the surgeons’ “soul”. We argue that as a form of governance, nurses’ knowledge of surgeons is a subjugated form of knowledge, located low down on a hierarchy of knowledges. Furthermore, as a form of governance that has previously been unarticulated in the literature, it transcends the traditional lines of authority and control in the nurse–doctor relationship. The data in this paper are drawn from an ethnographic study that explored a range of nurse–nurse and nurse–doctor communication practices in operating room nursing.

Introduction

This paper can be seen as a search for a productive understanding of operating room nursing, one in which nurses are attributed with some degree of responsibility for the governance and control of their practice. The impetus for this paper stems from the idea that ambiguity surrounds operating room nursing. On the one hand, operating room nursing is perceived as glamorous and attractive because of the close association nurses have with surgeons, the appeal of teamwork and the highly technical work (Happell, 2000). Yet, on the other hand, operating room nursing is devalued and alienated from the wider profession because of nurses’ perceived subservience to surgeons where nurses are often conceptualised as handmaidens (Gruendemann, 1970, p. 349). While there is an increasing body of knowledge about social relationships in operating rooms (Fox (1992), Fox (1997); Moreira, 2004; Riley & Manias, 2005; Tanner & Timmons, 2000; Timmons & Tanner, 2004; Walker & Adam, 2001; Walby, Greenwell, MacKay, & Soothill, 1994), very little evidence provides insight to the subjectivity of operating room nurses or technologies of power that shape their practice. As a consequence, we asked the question: How is operating room nursing practice constructed and governed in the clinical setting?

To begin this exploration into the governance of operating room nursing we provide some background about the social positioning of this specialty area of practice, both within nursing and in the broader public domain. Next, we provide details of the theoretical and methodological approaches used in this study. Segments of data are drawn from a larger ethnographic study investigating communication processes and practices to illustrate different technologies of governance. We argue that while nurses are subjected to the disciplinary power of surgeons, nurses come to use their knowledge of them, gained through their close association, to govern and shape practice in operating rooms.

Section snippets

Background

The image of nurses as handmaidens to doctors, or what Sandelowski (2000, p. 116), has called the “third hand” (p. 116) is one that has applied across nursing as a whole. References to it are easily identified in contemporary literature (Berg, 1996; Brown & Crawford, 2003; Lupton, 1995; Sigurosson, 2001; Sweet & Norman, 1995). However, while it has been proposed that nursing in general outgrew the handmaiden image in the 1970s, it has remained a dominant perception about operating room nursing (

Methods

A postmodern ethnography, informed by the work of Michel Foucault (1977), Foucault (1978), Foucault (1979), Foucault (1980), Foucault (1980), Foucault (1981), was undertaken. Data were collected from three different clinical departments and ethics approval was gained from each hospital, in accordance with national guidelines in Australia (NH&MRC, 1999). The three operating room departments were originally thought to represent a cross-section of institutional settings. However, in reality,

Results

It is a major contention of this paper that operating room practice is shaped and governed by nurses’ personal knowledge of individual surgeons. Concentrating mostly on data examining the role of instrument and circulating nurses, we identified three different ways in which nurses used their knowledge of surgeons to govern practice. Nurses had technical knowledge of surgeons’ needs for surgery, they inscribed them in discourses of time, and borrowing a term used by Brown and Crawford (2003),

Discussion: historical subjugation of closeness to surgeons

As we have already suggested, nurses play an integral role in the conduct of surgery, in which the handing instruments to surgeons is merely one part, albeit an important part that allows the surgeon to “temporarily [give] some control over his body to the socio-technical apparatus of surgery” (Moreira, 2004, p. 126). The act of surgery would be extremely difficult without the assistance of a skilled and dextrous nurse. We argue not so much that nurses are not handmaidens to surgeons, as the

Conclusion

This study adds another dimension to nurses’ repertoire of knowledge. The different forms of knowledge previously elaborated by nursing scholars (Carper, 1978; Jacobs-Kramer & Chinn, 1988; Liaschenko & Fisher, 1999; White, 1995) have focused predominantly on nurses’ personal knowledge of patients. Furthermore, until recent years, the ways of knowing in nursing have tended to concentrate on theoretical argument to the relative exclusion of studies that have demonstrated the social construction

Acknowledgements

This research was undertaken with the support of a Melbourne Research Scholarship.

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