Lost in transition: Entry to operating room nursing

The main objective of this study is to explore the interplay between agency and structure shaping entry to operating room (OR) nurse in Australia. Becoming an OR nurse can be challenging. It can require overcoming barriers to employment, adapting to hands-on learning in a high stakes environment, and pursuing further education. The shortage of experienced nurses further complicates this situation by increasing the general demand for nurses while restricting opportunities for newcomers.
The application of critical realism in this study allowed for the construction of knowledge and theorising about possible structures and mechanisms involved in entry to OR nursing. The study aimed to move beyond surface-level descriptions and to instead investigate the underlying factors that shape the experiences of nurses entering the OR nursing specialty. The ultimate goal was to provide a comprehensive understanding of the complexities involved in becoming an OR nurse and to generate insights and recommendations for policy and practice within the nursing workforce.
The study focuses on understanding how entry to OR nursing is represented in policy, exploring whether nurses share common experiences as newcomers, and proposing actionable knowledge based on the findings. The research uncovers the structural factors that shape these experiences, including policies, norms, and power dynamics, using a critical realist theoretic framework. The study specifically focuses on the roles of scrub and circulating nurses, in this study collectively called ‘OR nurses’.
Three research questions were employed to achieve these aims:
1. How is entry to OR nursing represented in policy?
2. Do newcomers have any common experience in entry to OR nursing?
3. What actionable knowledge can be proposed for entry to OR nursing?
To achieve the study's aims, a critical realism-informed explanatory mixed methods research design is used. In answering the first research question, the theoretical concept of problematization was employed implementing Bacchi’s WPR approach to analyse relevant policy documents available in Australia. Then, explanatory concurrent triangulation mixed methods and retroduction informed by critical realism were utilised to attain a complete understanding of the reality of entry to OR nursing. The data related to the Australian OR nurses' perspectives were collected through an online survey in which 228 OR nurses from a graduate perioperative nursing subject participated.
The analysis of the available entry to OR nursing policies established that there is limited governance of entry to OR nursing or guidance about teaching and learning. Formal qualifications in perioperative nursing are ambiguously depicted in policy as optional self-directed learning but necessary for specialisation. From an exploratory factor analysis of the survey data obtained from OR nurses, two primary constructs emerged: ‘Legitimate learners’, which represented learner-centred experiences during entry to OR nursing, and; ‘Useful bodies’, signifying task-focused and operationally constrained learning experiences. These results indicate that the conditions of workplace learning significantly influence the transition into OR nursing. The thematic analysis of responses to open-ended question yielded three primary themes: ‘Can't see/be’, ‘Beginner's luck’, and ‘Thrown in’. The findings centred on the pre-entry visibility of OR nursing as a viable career choice, barriers to gaining entry, and post-entry learning challenges.
Generative mechanisms were identified through retroductive theorising, including policy framing, situated vulnerability, and system bottlenecks. These mechanisms were theoretically supported by bounded rationality, managerialism, situated learning theory, spatial theory, the theory of constraints, and social discontinuity theory. The integrated findings led to an overarching meta-inference, proposing power asymmetry as a valid inference, with 'power over' dominant in shaping entry to OR nursing. Within this context, three forms of power were identified: institutional gatekeeping, episodic inclusion, and ontological insecurity.
Finally, the third research question was addressed by determining the actionable knowledge arising from the findings related to the challenges and complexities of entry to OR nursing in Australia. The findings of this study inform several recommendations, including the need for further research into pedagogical content knowledge for OR nursing entry and an exploration of the potential benefits of occupational closure for the specialty. In conclusion, the study highlights the importance of addressing broader structural and power-related issues to enable emancipatory changes in entry to OR nursing.