problem statement of research in medical surgical nursing

Research in Medical-Surgical Nursing

Affiliation.

1 1 Department of Nursing, Faculty of Nursing and Podiatry, University of Valencia, Valencia, Spain.
PMID: 28198197
DOI: 10.1177/1099800416684586

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Research in Medical–Surgical Nursing

2017, Biological Research For Nursing

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Registered nurses' perceptions of their roles in medical‐surgical units: A qualitative study

1 Nursing Science Department, Université du Québec en Outaouais, Gatineau Quebec, Canada

Isabelle St‐Pierre

Denise pangop.

2 Agente de Planification, de Programmation et de Recherche, Centre Intégré de Santé et de Services Sociaux de l'Outaouais, Gatineau Quebec, Canada

Associated Data

Data available on request due to privacy/ethical restrictions

The aim of this study was to gain insight into the perception of nurses about their roles in medical‐surgical units.

As a result of ever‐changing work environments, medical‐surgical nurses find it difficult to know and practice according to the full scope of their roles.

A qualitative descriptive study.

Semi‐structured individual interviews were conducted with 21 nurses on three campuses of a large tertiary care hospital located in Quebec, Canada. Thematic analysis was used to construe meaning from the interviews. This research adheres to the Standards for Reporting Qualitative Research guidelines and checklist.

The data analysis resulted in three main themes: (i) confusion in nurses' roles and scope of practice; (ii) challenges in the continuity of care and (iii) factors affecting the roles of nurses in medical‐surgical units.

Attention must be paid to the care continuum as it represents a critical element for surgical patients' quality and safety of care.

Relevance to clinical practice

Medical‐surgical nurses should understand their roles and the factors that limit their full scope of practice in order to provide and manage complex care situations. Additionally, an interdisciplinary approach is a strategy that may better respond to patients' clinical needs across the surgical journey.

1. INTRODUCTION

The past several years have seen many changes that have resulted in increased complexity of care such as reductions in the length of hospital stays, increased reliance on healthcare technology and increased patient acuity (Tonelli et al., 2018 ). Additionally, the worsening working conditions found in hospitals as a result of staff shortages, nurse turnover and high nurse‐to‐patient ratios are impeding the ability of nurses to provide quality care (Copanitsanou et al., 2017 ; Phillips, 2020 ). For example, the high acuity of care required of nurses to take care of surgical patients has resulted in them questioning the very nature of their roles. Little research was found describing the roles of medical‐surgical nurses, which serves to justify the current study.

2. BACKGROUND

Registered nurses are essential healthcare providers on adult medical‐surgical units, which include pre‐operative (e.g. pre‐admission) and postoperative units where care is provided (Academy of medical‐surgical nurses, 2021 ; Aiken et al., 2014 ). In 2020–2021, there were 304,558 registered nurses licensed to practice in Canada and 80,491 licensed to practice in Quebec. Half of those working in general and specialty care, which includes medical‐surgical units where they play a critical role in the provision and coordination of complex care (Canadian Institute for Health Information, 2020 ; Ordre des infirmières et infirmiers du Québec, 2021 ). Nurses' roles are defined as pre‐established expectations in helping individuals, families and groups identify and realize their full physical, mental and social potential based on the requirements acquired through their professional education. Nurses are trained to meet patients' healthcare needs by using current nursing knowledge and skills to improve the delivery of care (White et al., 2008 ). The Canadian Nurses Association recognized nine roles of the registered nurse required to give competent, safe, ethical, compassionate and evidence‐informed nursing care in any practice setting. These are as follows: clinical, professional, collaboration, communication, coordination, advocacy, leader, educator and scholar roles (Almost, 2021 ). However, it has become increasingly difficult for nurses to understand and articulate their roles, given the ever increasing complexity of care and the unprecedented changes to healthcare service delivery models resulting in many facets of the clinical nursing practice to undergo significant changes (Huber et al., 2021 ; Kentischer et al., 2018 ). Sahakyan et al. ( 2020 ) highlighted the importance of nurses understanding their own roles in order to improve processes of care, patients' outcomes and work within their scope of practice (Kieft et al., 2014 ), which reflects the full range of activities, responsibilities and functions, that registered nurses are educated, competent and authorized to perform (White et al., 2008 ). Since they can either support or hinder practice development, it is important to give opportunities for nurses to develop their professional roles.

Several studies have explored the roles of nurses in different contexts. Intensive Care Unit (ICU) : In a literature review of 20 articles, Noome et al. ( 2016 ) noted that while ICU nurses had a critical role during end‐of‐life care, their exact roles pertaining to the interaction between patients, family and nurses remained unknown, unclear and ambiguous. They concluded that developing clear roles for ICU nurses may be helpful in preventing anxiety, stress and depression in patients and family members. Palliative care : In the context of palliative care, Johansen and Helgesen ( 2021 ) found that nurses played an important role in hospitals and community palliative care in facilitating reflection and collaboration in the palliative care team, promoting high‐quality palliative care and contributing to ethical awareness about end‐of‐life issues. Moreover, by sharing their knowledge and experience and being role models, nurses working in palliative care reinforced their colleagues' confidence and skills in palliative care and contributed to a shared view of the quality of care. Similarly, Sekse et al. ( 2018 ) conducted a qualitative meta‐synthesis of 28 articles to explore how nurses describe their roles in palliative care. They stated that it was difficult to precisely define those roles because nurses' work is complex, partly invisible and taken for granted. They also found that the nurse's roles are integrated into all dimensions of care: practical, relational and moral, which makes it even more important for nurses to clarify their roles. Primary health care . In primary health care, Halcomb et al. ( 2020 ) found that despite nurses having clear roles in infection prevention and control where they support people in the community to maintain health through education around infection control, key supports such as additional staffing and standardized care protocols were required to optimize their roles in the follow‐up of chronic diseases and mostly during health crises such as pandemics (e.g. COVID‐19).

2.1. Perioperative care

Studies have also explored the roles of nurses during perioperative care. For example, an Australian study by Iddrisu et al. ( 2018 ) found that nurses felt confident about their clinical assessment skills and monitoring but had a limited understanding of their role in recognizing and responding to clinical deterioration in surgical patients. According to Di Santo ( 2019 ), cognitive deterioration is common in perioperative settings, and the roles of nurses to recognize and act on it are of great importance and should be emphasized. For example, during pre‐ and postoperative periods, nurses have to intervene by managing stressors that can trigger symptoms and assess for predisposing factors and types of surgery to evaluate the risk of developing cognitive changes. In a study on the role of nurses in orthopaedic surgery, Copanitsanou and Santy‐Tomlinson ( 2021 ) highlighted the importance for nurses to understand how to accurately carry out their role effectively as part of surgical wound infection care and surveillance during the ambulatory/outpatient, pre‐operative, perioperative, postoperative and postdischarge care. Early recognition and diagnosis of surgical wound infection is part of the process of wound monitoring and healing and is central to the prompt treatment of wounds. Ielapi et al. ( 2020 ) found similar results with respect to the roles of vascular surgery nurses. They noted their pivotal role in optimizing patients' clinical outcomes by providing skilled and advanced care to reduce possible adverse events such as postoperative myocardial infarction or vascular access complication rate. Several studies also explored the roles of nurses in surgical units during the implementation of enhanced recovery after surgery (ERAS) protocols – a multimodal, multidisciplinary programme that aims to limit surgical stress during the perioperative period. Pignot ( 2019 ) highlighted that nurses in medical‐surgical units using ERAS protocols had several major roles to play such as reducing the consequences of surgical stress by focusing on core aspects of surgical recovery to accelerate patient recovery times; ensuring the coordination of care amidst the various healthcare professionals; planning and preparing discharge and supporting patients in regaining their autonomy.

2.2. Three categories of nursing roles

As part of the Nursing Role Effectiveness Model , Doran et al. ( 2002 ) classified the nursing role as independent, dependant and interdependent. The independent nursing role pertains to the role functions for which nurses are held accountable. It includes the activities of patient assessment, decision‐making, intervention and follow‐up activities (e.g. assessment of patients' physical and mental condition and patient positioning). Nurses' dependent role includes the functions and responsibilities associated with implementing medical orders and treatments (e.g. performing and adjusting medical treatments as prescribed). Nurses' interdependent role relates to the functions and responsibilities that are partially or totally contingent on other healthcare providers (e.g. mobilization exercises). This classification was used in the current study.

Given their multiple interactions with other healthcare professionals as part of a multidisciplinary team and with patients and their families, the need to better understand medical‐surgical nurses' perceptions of their roles is crucial. The aim of this study was therefore to explore the perception of nurses about their roles in medical‐surgical units. The two research questions were as follows: (i) How do nurses describe and perceive their role as caregivers in medical‐surgical units? (ii) What are the factors that influence the roles of nurses in these units?

3.1. Design

A qualitative descriptive methodology was used in this study. According to Miles et al. ( 2020 ), qualitative data “are a source of well‐grounded, rich descriptions and explanations of processes in identifiable local contexts. With qualitative data, one can preserve chronological flow, see precisely which events lead to which consequences, and derive fruitful explanations.” (p. 3) Qualitative descriptive studies offer a straightforward descriptive summary of the data in everyday language and are characterized by lower levels of interpretation (Colorafi & Evans, 2016 ). The Standards for Reporting Qualitative Research was chosen for this study.

3.2. Data collection and analysis

3.2.1. recruitment.

A total of 21 nurses from three campuses took part in the study: HH ( n = 10), HG ( n = 5) and HP ( n = 6). Participants were nurses working on medical‐surgical units including pre‐admission and postoperative units. More specifically, four nurses worked in pre‐operative care (pre‐admission clinics) where patients are referred prior to surgery to help them prepare for the procedure, and 17 worked in postoperative units where patients are recovering following a surgical procedure (postoperative care). Participants were between 25 and 60 years of age. Nineteen were women and two were men. They averaged 14 years of experience in the nursing profession. The majority of participants had completed their undergraduate nursing education and were employed full‐time.

Participants were recruited using a number of strategies: (i) distribution of recruitment fliers on the three campuses; (ii) meetings with medical‐surgical unit managers to inform them about the study and ask them to promote it to the nursing staff and (iii) five visits by the main researcher to the medical‐surgical units to inform nurses about the research and invite them to participate. Sampling included convenience and snowball sampling to increase the sample size. Participants were eligible to participate in the study if they were registered nurses, able to speak French and working in a medical‐surgical unit on one of three campuses.

3.2.2. Data collection

Data collection was between April 2019 and March 2020 when data saturation was achieved. One‐on‐one semi‐structured interviews were conducted at a place and time that was convenient for participants. The interview guide consisted of eight to nine open‐ended questions (Table 1 ). Following each interview, field notes and reflective memos were written to allow the researcher to reflect on the interview process and whether some interview questions should be added or modified before the next one. Interviews lasted between 30 min and 1 hr and were digitally recorded and later transcribed. Audio files and transcripts were then stored securely on the main researcher's password‐protected computer.

Summary of interview questions

3.2.3. Data analysis

A three‐step qualitative thematic analysis as described by Sundler et al. ( 2019 ) was used in this study. The first step required the researchers to independently read the transcripts several times with an open mind to become familiar with the data and its meanings. The second step consisted of moving back and forth in the text to search for meanings and themes about nurses' perceptions of their roles. Researchers searched for patterns by relating meanings to each other. Memos and notes were written in the margins to identify emerging themes which were then compared among researchers to test reliability and to avoid relying on the subjective judgements and interpretations of one researcher. This step was to understand the essence of meanings. As part of the third step, results were written and rewritten to achieve meaningful wholeness and to further consolidate themes. The themes and subthemes were then discussed and compared between researchers to bring to light similarities and differences. When there was disagreement, the discrepancies were discussed and themes were renamed, merged or deleted.

Three main themes were identified from the analysis; confusion in nurses' roles and scope of practice, challenges in the continuity of care and factors affecting the roles of medical‐surgical nurses (Table 2 ). The following sections explore each of the themes in more detail.

Summary of themes and subthemes

4.1. Confusion in nurses' roles and scope of practice

This first theme pertains to the inability of nurses to explain the role they play beyond the completion of clinical tasks or the contribution [added value] they bring to the medical‐surgical units. Postoperative nurses struggled to articulate the independent, dependent and interdependent roles they play in these units. They stated that learning about their roles predominantly occurred as part of their initial training to become nurses, and more specifically, during their clinical placements while observing other nurses and realizing what was expected of them. They perceived their roles as very broad, as a series of tasks that needed to be performed on a daily basis to prevent postoperative complications. They identified the clinical assessment of patients as the main focus of their roles. “Assessment is the core of nursing in the sense that it's not something you're going to ask a nursing assistant to do” (Participant 12). Postoperative participants reported that they regularly had to perform non‐nursing tasks or tasks for which they did not have the experience or skills to perform, potentially having an impact on the quality of care and patient safety.

It's hard to explain my role… in this medical‐surgical unit my role is much more on the floor. I do a lot of dressings, I mobilize patients, I do lifts, panty changes, hygienic care, and everything… In addition, we sometimes play the role of stretcher bearer. These do not necessarily fit into the role of the clinical nurse. So, there can be impacts on patients. (Participant 7) [free translation].

Postoperative participants said concerns about management viewing nurses as “a nurse is a nurse is a nurse” rather than valuing specific clinical expertise, thus preventing nurses from working to their full scope of practice.

Every nurse has a little more of a specialty, except that the way the work is distributed here, people do not work according to their expertise because we have to go to all the medical‐surgical units. Therefore, people's potential is not optimally exploited. (…) In fact, they ask people to be really versatile. I do not see that as an advantage. They do. It's certain that the unit manager wants us to be versatile so that she can move us to her liking. I think that we cannot be good at everything…You only have to be good in a few places because people develop an expertise, and at some point, if you do not allow them to develop an expertise, people become less involved. (…) If someone is more dedicated to a specialty, he will be more involved. Someone who goes around everywhere takes less ownership of his role. (Participant 19) [free translation].

In terms of the perception of the nurses' independent roles, the data showed that postoperative nurses were aware that they could practice independently by performing tasks that could be undertaken without physicians' orders. They described exercising their autonomy [independent roles] when performing specific nursing activities such as patients' assessment and education, clinical judgement, surveillance and clinical follow‐up 24 hr a day.

In the case of a patient who has a bowel obstruction with a nasogastric tube, for example, if I see the blood in the suction tubing, I'm not going to wait for the physician, I will stop it right away. I do not need the physician's prescription to stop it. (…) I'm not going to call the doctor for everything. I will always make my clinical judgement first and […] I will say [to the doctor] here's what I've done, do you want us to continue or not. I do not take the place of a doctor, but I think I give my opinion because I am closer to the patient than the doctor. There are things that I see that he cannot see. There are things I know that he does not. Most of the time we are the ones who give the information to the doctors. (Participant 11) [free translation].

In some instances, the ability to enact their independent roles will depend on the surgical specialty. In postoperative units where there are standardized protocols, clinical pathways, evidence‐based interdisciplinary care and management plans, the nurses know exactly which interventions to do and when:

In this orthopaedic surgical unit, everything is performed according to the protocols and clinical pathways. But, the assessment of the patient is autonomous and in terms of teaching before discharge, it is certain that each surgeon has his own specificities that he wants the patient to receive as information, but teaching the patient is also … [part of the] autonomous role of the nurse. (Participant 19) [free translation].

A few participants working on postoperative units described the challenges associated with exercising their independent roles. For example, novice nurses, those with less experience in assessing, teaching or using clinical judgement – elements they are still developing and have not mastered well yet – reported feeling less confident and less competent. They were aware of the increased responsibilities that come with experience and the need to keep acquiring knowledge and skills to practice more independently. The ability to refer to experienced nurses when in doubt was considered vital to playing their independent roles. Because experienced nurses can easily rely on their skills and clinical judgement, they can assist novice nurses in understanding the nurses' roles and what needs to be done:

You know, sometimes you do not know what the problem is or what you should do, but you know that the experienced nurse right away she's going to assess the patient. She will say: Ah! I'm sure that's what's going on, we'll call the doctor or it's normal in this patient's situation. They act very much as a referral tool. But, of course, when you have less experience you can miss things, or you did not see that there was a problem […]. Sometimes you can even create problems when in fact there were not any. (Participant 1) [free translation].

As for their dependent roles, participants acknowledged that depending on their inpatient postoperative units, the nurse's roles could truly be dependent on the physician. They commented on the lack of confidence and self‐doubt experienced by some nurses when faced with physicians' prescriptions. For example, poorly written medical orders or those containing errors, time wasted locating a physician to have a prescription ordered or renewed and a basic lack of communication all impacted the dependent roles of the nurse. Participants expressed the importance of questioning physicians' prescriptions and using their clinical judgement before delivering “prescribed” care.

I think that many nurses unfortunately apply, execute without questioning… to be relegated to just taking vitals signs and giving medications is very reductive for nurses. […] Sometimes we are obliged to follow medical prescriptions even if we can be personally in conflict… or have an internal conflict by saying well I do not really understand why this medication has been prescribed. The first thing to do is to discuss it with the doctor if you have the opportunity. […] It proves that there is a reflection behind it [execution of the task] rather than to do it stupidly without questioning. (Participant 12) [free translation].

In terms of their interdependent roles, some nurses working in postoperative units viewed the enactment of these roles as part of interprofessional collaboration and as having mostly positive implications for patients. They recognized that they play a pivotal role in facilitating referrals and as a liaison among the many disciplines to ensure continuity of care. Together with physiotherapists, occupational therapists, social workers and physicians, they are able to give holistic and safe patient care. Other participants considered this collaboration to be indirect since the head nurse, and not the frontline nurse, is usually the one who is made aware of these multidisciplinary interventions:

Is the collaboration with other professionals going well? I would say yes and no. In my unit, I find that we do not have much of a relationship with the physiotherapists, occupational therapists, etc. It's more with the head nurse that they'll talk… it's very rare that I get feedback from them. Sometimes I find that I'm missing information. I'd like to know what they are going to do because the patients are mine too. So, I wait until they are done to go read their notes. (Participant 21) [free translation].

According to some participants, nurses' heavy workloads do not allow them to take the time to discuss with other professionals about a patient's health status. Nurses working in postoperative units also noted that collaboration with physicians can sometimes be difficult, especially when they do not take into consideration nurses' assessments:

Collaboration with other professionals… I really think there is a lack of time to do that. I do not have time to sit down and read the physiotherapist's note for example. We'll communicate quickly in the hallway. When we make referrals for the patient to be seen by the physiotherapist, we do not have time to make sure that patients are actually seen. Also, we make nursing notes, and, seriously it's rare that the doctors read my notes. Sometimes to make sure they read my nursing notes, I'll write a little note on the top of the chart to get Dr. X or Dr. Y's attention. (Participant 8) [free translation].

For their part, pre‐admission nurses were able to articulate their perceptions of their independent, dependent and interdependent roles. The four participants clearly described three main roles: preparing patients for surgery by providing the necessary education to ensure a safe return home, reviewing the patient's health condition and the medications to be taken or not taken prior to surgery and verifying that the results from the required medical exams are on file and whether other(s) are needed. They mentioned that it is the role of the pre‐admission nurse to ensure that pre‐operative examinations are done to reduce the risk of postoperative complications:

My role in pre‐admission is patient assessment. That is… I'm the one who prepares them for surgery, who tells them what they have to do… we have to teach them too. We do all the preadmission questionnaires, blood works, EKG, really all the preoperative tests. We also prepare [them] for the post‐op. That's my role. (Participant 18) [free translation].

Participants also reported that in pre‐admission settings, nurses perceived their independent roles to be minimal as it could only be performed during the patient's initial assessment or when requesting a consultation. Conversely, dependent roles were very present since these nurses have to follow protocols or decisional algorithms written by surgeons and anaesthetists. Regarding the interdependent roles, pre‐admission nurses acknowledged the positive collaboration they have with physicians, physiotherapists or other health providers. These nurses felt confident in their interdependent or dependent roles:

For the doctors, once the patients are in preadmission, they forget them, it's us who do the follow‐ups. (…) Having a lot of interdependent or dependent roles… oh dear! I think it's even safer in pre‐admission to have things like that [surgery protocols] to decrease the risk of complications. (Participant 5) [free translation].

4.2. Challenges in the continuity of care

This theme refers to the challenges associated with service delivery to patients in a coherent, logical and timely fashion. Some postoperative units' participants viewed continuity of care as the prolongation of the care that was started in the pre‐admission unit (before the surgery) and the recovery room (immediately after surgery):

For my part, depending on vital signs for example, I refer to the patient pre‐admission file to see how he was before and I will refer also to the recovery room notes to see how he was after the surgery. I try to see the continuity between the pre‐admission and what has now changed. (…) I have to check for what has happened…get a global idea of the patient's condition. (Participant 7) [free translation].

Pre‐admission nurses noted that when patients are transferred to the postoperative units, there appears to be a disconnect between care received in pre‐admission clinics and the continuity of care in postoperative units. They wondered whether postoperative nurses took the time to read the patients' charts. They believed that the documentation and reports found in the pre‐admission section of the chart make it possible to follow the care process and ensure continuity of care:

As I say… I send what's available, all my documentation. Sometimes I go to the nurse who's going to take care of the patient [on the postoperative unit] and I tell her “look I've put the file together. Everything is complete for tomorrow, you're going to send it to the OR tomorrow morning. My data collection is there, everything is there”. They're always very happy to get it. But what they are going to do next, I cannot say. (Participant 10) [free translation].

More importantly, pre‐admission nurses and those working on postoperative units do not seem to really understand and often do not even know what each other's job is. Each group of nurses seems to work in silos, as explained by a pre‐admission nurse:

I do not think our roles is understood by the nurses on the floors, (…) If you want my perception, it seems that it's not the same reality, I think it's two worlds. (…) What we do before they see the patients, all the paperwork. Nurses do not see all the work that is done before the patient arrives on their unit (Participant 5) [free translation].

In fact, most nurses in postoperative units stated that they only took into consideration the assessments and data documented in the recovery room. They indicated that they did not even know where to find pre‐admission data and whether these would in fact make a difference in patients' care. Postoperative nurses recognized that they are working in silos without necessarily having any connection with pre‐admission nurses:

In pre‐admission… I know there are forms that are filled out, but I do not really check those forms. I do not even think I know where they are in the patient's chart. (…) I personally do not feel that my role as a nurse on the surgical wards is a follow‐up to that of the preadmission nurses… because I really do not have any idea what is done in preadmission. (Participant 1) [free translation].

It depends on the patient's case. If it's a complex case with multiple co‐morbidities, yes, I'll look at the preadmission file to know what to expect because complications arise not only from the surgery, but also from previous illnesses. Then if there are social issues, I'll also read it to see if I need a social worker or someone else for the discharge. But often there's no time (…) and sometimes there's no need [to look at the pre‐admission file]. (Participant 3) [free translation].

Additionally, novice nurses working on postoperative units sometimes reported difficulty in understanding their roles in the management of a postoperative patient, which made it difficult to ensure continuity of care. Informal verbal communication with experienced nurses seemed to be how these nurses ensured patients' continuity of care. Postsurgical complications appeared to be more frequent in units lacking surgical protocols or standard postoperative follow‐up forms. Thus, a priority to ensure continuity of care for the organization was to put in place clear guidelines and clinical pathways for postoperative nurses, particularly novice nurses, so they could plan their tasks according to patients' individual needs:

If the patient does not experience surgical complications, he does not stay long. But, there was one who developed an abscess that got super infected, she stayed a month in the hospital. (…) I feel like … It's disorganized on my unit, there's no structure. You know, it's nobody's fault really… it's probably the lack of staff. I think that's why we do not have any guidelines as well. (…) As a nurse, you work according to what you think. On our unit, we have major and super super varied surgeries, so maybe that's because of that too. (…) It might be a good thing to have some guidelines (Participant 1) [free translation].

4.3. Factors affecting the roles of nurses in medical‐surgical units

This last theme illustrates how the healthcare organization can positively or negatively influence nurses' perception of their roles. Working conditions such as understaffing and high nurse‐to‐patient ratios were perceived as impeding nurses' roles. A registered nurse paired with a registered practical nurse sometimes shares 12 or 13 postoperative patients, thus prioritizing treatment becomes the only way to ensure a basic level of care. As the workload increases, the risk of errors increases as less time and attention are paid to tasks, resulting in negative patient outcomes. Participants reported that on days when there is a staff shortage, postoperative nurses find it difficult to regularly assess patients and deal with issues compared to days when there is proper staffing. While it cannot be contested that administrative duties take nurses away from patient care, participants' perception was that administrative activities were so burdensome and time‐consuming that little time remained for nurses to interact with patients:

If one day all the nurses are there, it's fine. But, usually it's a really heavy workload… there's a lot to do on the unit. A lot of times you have to prioritize. If there are things that absolutely have to be done today, you are not going to go take care of things that you can leave. For example, leaving the dressing for the evening shift. (…) Sometimes I realize after my shift that I've just been executing, just doing techniques, so we take less time to spend with our patients. Yes, I would like to spend more time with my patients, to support them morally, we do not have the time to do that. You cannot sit down with your file, and think about why this, why that, get a general picture of your patient… it has a great impact on the health of the patients. But that's how it is! Then… there are a lot of people leaving because it's hard to work on the units. (Participant 4) [free translation].

Postoperative nurses perceived that having to reinput patient information in multiple forms can lead to documentation being duplicated and wasted time. These nurses reported that they often do not have time to complete all the administrative paperwork because of the complexity of patient care and the lack of adequate staffing on the units.

I assess the patient's history quickly…I do not have time to look at every file, it's impossible…it goes fast. We're on a unit where you have to be quick on the uptake, the workload is heavy… and there's a lot of paperwork that needs to be filled out, but it's not filled out, not because we do not want to, but because there are other priorities and I think it's more important to get my patient up than to fill out forms. For sure, I'll write my nursing notes; for problematic patients, I'll definitely make a note, but I'll work on his problem first. (Participant 8) [free translation].

Concern was also expressed about the inability of casual staff nurses or float nurses to work to their full capacity because of their unfamiliarity with the unit, patients, equipment and material. When these nurses are working on units, permanent nurses to the units have to cover by performing extra duties as they are the only ones with the most up‐to‐date information about the patients or the functioning of the unit.

For their part, pre‐admission nurses perceived their work environment to be helpful and collaborative. Nevertheless, they were frustrated about time constraints, as per organizational guidelines, specifying how much time to spend with the patients depending on the type of surgery. They also experienced heavy workloads and are often understaffed resulting in having to see a large number of patients per day. They mentioned that it was important that enough time be allocated to give quality education so that patients could fully understand the surgical procedure they were to undergo and its associated care:

Let us talk about the workload. As I said before, we have about 20 minutes for our appointment, sometimes it's enough, but it's very rare… 20 minutes to manage to do everything: take vital signs, fill in forms and then explain the surgery to the patient, teaching them., that's what takes the longest, especially if the patient has questions. […] 20 minutes will turn into 30 or 40 minutes. So, I will be late with my next appointment, […]. And on top of that, we have follow‐up calls to make. (Participant 2) [free translation].

Moreover, pre‐admission nurses reported the importance for the organization to have a culture of learning by facilitating access to continuing education to ensure their knowledge remains current and the care they provide is evidence based:

Often only CPR training is offered. Nothing else. Training is needed to prevent and avoid postoperative complications and to ensure that the nursing staff is kept up to date. Even when changes are made to surgical procedures or to the equipment used during surgeries, there is no training to ensure nurses to learn about these changes. The employer tells us to sign up for training, but they do not do much. (Participant 18) [free translation].

Both pre‐admission and postoperative nurses deplored the lack of nursing retention strategies put in place by the organization. For example, participants reported that offering standardizing processes and tools and clinical support for new nurses could promote staff retention, thus ensuring sufficient human resources and manageable workloads. Conversely, participants also commented on how managers' attitudes such as demonstrating flexibility, empathy and understanding contributed to a more positive work environment:

The workload on our medical‐surgical unit is [that of a] heavier unit … I think. Maybe that's why we lose nurses too because of the heaviness of the tasks. But our unit manager is great! (…). He bought new equipment, new materials. So slowly it's getting better […] Equipment that works is very important. And he has organized our staff room, which helps. Even though we are so short of staff, he is flexible in terms of schedules. We can talk with him. We can organize ourselves. (Participant 3) [free translation].

Participants also mentioned how having a positive and supportive team helped make a difference in their work environment:

When the recovery room does not send us all the patients at the same time, it's fine. But if there is a patient who is not doing well, everything falls apart (…) it's then that we have to stick together. There has to be a team spirit. When I see that there is another nurse who is super busy with a patient who is not doing so well, I'm going to go see her [and ask]: do you want me to do something? That's the team spirit. (Participant 13) [free translation].

The study finding shows that nurses in pre‐admission and postoperative units perceived challenges with the enactment of their roles resulting in them not working to their full scope of practice. This is problematic given the complexity of patient care and the shortage of healthcare professionals.

5. DISCUSSION

The aim of this study was to gain further insight into the perception of nurses about their roles as medical‐surgical nurses. Our findings align with that of previous studies which showed that nurses tend to perceive their professional roles as vague (Allen, 2020 ; Bittner, 2018 ). In a review of the literature including 103 articles, reports and other documents about nurses' role ambiguity and its impact among nurses in Alberta, Canada, Tycholiz ( 2021 ) explained that role ambiguity characterized by lack of clarity about roles, responsibilities and/or procedures to achieve what is expected of them, can contribute to role confusion, role overlap, decreased collaboration, ineffective workforce planning, diminished professionalism and inefficiencies. The inability of nurses to explain their roles can also lead them to feel uncertain or confused about how their tasks or activities should be accomplished, resulting in negative patient outcomes (Blanco‐Donoso et al., 2019 ). Additionally, while studies showed that nurses' roles and subsequent performance can be explained by variables such as nurses' level of education (Doran et al., 2002 ; Furåker, 2008 ), our study showed no difference between the roles of medical‐surgical nurses with a bachelor's degree and those with a college education. Rather, the vagueness and confusion about the nursing roles was found in these two groups.

Our study showed that patients' assessments were perceived to be the most important clinical role enacted by medical‐surgical nurses. However, it is well documented in the literature that nurses do a lot more than assess patients, as described by the nine nurses' roles identified by Almost ( 2021 ) for the Canadian Nurses Association. For example, she and others have reported that nurses are professional leaders with independent roles, who educate clients/families, ensure cohesive and coordinated care, collaborate in curing diseases, participate in rehabilitation and provide support and advocate for the patients to name a few (Choi, 2015 ; Kang et al., 2020 ; Luther et al., 2019 ).

In this study, medical‐surgical nurses are concerned about the underutilization of their scope of practice and performing non‐nursing tasks. Frogner et al. ( 2020 ) identified two major consequences associated with restricting the scope of practice of qualified and competent workers like nurses who are trained to safely and efficiently provide services: (i) skills are not used to their full extent and (ii) workers do not meet patient's care needs. According to Déry et al. ( 2022 ), nurses should be able to practice to their full scope to maximize their contribution in the healthcare system and to ensure accessibility and continuity of care.

The study also identified a lack of continuity of care as a challenge. Study participants acknowledged that they were working in “silos” and not maximizing the use of the information collected throughout the perioperative continuum. This result was surprising given the importance of the information collected as part of the pre‐operative assessment which is known to help establish a baseline for surgical patients by becoming aware of their vulnerabilities (Akhtar et al., 2013 ) and identifying their needs and risk factors (McShane & Honeysett, 2013 ). Malley et al. ( 2015 ) reported similar findings where the urgency to complete tasks and lack of communication when transitioning patients to the next level of care rendered the work of pre‐operative nurses invisible.

Finally, the findings from the current study which highlights that the working conditions and the work environment of nurses can negatively affect their performance and their ability to fully enact their three categories of roles (independent, dependent and interdependent) are consistent with that of other studies that found similar results (Er & Sökmen, 2018 ; Shao et al., 2018 ). In fact, the dependent and interdependent roles were perceived by pre‐admission nurses and novice nurses working on the postoperative units as safeguards to prevent them from making errors. Experienced nurses stressed the importance for nurses to master their independent roles because the dependent and interdependent roles were perceived as a barrier to nurse autonomy. In their study, Pursio et al. ( 2021 ) found that when nurses have professional autonomy, they are more satisfied with their work and are more occupationally committed and empowered when they can prioritize, schedule and pace their tasks. Health organizations have a responsibility for providing the necessary means for nurses to act autonomously by communicating clear roles and enhancing practice and decision‐making to ultimately improve nursing performance, quality of care and patient outcomes (Cho & Han, 2018 ; Oshodi et al., 2019 ). Research have also highlighted the risks to nurses' physical and mental health (e.g. burnout and anxiety) and an increased intention to leave when having to practice in poor working conditions (Havaei et al., 2020 ; Nantsupawat et al., 2017 ). However, because these have been the reality of nurses for so long, there is now a normalization of these deviant practices (delays in care, absence of care, non‐evidence‐based practices, etc.; Banja, 2010 ).

6. LIMITATIONS

This study has a number of limitations. First, the findings are based on the perception of 21 nurses working in one large tertiary hospital. Second, the study over‐represented experienced nurses (the average number of years of experience was 14 years). Third, the study did not include intraoperative (operating room and recovery room) nurses who could have provided a valuable, albeit different, perspective given the nature of their roles.

7. RECOMMENDATIONS

The current findings have implications for academic training programmes. For example, a focus should be on the ability of nurses to describe and articulate their different roles in relation to safe and ethical care, decision‐making and critical thinking. Moreover, leadership courses should also be part of nurses' initial training (Poorchangizi et al., 2019 ).

Similarly, in clinical practice, mechanisms, such as making continuing education more readily available, should be put in place to allow nurses the opportunity to enhance their individual skills and develop their competence to recognize and respond to surgical patient needs and prevent adverse patient outcomes (Iddrisu et al., 2018 ).

At the management level, unit managers are in a strategic position to implement reforms to improve the work environment of nurses. This can be done by: (i) allocating sufficient resources at the unit level to have the right professional perform the right tasks (e.g. adequate staffing ratios and appropriate staff mix); (ii) developing and implementing evidence‐based policies, care pathways and guidelines that clearly outline nurses' roles, responsibilities and boundaries; (iii) ensuring continuing quality improvement measures and initiatives and (iv) facilitating regular reviews of nursing roles so that nurses can work to their full potential (College of Nurses of Ontario, 2018 ).

While they are frequently told to engage in politics, nurses' political roles have mostly been discussed in the context of administrative roles in healthcare organizations (McMillan & Perron, 2020 ). However, political action is imperative to further develop the nursing profession. As a result, medical‐surgical nurses must not only focus their practice on clinical tasks and patient care, but should also be involved in the political process and decision‐making to ensure that policies do not impede their roles (Wilson et al., 2022 ).

8. CONCLUSION

Medical‐surgical nurses play a pivotal role in the perioperative continuum ensuring that patients are well cared for before, during and after their surgery. Findings from the current study suggest that nurses struggle to articulate their roles and to work to their full scope of practice. Results also highlight that siloed clinical practice due to hierarchical organizational culture and poorly organized work environment can have a negative impact on nurses' clinical practice and potential patient outcomes. A team approach is a strategy that would better respond to patients' clinical needs across the surgical journey, thus reducing the incidence of adverse events. Further research is warranted to better understand the magnitude and the impact the lack of understanding of the nurses' roles has on nurses, healthcare teams and patients, and to identify concrete and sustainable strategies to support medical‐surgical nurses in working to their full roles and scope of practice.

9. RELEVANCE TO CLINICAL PRACTICE

Since nurses in medical‐surgical units play a critical role in ensuring clinical monitoring and continuity of care and reducing the risk of adverse events and complications, it is important that they understand and articulate their roles and work to their full scope of practice. Allowing medical‐surgical nurses to be fully contributing members of the interprofessional team by allowing them to have greater involvement in decision‐making about patient care and discharge is essential. Improving the work environment of medical‐surgical nurses is also required if they are to work to their full potential. This can be done, for example, by having a flexible work environment with better working conditions and manageable workloads.

Impact statement

What does this paper contribute to the wider global clinical community?

The relevance of the work performed by pre‐admission nurses is not well understood by postoperative nurses resulting in the information collected in the context of pre‐admission being underutilized.
Nurses working in postoperative units currently do not fully understand their roles and scope of practice, raising concerns about their ability to recognize and manage patients whose conditions may be deteriorating.
Continuity of care, an essential care principle that is particularly meaningful in the context of perioperative care, is lacking, thus potentially having a negative impact on the quality of care delivered and patient safety.

AUTHOR CONTRIBUTIONS

All authors, Evy Nazon, Isabelle St‐Pierre and Denise Pangop, have approved the final text. Denise Pangop was involved in the design and data collection. All authors Evy Nazon, Isabelle St‐Pierre and Denise Pangop analysed and prepared the manuscript.

ET: conceptualization and data acquisition. ET and LA: methodology. ET, DW, GD and LA: analysis of data, resources and writing (drafting, reviewing editing). LA and SR: funding acquisition.

All authors have agreed on the final version and meet at least one of the following criteria [recommended by the ICMJE ( http://www.icmje.org/recommendations/ )]:

substantial contributions to conception and design, acquisition of data or analysis and interpretation of data;
drafting the article or revising it critically for important intellectual content.

FUNDING INFORMATION

This research was supported by the Fonds institutionnel de développement de la recherche et de la création (FIRC) – Université du Québec en Outaouais [#325288].

CONFLICT OF INTEREST

The authors declare that there is no conflict of interest.

ETHICAL STATEMENTS

The study received ethics approval from the Research Ethics Boards of the Université du Québec en Ouatouais and a large tertiary care hospital located in Quebec, Canada. The 21 participants signed the consent form before participating in the study. Data anonymity and confidentiality were maintained throughout the study. There were no risks associated with the research and study purpose.

PATIENT OR PUBLIC CONTRIBUTION

The public involvement included one nurse working on a medical‐surgical unit who accepted to review and comment on the interview guide.

ACKNOWLEDGEMENTS

We would like to thank all participants and hospital employees, especially the nursing management who supported us on‐site.

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Open access
Published: 25 March 2024

Outcomes of professional misconduct by nurses: a qualitative study

Shokoh Varaei ORCID: orcid.org/0000-0001-7126-2014 1 ,
Nahid Dehghan Nayeri ORCID: orcid.org/0000-0003-1594-6790 2 ,
Leila Sayadi ORCID: orcid.org/0000-0001-7613-3051 3 ,
Mehraban Shahmari ORCID: orcid.org/0000-0002-2501-8667 4 &
Akram Ghobadi ORCID: orcid.org/0000-0002-7673-7362 5

BMC Nursing volume 23 , Article number: 200 ( 2024 ) Cite this article

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Metrics details

Professional misconduct by nurses is a critical challenge in providing safe quality care, which can lead to devastating and extensive outcomes. Explaining the experiences of clinical nurses and nursing managers in this regard using an in-depth qualitative method can be beneficial. This study was conducted with the aim of explaining the experiences of nurses regarding the outcomes of professional misconduct.

The present study used a qualitative descriptive with a conventional content analysis approach. A total of 22 clinical nurses and nursing managers were selected through purposive sampling until data saturation was reached. Data were collected using semi-structured in-depth interviews and analyzed using Graneheim and Lundman’s approach.

Analyzed data were categorized into four main themes and 11 subthemes: (1) Physical outcomes: critical threat and weakening patients’ safety; (2) Psychological outcomes: psycho-emotional responses of patients and their families, moral distress, and cautionary tale of nurses; (3) Financial outcomes: imposing costs on the patient and financial loss of the nurse; (4) Organizational outcomes: the normalization of misconduct, chaos in the organization, waste of the organization’s resources, and reputational damage to the organization.

Professional misconduct by nurses can have adverse outcomes for patients in physical, mental, and financial dimensions, their families, nurses, and healthcare organizations. Therefore, it is indispensable to adopt management strategies to reduce the rate of professional misconduct.

Peer Review reports

Nurses play a vital role in ensuring patients’ well-being and recovery. They are patients’ trustworthy caregivers, advocates, and instructors [ 1 ]. According to the code of ethics for nurses, they have the responsibility for protecting the patient, society, and the profession against possible harm [ 2 ]. Maintaining nurses’ ethical standards and professional conduct is imperative in ensuring patient safety, trust, and integrity of the nursing profession [ 1 , 3 , 4 ]. In the nursing profession as a caring and humane profession, there is the possibility of another reality termed professional misconduct [ 5 , 6 , 7 ]. Professional misconduct refers to any practice or action by nurses that deviates from the established ethical and professional standards and guidelines [ 8 , 9 ].

Professional misconduct in nursing is a multifaceted issue with wide-ranging outcomes in patient safety (physical and mental harm or even death), trust in the healthcare system, and healthcare workers’ well-being. Professional misconduct can damage the profession’s reputation and weaken nurses’ vital role in society [ 10 , 11 ].

Considering that professional misconduct weakens the integrity of nursing practice, perceiving consequences is of particular importance for nurses, healthcare managers, and policymakers since it emphasizes the prominence of maintaining the highest professional standards [ 12 ]. As part of a broader research initiative, this study extensively examines the multifaceted repercussions of such misconduct, extending beyond immediate effects, to deepen understanding across various dimensions. Given healthcare organizations’ mandate to deliver high-standard care with minimal harm, comprehending these implications becomes paramount. The research enhances related knowledge by categorizing the consequences of misconduct, highlighting potential dangers and irreparable harm. Also, it emphasizes the imperative of responsibility and ethical conduct to enhance patient quality and safety. Through this endeavor, the study addresses gaps in understanding within the field.

Study design, setting, and participants

This qualitative descriptive study was conducted through the generic qualitative design and content analysis approach to data analysis. The study setting was different wards of general and referral hospitals in the capital of one of the western provinces of Iran. The participants included in the study were selected using purposive sampling. The inclusion criteria included at least a bachelor’s degree in nursing, an experience of observing professional misconduct by colleagues, and the willingness to discuss experiences. Before conducting the interview, the researcher coordinated the interview time and location while establishing communication with the eligible participants and explaining the study objectives. In order to achieve maximum diversity and richness of data, participants with diverse personal and professional characteristics were selected. Sampling continued until saturation, resulting in the inclusion of 22 nurses and nursing managers aged between 25 and 48 years (Table 1 ).

Data collection

After preparing the interview guide using the expert opinions of the research team, the data were collected through a semi-structured individual interview. Each interview lasted between 45 and 90 min. Data collection was performed by the first author under the supervision and cooperation of the research team. Participants were asked: “Describe your experience on the outcomes of professional misconduct.” “Who is affected by the outcomes of professional misconduct? Explain it.” At the end of the interview, open questions were asked. The interviews were recorded using a mobile phone with the participants’ permission. Data collection and analysis were performed simultaneously from February 2021 to August 2021.

Data analysis

The conventional content analysis method was employed by following five steps proposed by Graneheim and Lundman [ 13 ]: (1) Implementing the entire interview immediately after each interview, (2) Reading the entire text several times to get an overall understanding of its content, (3) Determining semantic units and basic codes, (4) Classifying primary codes in more comprehensive categories, and (5) Determining the main theme of categories.

Interviews were recorded and transcribed using Word software, followed by iterative readings for content understanding. Semantic units were identified based on study objectives, and primary codes were derived. The initial codes were categorized, and the main and sub-themes were determined. Data management was facilitated by MAXQDA10 software.

It is noteworthy that the researcher, aimed to maintain objectivity during the coding process by closely aligning the codes with the data, and setting aside personal biases and preconceptions.

Trustworthiness

The following strategies were used to establish the trustworthiness of Study [ 14 ] Credibility was achieved through trust-based communication and prolonged engagement with the participants and the data and by providing a lot of time for data collection. Dependability was ensured by checking the consistency between quotes and codes/subthemes by the research team and two external observers familiar with qualitative research. In addition, confirmability was established by presenting the quotes extracted from each interview and returning the text of several interviews to a number of participants and applying their opinions, Transferability was enhanced by selection of participants with maximum diversity in terms of age, gender, work experience, educational level and position and detailed description of the research process, participant characteristics, and study context. In addition, quotes were expressed directly by providing each participant’s quote (P).

Ethical considerations

The Joint Ethics Committee of the Faculty of Nursing, Midwifery, and Rehabilitation of Tehran University of Medical Sciences approved this study with the ethics code IR.TUMS.FNM.REC.1400.187. The study objectives were explained to the participants at the beginning of the interviews. Due to the disapproving nature of professional misconduct and the sensitivity of the issue, the possibility of voluntary participation, confidentiality, and anonymity of individuals and their organizations were guaranteed. Written informed consent was obtained from all participants. Transcripts were securely stored in an encrypted file on a personal computer and destroyed following data analysis to further protect the confidentiality of participants.

The outcomes of professional misconduct by nurses were categorized into four main themes and 11 sub-themes (Table 2 ).

Physical outcomes

Data analysis indicated that patients were the primary individuals affected by professional misconduct by nurses and experienced more harm than other parties. One of the most critical outcomes of misconduct is the physical impact on patients. This theme is subdivided into two aspects: critical threat and undermining of patient safety.

Critical threat to patients

The participants’ experience showed that professional misconduct by nurses exposes patients to critical and adverse events such as death, disability such as leg amputation, and critical injuries such as pneumothorax, finger gangrene, tissue necrosis, burns, bleeding, and falls.

“ The patient was critically ill and we announced the CPR code ten minutes after the shift was handed over. We checked and noticed that they hadn’t inserted an IV line for him. It was impossible to do it with a blood pressure of 65. We finally inserted the intravenous) IV (, but it was in vain…” (Participant 9).

Weakening patients’ safety

According to the participants’ experiences, in addition to critical injuries, less life-threatening injuries such as mouth sores and infections could occur following professional misconduct by nurses. There was also the possibility of unwanted side effects. Yet most of these complications may not appear right away and be noticed after discharge from the hospital.

“ One of the colleagues, as she said, made a potion, combined several antibiotics into the Microset, and injected it into the patient .” (Participant 14).

This theme shows that considering the physical aspect, professional misconduct by nurses ultimately leads to a decrease in the quality of care and safety and delays the treatment process.

Psychological outcomes

Based on data analysis, professional misconduct by nurses affects psychological aspects in addition to physical dimensions. This outcome may involve not only patients but also their families and nurses. This theme includes the psycho-emotional responses of patients and their families, moral distress, and edification of nurses.

Psycho-emotional responses of patients and their families

Nurses’ experiences showed that professional misconduct sometimes caused psycho-emotional reactions in the patient or their companions. These side effects were reported as crying, feeling abandoned, distrust, dissatisfaction, cursing, aggression, objection, reporting to the authorities, and complaints.

“ At the beginning of the outbreak, a patient suspected of being infected with coronavirus was hospitalized in the ward and was left in the room; the door was closed. She was ordered not to get out of the room because she could spread the coronavirus to other patients; she was crying all the time.” (Participant 11).

Moral distress of nurses

Sometimes, the repercussions of professional misconduct by a nurse affect both the perpetrator and the cooperating and witnessing nurse. The participants stated that, at times, they experienced various emotional reactions, including discomfort, remorse, guilt, and even psychological complications and quitting work after committing misconduct. In addition, the colleagues of a nurse who is the perpetrator of the misconduct may express regret, discomfort, and anger upon witnessing this situation.

“ I know that catheterization is a sterile procedure, and I’m fully aware of it, but at that moment, there may not be a betadine or a sterile set or gloves. I may not do it correctly and scientifically as I should, which is really sad. Most of the time, we feel guilty.” (Participant 10).

Cautionary tale

According to some participants’ experiences, the effect of a nurse’s encounter with a colleague’s misconduct depended on the morale and personality of the witnessing nurse. By witnessing misconduct and its negative outcomes for the patient and the nurse committing it, the nurse may learn never to commit such misconduct. According to the famous quote, “A man profits more by the sight of an idiot than by the orations of the learned,” it should also be instructive and improve patient care quality.

“ Misconduct by a colleague can influence the nurse seeing it and make them improve, that is, not perform that wrong deed. Due to a written warning to a few colleagues because of the rapid infusion of antibiotics, the others learned and are now very careful .” (Participant 10).

This theme showed that professional misconduct by nurses might harm patients not only physically but also mentally and occasionally cause psychological problems for the nurses. It should be noted that, besides all the negative outcomes, professional misconduct by nurses has a positive consequence, which is a cautionary tale of other nurses and, subsequently, efforts to improve care.

Financial outcomes

Data analysis showed that another outcome of professional misconduct by nurses was the financial outcomes that could affect the patient or nurse. This theme includes two subthemes: ‘imposing costs on the patient’ and ‘financial loss of the nurse.’

Imposing costs on the patient

According to the obtained data, additional costs are imposed on the patient due to adverse events and unwanted complications caused by the reduced care quality resulting from professional misconduct by nurses. These costs may be related to increased length of hospital stay and the need for additional procedures or medication.

“ Unfortunately, some colleagues don’t observe the principles of sterile technique when dressing, which can cause the patient to return with an infection at the surgery site and need to take intravenous antibiotics such as Ciprofloxacin and Clindamycin and be hospitalized for a few days, all of which impose an additional cost to the patient.” (Participant 11).

The financial loss of the nurse

Several participants’ experiences showed that the nurse might experience legal issues such as warnings, reprimands, and referrals to the administrative violations department following committing misconduct, which, especially if repeated, could negatively affect the process of recruiting the training nurses or changing their employment status, in-service promotion process when being appointed to a position until retirement. Based on the participants’ experiences, addressing misconduct might have financial outcomes for the nurse who committed it. These financial damages included a deduction of salary and wages, no further promotion after warning, reprimand and its negative impact on salary, and incurring damages.

“Our nurse colleague hadn’t paid attention to the warmer’s temperature. The mask on the baby’s nose was almost burnt and caused nasal necrosis. The baby’s family pursued it. The nurse was fined to pay the damages. ” (Participant 8).

This theme generally indicated the financial damages resulting from professional misconduct by nurses, which might affect patients and nurses.

Organizational outcomes

Professional misconduct by nurses has negative outcomes not only for individuals but also for the organization. This theme includes the subthemes of normalization of misconduct, chaos in the organization, waste of the organization’s resources, and reputational damage to the organization.

The normalization of misconduct

Participants stated that one of the organizational outcomes of misconduct was its normalization for the perpetrator, modeling, and contagion of misconduct to other colleagues, leading to the normalization of erroneous conduct in the organization.

“M isconduct possibly affects others as well, as it is considered a routine, as they think somebody did it, and there was no problem. Now, in ward X, it has become routine that vital signs aren’t monitored and are only recorded .’ (Participant 10).

Chaos in the organization

The data analysis showed that due to professional misconduct by nurses, colleagues might be forced to compensate for their colleague’s misconduct by carrying out the medical orders for the maltreated patient. As a result, nurses usually avoided working shifts together with that nurse. There might also be turmoil, chaos, arguments, protests, complaints, and even physical encounters between patients and their companions with the medical staff or colleagues.

“ My colleague’s work burden falls on my shoulders, so I should also manage her duty. For example, in my shift, I followed up on a medicine that had to be prepared in the previous shift and made a prescription for the patient; the patient prepared it but growled at me because the medicine was expensive. The doctor talked to me as if I was the one who hadn’t done it while it hadn’t been followed up in the previous shift .” (Participant 19). “ Colleagues who impatiently do the patient’s tasks get angry at the patient. The patient or the companion asks one question or two; upon the third question, they conflict with the patient’s companion. We have a code called code 44 for a security guard, which is often announced during their shifts.” (Participant 19).

Waste of the organization’s resources

After analyzing the data, it was revealed that due to the professional misconduct by nurses, the patient might need a transfer to the intensive care unit or more specialized centers, additional procedures, such as debridement, intubation, dialysis, surgery, re-surgery, or cancellation of surgery, increased hospital stay, and re-hospitalization. By jeopardizing the quality and safety of patient care, these cases lead to complications, and managing them can impose additional costs on the hospital. Some participants believed that failure to provide optimal care caused the patient’s condition to aggravate and the nurse’s workload to increase.

“ The patient, who was just discharged from the operating room, was bleeding badly. The nurse hadn’t followed up or informed the doctor. The patient was transferred to the ICU due to severe bleeding and was treated for approximately 15–16 days. He was operated on twice .” (Participant 14).

In addition, nurses’ professional misconduct directly leads to the waste of resources and equipment.

“ For example, in the COVID-19 situation, when the equipment and supplies were scarce from the beginning, they rationed it for the wards. A male colleague poured Septicidine. Well, it was wasted. It could be used in the COVID-19 ward .” (Participant 7).

Reputational damage to the organization

According to the data analysis, professional misconduct could lead to damage to the reputation and credibility of the nursing profession and loss of public trust in nurses and healthcare organizations in general.

“ Sometimes we refer the patient to a certain hospital, but they say they wouldn’t go there even if they die. They believe whoever is referred to that hospital won’t stay alive .” (Participant 13).

This theme revealed outcomes of misconduct that threatened and affected the healthcare organization.

In the present study, nurses’ experiences regarding the outcomes of professional misconduct were investigated. The results showed that this phenomenon had widespread outcomes in different dimensions and levels, including patients, nurses, and healthcare organizations. In line with the present study, researchers concluded in a systematic review that unprofessional conduct included multidimensional issues and serious outcomes concerning patient safety, nurses, colleagues, managers, and healthcare organizations [ 6 ].

One of the significant outcomes of professional misconduct is physical outcomes, which can critically threaten patients’ health and life or jeopardize their safety. In a review, the threat to patients’ safety has been identified as the main reason for adopting disciplinary measures against nurses [ 15 ]. In addition, in a qualitative study, various unsafe practices leading to physical harm to patients have been identified and classified [ 16 ]. In line with the present study, Rooddehghan et al. (2018) reported that missed nursing care could lead to the elimination or postponement of scheduled therapies, which causes serious life threats, complications, and, as a result, patient dissatisfaction [ 17 ]. Professional misconduct in health care can jeopardize patients’ safety, health, and well-being [ 5 , 18 , 19 ]. Since the main goal of health care is to provide quality and safe care to patients, the physical outcomes of professional misconduct by nurses are considered the most important outcomes, and their prevention is absolutely vital.

Another consequence of professional misconduct by nurses is its psychological effects on patients and nurses. Healthcare workers’ misconduct can cause psychological harm to patients, including anxiety, feeling insulted, and fear [ 18 ]. Moreover, misconduct demonstrates the violation of patients’ human rights and dignity [ 7 ]. Since the quality of services provided to patients is an important component of their satisfaction [ 20 ], professional misconduct can reduce patient satisfaction by negatively affecting the quality of care. Nurses charged with professional misconduct face a variety of outcomes, including psychological, physical, and mental suffering [ 21 ]. Furthermore, observing misconduct can lead to moral and emotional distress, sympathy for patients, and increased negative emotions such as distress, sorrow, guilt, bias, and negative stigma in fellow nurses [ 18 , 22 ]. These nurses may to leave their positions and may experience anxiety, sleep disturbances, and uncertainty in dealing with their colleagues [ 16 ]. In general, professional misconduct can cause psychological problems not only for patients but also for nurses, which supports the need for prevention and corrective action.

Unprofessional conduct is a complex phenomenon that impacts nurses’ practice [ 6 ]. In the present study, it was found that professional misconduct could serve as edification for other nurses. In other words, misconduct by colleagues can serve as a cautionary tale to assist nurses in improving their performance. In this regard, studies have shown that unsafe practices by colleagues and related complaints can provide an opportunity for nurses to strengthen their abilities by focusing more on themselves and being more attentive, and contribute to professional development and increased patient safety [ 16 , 23 ]. Therefore, it seems that, when encountering colleague misconduct, nurses can use negative experiences in the organization and enhance their skills and precision in order to improve professional conduct and patient safety.

Other outcomes of professional misconduct by nurses obtained in the present study were financial outcomes that could affect patients and nurses. In line with this finding, a study shows that unsafe practices can impose additional costs on patients [ 24 ]. The financial losses of nurses caused by professional misconduct can be related to legal outcomes such as restrictions, suspension, revocation of professional license, or finement [ 15 , 25 , 26 ]. It can be concluded that, regarding economic issues, professional misconduct by nurses can harm the patients and even the nurses.

Professional misconduct by nurses has outcomes not only for patients and nurses but also for the healthcare organization. These outcomes include issues such as the normalization of misconduct, chaos in the organization, waste of the organization’s resources, and reputational damage to the organization. These issues can reduce the organization’s efficiency and cause concerns about the safety and quality of services provided by nurses. Professional misconduct is often initiated by one individual; however, it can spread quickly, change the organization’s dominant values, norms, and behaviors, and become established [ 27 ]. These disciplinary processes affect the nursing profession, and these impacts become more significant in retaining nurses, particularly in global staffing shortage conditions [ 25 ]. In addition, professional misconduct in health care can jeopardize the quality of nurses’ teamwork [ 5 ], increase colleagues’ workload [ 22 ], and threaten the organization’s long-term credibility and ultimate sustainability by deviating the organization from achieving its main goals [ 10 ]. Misconduct in health care can cause patients and the general public to mistrust medical affairs and damage the reputation of the nursing profession and the organization [ 24 , 28 , 29 ]. Jeopardizing satisfactory standards of practice is a clear violation of nursing ethics, norms, and laws, particularly public trust in nurses and the nursing profession as a whole [ 30 ]. To prevent these challenges, the organization can create a safety culture, develop protocols to report misconduct, and encourage and support nurses. These measures can prevent misconduct, help increase public trust in the nursing profession, and improve the working conditions of nurses.

The present study had several limitations. At first, some participants had doubts about the confidentiality of their names and institutional information in the study. This concern was resolved by assuring them about the anonymity and confidentiality of the information. This research was conducted qualitatively, and therefore, the generalizability of the findings is limited.

According to the results of this study, it is revealed that the outcomes of professional misconduct in the nursing field affect not only patients and nurses but also the healthcare organization. The outcomes of professional misconduct have diverse and widespread dimensions. Physically, professional misconduct can lead to a critical threat to patients or jeopardize their safety. Psychologically, it can create psychological responses in patients and nurses or become an edification for other nurses. Financially, it might impose costs on patients and financial losses for nurses. Organizational effects include the normalization of misconduct, chaos in the organization, waste of resources, and damage to the dignity and credibility of the organization. To prevent these complications, there is a need for programs and management measures to deal with professional misconduct and ensure the provision of safe, quality, and compassionate care to patients. To reduce serious outcomes, further studies in diverse nursing communities are required.

Data availability

Availability of data and materials: Data are available by contacting the corresponding author.

Abbreviations

Cardiopulmonary resuscitation

Intravenous

Intensive care unit

Coronavirus disease 2019

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Acknowledgements

The research team appreciates the School of Nursing and Midwifery of Tehran University of Medical Sciences.

This research received no specific grant from any funding agency in the public, commercial, or not-for-profit sectors.

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Shokoh Varaei

Nursing and Midwifery Care Research Center, School of Nursing and Midwifery, Tehran University of Medical Sciences, Tehran, Iran

Nahid Dehghan Nayeri

School of nursing & midwifery, Nursing and Midwifery Care Research Center, Tehran University of Medical Sciences, Tehran, Iran

Leila Sayadi

Department of Medical-Surgical, School of Nursing and Midwifery, Ardabil University of Medical Sciences, Ardabil, Iran

Mehraban Shahmari

School of Nursing and Midwifery, Kermanshah University of Medical Sciences, Kermanshah, Iran

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Study conception and design: ShV, NDN, and AGh; Drafted the article: AGh, NDN,LS,MSh and ShV; Critical revision of the article: NDN,LS,MSh and ShV; Approved the version to be published: AGh, NDN,LS,MSh and ShV.

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The proposal for this study was approved by the Ethics Committee of the Research Council of Tehran University of Medical Sciences (TUMS), with the IR.TUMS.FNM.REC.1400.187. To participate in the study informed written consent obtained from the participants.

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Varaei, S., Nayeri, N.D., Sayadi, L. et al. Outcomes of professional misconduct by nurses: a qualitative study. BMC Nurs 23 , 200 (2024). https://doi.org/10.1186/s12912-024-01859-3

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Medical Surgical Nursing - Science topic. Mochamad Heri. G. Nur Widya Putra. Desak Ketut Sugiartini. Explore the latest full-text research PDFs, articles, conference papers, preprints and more on ...
(PDF) medical-surgical nursing Assessment and Management of Clinical
Academia.edu is a platform for academics to share research papers. medical-surgical nursing Assessment and Management of Clinical Problems ... Common Principles Underlying Medical and Surgical Nursing Practice 1 Chapter 1 Principles of nursing assessment 2 Naomi Elliott Chapter 2 Principles of drug administration 12 Sue Jordan Chapter 3 ...
(PDF) Research in Medical-Surgical Nursing
This issue measured either in saliva or in serum, to predict cohorts with of Biological Research for Nursing, ''Research in Medical- the poorest functional outcomes from among patients with Surgical Nursing,'' reflects nursing science at the leading edge heart failure. Their results suggest that salivary CRP and of this growing ...
Predicting medical-surgical nurses' work satisfaction and... : Nursing
The facility has 10 medical-surgical units with approximately 285 RNs. These include oncology, neurology, telemetry, orthopedic/neurology surgery, general surgery, and general medicine. Three hundred and fifteen nurses attempted the survey; however, eight (2.54%) weren't RNs, 107 (33.97%) weren't primarily assigned to a medical-surgical unit ...
Medical Surgical Nursing Care Clinical Research
M.Sc (N) Medical surgical nursing-project Ms. Gomathi: Departmental: 2016-17: 2: Effectiveness of pranayama on bio-physiological parameters among patients with Bronchial asthma: M.Sc (N) Dissertation: Ms. Sharmila P. Departmental: 2016-17: 3: Assessment of patient's satisfaction of nursing care in medical wards at a selected hospital in ...
Problem Statements CHN 2017
Problem statements chn 2017 - Free download as PDF File (.pdf), Text File (.txt) or read online for free.
PDF Research 2016-17 List of M.sc Thesis (Year-2016-17) Sr No Department
22 Medical Surgical Nursing Mr. Sandip Chavan "Effectiveness of an Educational intervention on knowledge regarding post operative care among patients undergoing coronary artery bypass graft surgery in selected hospitals." Mrs. Prajkta Adhav 23 Medical Surgical Nursing Ms. Chalise Radhika "Effectiveness of Breathing exercise on the
2654 PDFs
Explore the latest full-text research PDFs, articles, conference papers, preprints and more on SURGICAL NURSING. Find methods information, sources, references or conduct a literature review on ...
medical surgical nursing Latest Research Papers
The study was planned to integrate three subjects namely Medical Surgical Nursing, Pathology and Pharmacology together for better understanding and relevant learning. The research approach for this study was quantitative research approach. A Pre experimental Single group pretest posttest design was used.
PDF R GUHS (An Official Publication of RGUHS) Journal of Nursing Sciences
Each year, women are the victims of more than 4.5 million violent crimes, including approximately 500,000 rapes or other sexual assaults. Men, however, were more likely than women to experience violent crimes. In fact, men were about twice as likely as women to experience. 3 acts of violence by strangers.
Registered nurses' perceptions of their roles in medical‐surgical units
2. BACKGROUND. Registered nurses are essential healthcare providers on adult medical‐surgical units, which include pre‐operative (e.g. pre‐admission) and postoperative units where care is provided (Academy of medical‐surgical nurses, 2021; Aiken et al., 2014).In 2020-2021, there were 304,558 registered nurses licensed to practice in Canada and 80,491 licensed to practice in Quebec.
PDF Kind Attestation14th Batch Student's Sub: Problem Statement have been
Nursing Medical Surgical Nursing A Study to develop Nursing Care Standards and Protocols on care of patients receiving Cancer Therapy and evaluate in terms of Nursing Care Practices and Patient Outcome in a selected hospital of New Delhi. 7 Ms.Manita Dalal Dr. Lekha Viswanath, Professor ,Himalayan College of Nursing, Swami Rama Himalayan
Outcomes of professional misconduct by nurses: a qualitative study
Professional misconduct by nurses is a critical challenge in providing safe quality care, which can lead to devastating and extensive outcomes. Explaining the experiences of clinical nurses and nursing managers in this regard using an in-depth qualitative method can be beneficial. This study was conducted with the aim of explaining the experiences of nurses regarding the outcomes of ...
Human brains are getting larger. That may be good news for dementia risk
The research led by UC Davis compared the MRIs of people born in the 1930s to those born in the 1970s. It found gradual but consistent increases in several brain structures. For example, a measure that looked at brain volume (intracranial volume) showed steady increases decade by decade.
Improvement Method of Antenna Negative Sidelobes on Cross Beam ...
The Mills cross measurement system processes the received signals of two orthogonal fan beams and achieves "pencil" beam observation at the intersection of the fan beams [1,2].This system was first used in astronomy [3,4,5] and is a simple, small-area, low-cost antenna system design solution.In recent years, advancements in digital signal processing technology and microwave technology have ...