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R E S E A R CH A R T I C L E
Lived experiences of international operating room nurses inorgan procurement surgery: A phenomenological study
Weili Gao RN, PhD1 | Virginia Plummer RN, PhD2 | Lisa McKenna RN, PhD3
1School of Nursing and Midwifery, Monash
University, Melbourne, Victoria, Australia
2School of Nursing and Midwifery, Monash
University and Peninsula Health, Melbourne,
Victoria, Australia
3School of Nursing and Midwifery, La Trobe
University, Melbourne, Victoria, Australia
Correspondence
Weili Gao, School of Nursing and Midwifery,
Monash University, Building E McMahons
Road, Frankston, VIC 3199, Australia.
Email: [email protected]
Abstract
International operating room nurses come from different regions of the world with diverse
social and cultural backgrounds, religions, personal beliefs, and education. They are likely
to form unique attitudes toward multi-organ procurement that potentially might affect
their opinions and clinical practices. The aim of this phenomenological study was to
explore the lived experiences of international operating room nurses participating in
deceased organ procurement procedures in Australia. Semistructured interviews were
conducted with 18 international operating room nurses. van Manen's phenomenological
data analysis method was adopted to uncover and interpret meanings from these nurses'
descriptions. Four essential themes emerged and evolved to signify the meanings of partic-
ipants' experiences in organ procurement procedures: the surreality of death, personal and
professional challenges, becoming stronger, and personal beliefs and wishes. The present
study highlights the importance of cultural awareness in dealing with death, organ procure-
ment, and interprofessional collaboration in the multi-cultural perioperative context. It is
essential to provide clinical education and support around culture and practice transition
for international operating room nurses to increase and maintain their professional confi-
dence, career satisfaction, health, and well-being during organ procurement surgery.
K E YWORD S
culture, death, nurse, operating room, organ procurement
1 | INTRODUCTION
Organ donation is a life-saving medical treatment to improve the qual-
ity of life for patients with no alternative treatment options for their
end-stage organ failure. These life-transforming procedures involve
the removal of solid organs and tissues from one person's body and
transplantation of the tissue into that of another person's body. Peo-
ple's attitudes toward deceased organ donation can be influenced by
religion, with different religions having their unique philosophic views
of life and death (Shih, Chu, Hsu, Weng, & Wang, 2009).
1.1 | Literature review
The attitudes of healthcare professionals toward organ donation have
been explored in different countries. Discrepancies between their
attitudes and actual commitment to deceased organ donation have
been identified in several studies (Cantwell & Clifford, 2000; Chung
et al., 2008; Marck, Weiland, Neate, Hickey, & Jelinek, 2012). For
example, Chan, Po-lin, Lee, and Wong (1997) examined nurses' atti-
tudes toward deceased organ donation in Hong Kong and discovered
that one of the main reasons for unwillingness to donate organs was
concern for maintaining body integrity. This concern also exists in
other cultures and societies, such as Chinese Canadians, Koreans, and
Filipinos (Albright et al., 2005; Chung et al., 2008; Kim, Elliott, & Hyde,
2004; Pan et al., 2014; Starzomski & Curtis, 2010).
Operating room (OR) nurses play an essential role in the organ
donation process, predominantly in deceased organ procurement
surgery, and their personal experiences and feelings might generate
different attitudes toward organ procurement. As healthcare profes-
sionals, nurses' attitudes toward organ procurement have the
Received: 25 May 2019 Revised: 28 July 2019 Accepted: 26 August 2019
DOI: 10.1111/nhs.12651
Nurs Health Sci. 2020;22:5–13. wileyonlinelibrary.com/journal/nhs © 2019 John Wiley & Sons Australia, Ltd 5
potential to influence the attitudes of patients and the general public,
which might facilitate or hinder organ donation and transplantation
activity. A systematic review conducted by Gao, Plummer, and Wil-
liams (2017) found that OR nurses felt distressed, emotionally iso-
lated, and physically drained during their participation in organ
procurement. Often, they are not familiar with procurement proce-
dures (Regehr, Kjerulf, Popova, & Baker, 2004; Smith, Leslie, &
Wynaden, 2015a), because such surgery is not a common procedure
in the operating room. According to ShareLife (2018), a total of
87 hospitals performed organ procurement surgeries for 510 deceased
organ donors in 2017 across Australia, and 64% of these hospitals
only had four or fewer deceased organ donors. Therefore, it was
evidenced that there were few organ procurement opportunities for
OR nurses to experience. Furthermore, OR nurses reportedly find it
difficult to accept patients' deaths in the OR (Carter-Gentry &
McCurren, 2004; Wang & Lin, 2009), and are not familiar with post-
mortem care, because death and death-related care are rare events in
the OR (Fox, 1999; Gao et al., 2017).
The migration of international nurses is one of several strategies
currently addressing the Australian nursing workforce shortage, and
as the population is becoming more diverse and requiring bilingual
and bicultural care, the healthcare workforce gathers benefit from
valuable contributions of overseas nurses (Jones & Sherwood, 2014).
As international nurses move to a new country, the period of adjust-
ment to new living and work environments can also vary. They might
have a range of challenging experiences during their transitions, such
as homesickness, social isolation, language difficulties, discrimination,
adjusting to different cultural norms, and religious values (Alexis,
2015; Department of Health, 2012; Konno, 2006). Culture has a
strong influence on a person's beliefs, values, and behaviors, such as
communication styles, interactions with other people, and ways to
seek support (Williamson, 2007). In relation to seeking support, inter-
national nurses reportedly feel less stressed about seeking help and
support from other overseas nurses with similar experiences and
backgrounds (Taylor, 2005; Zhou, 2014). Furthermore, different cul-
tural and religious beliefs might also affect international nurses' values
and practices in dealing with dying patients.
International OR nurses potentially provide a unique contribution
to the organ procurement process. Their cultural backgrounds and
beliefs might influence interactions with other surgical teams and
affect their professional behaviors when participating in deceased
organ procurement surgery. Their attitudes toward organ donation
might also influence their families, friends, and surrounding cultural
and social groups.
1.2 | Aim
The aim of this study was to explore the lived experiences of interna-
tional OR nurses from non-English-speaking backgrounds participating
in deceased organ procurement procedures in Australia.
2 | METHODS
2.1 | Design
Phenomenology has the potential to grasp rich and full descriptions of
personal experiences to understand a phenomenon and comprehend
what it means to individuals in their “life-world” (Schneider, White-
head, LoBiondo-Wood, & Haber, 2013). In this study, a phenomeno-
logical approach informed by the work of van Manen (2016) was used
to identify and interpret the nature and meanings of international OR
nurses' lived experiences in organ procurement procedures. van
Manen (2016) advances phenomenological practice in the human sci-
ences by combining phenomenological theory and methodology to
explore the interrelationship between being and acting in human life
(van Manen, 2014). His phenomenology provided the mechanism for
people and groups to hear international nurses' voices, gain insight,
and discover hidden meanings of their lived experiences in organ pro-
curement procedures.
2.2 | Participants
In total, 18 international OR nurses, 12 females and 6 males, shared
their lived organ procurement experiences. These nurses were rec-
ruited from nine countries with nine different first languages. The
majority (n = 15) came from Asia. Their ages at the time of data collec-
tion ranged from 31 to 57 years. Six participants reported their
highest qualification as a bachelor degree, nine participants held post-
graduate certificates or diplomas, and three held masters qualifica-
tions. Their experiences in Australian OR ranged from 3 to 20 years.
2.3 | Data collection
All participants were recruited by snowball sampling, which is an infor-
mal referral method to recruit future research participants from exis-
ting ones who knew and provided the names of others (Streubert &
Carpenter, 2011). Audio-recorded, face-to-face, semistructured con-
versational interviews were conducted in private meeting rooms at
the participants' workplaces in 2017. The interviews lasted between
30 and 60 min. Data collection was completed in 4 months, and the
interviews were all conducted in English.
2.4 | Ethical considerations
Ethics approval was obtained from Monash University's Human
Research Ethics Committee (reference no.: 2017-8590-10395)
prior to commencement of the data collection. All participants were
provided with a verbal explanation of the study, information sheet,
and consent form to read in advance of the interview. A signed
informed consent form was obtained prior to the interview. Each
participant was assigned a pseudonym in reporting to protect their
identity.
6 GAO ET AL.
2.5 | Data analysis
In accordance with van Manen's (2014, pp. 320–321) data analysis
method, the researcher adopted a four step thematic analysis to
uncover and interpret meanings from nurses' lived experience descrip-
tions. First, participants were given the opportunity to recall and
describe memorable moments during organ procurement surgery in
Australia. Second, narrative descriptions from interview transcriptions
were converted into shorter anecdotes by deleting extraneous mate-
rial, then reflecting on them. Third, van Manen's (2014, 2016) three
approaches of thematization (wholistic, highlighting, and line-by-line
approach) were utilized to disclose lived meanings of participating in
organ procurement procedures. Finally, all emergent themes or sub-
themes from the rich descriptions and anecdotes were defined and
grouped into major themes that represented the essential meanings
of international OR nurses' experiences in organ procurement
procedure. These themes directed the phenomenological reflective
writing.
2.6 | Validity and reliability
This study was guided by van Manen's (2014) four validation criteria
to validate the strength, originality, and significance of the research.
First, a valid phenomenological question was formulated and focused.
Second, van Manen's thematic analysis was adopted to analyze the
descriptive material. The data and sources were treated rigorously by
keeping reflective journals and personal log, and identifying and
suspending the researcher's pre-assumptions and biases during the
data-collection process. Third, the phenomenological attitude was
adopted during the research process to maintain a strong connection
and interpretation of the true phenomenon. Finally, emerging themes
were reviewed and refined by research supervisors and peers to
enhance internal validity of the findings.
3 | RESULTS
By aligning with van Manen's four step thematic data analysis, inter-
national OR nurses' lived experiences in organ procurement procedure
were explored. Four essential themes emerged from the analysis: the
surreality of death, personal and professional challenges, becoming
stronger, and personal belief and wishes.
3.1 | The surreality of death
This theme included two subthemes: the tragic pain of experiencing
death and being unaccustomed to a lifeless human body.
3.1.1 | The tragic pain of experiencing death
As the patient's life could not be saved, a sense of helplessness and
pain emerged. Moreover, the first experience of being exposed to
death was memorable for many participants, as it was disturbing to
realize the reality of death as a human and a nurse. It was described
as tragic and surreal. Henry recalled his pain of the first time seeing a
patient's death, being switched off from a ventilator during brain
death donation surgery:
I said to myself: “Oh God, it's just happening, it's really
happening now, they had to stop the ventilator.” I felt
like almost crying…I felt a bit shocked because I haven't
seen that before. We heard about this, but I actually
haven't seen it (with) my own eyes. It's very sad, very
emotional; it is something that you cannot understand
that first time really. (Henry, Indonesia)
3.1.2 | Being unaccustomed to a lifeless human body
Additionally, when they realized that there was another aspect of
nursing care, the postmortem care that needed to be undertaken after
organ procurement surgery, they felt overwhelmed and uncomfort-
able. Stella stated:
It's not a pleasant thing to do, to be a part of proce-
dure. I'm fine, but at the end (postmortem care) I'm not
very comfortable. (Stella, India)
Some nurses deliberately avoided this unpleasant situation by trying
to do something else, rather than the postmortem care. Scrub and
scout nurse, Kaylee, gave her personal experiences of trying to avoid
postmortem care after organ procurement procedures:
I try to concentrate on my scrub and scout paperwork
and instrument…by that time the anesthetic nurse and
someone come to tidy up the body and do the finger-
print, so I'm just waiting and waiting until they have
done most of that, so I don't need to do that job.
(Kaylee, South Korea)
3.2 | Challenges
This theme included two subthemes: personal challenges and profes-
sional challenges.
3.2.1 | Personal challenges
Organ procurement procedures were found to be complex and
encompassed a wide array of physical, mental, emotional, and spiritual
challenges for all participants. Various cultural beliefs about organ
donation emerged, as these nurses came from different countries and
cultural backgrounds, which shaped their unique understandings of
the meaning of death, the human body, and organ donation:
GAO ET AL. 7
Our tradition, our custom, is our body is from our par-
ents. We cannot do anything about that because it's a
gift, we have to keep it as it is. (Kaylee, South Korea)
She (the patient) was (being cut) apart…she was taken
away by so many people.…It's quite against our, cul-
ture, the Chinese culture, once the person is dead,
leave her or leave him in peace, but…a big group was
working on (her) this and that…it's a bad feeling (Gia,
China)
3.2.2 | Professional challenges
Practicing in different countries can be challenging. International OR
nurses expressed different feelings after attending organ procurement
procedures in Australia compared to the countries in which they used
to practice. Vincent felt that postoperative mortem care in Australia
was disorganized:
The way we did it here (in Australia) is quite different
from what I'm used to. We just get bits and pieces
from everywhere to do the cleaning and the dressing….
It wastes a lot of time, and doesn't look very profes-
sional. (Vincent, Nigeria)
A few nurses specifically mentioned religious beliefs and practices
in other countries at the end of organ procurement procedures; for
example, having a priest in the OR, a table with the Bible and candle,
and prayer, which they felt could bring more comfort to the donor's
family as well as health professionals and be respectful to the donor.
Chloe expressed her different experiences in New Zealand:
They're a little bit more respectful in terms of dealing
with the dead, such as treat the person with dignity,
and put them (donors) in a nice white cover and posi-
tion them nicely. (Chloe, Philippines)
Most participants described feeling “nervous” or “stressed” when they
attended organ procurement procedures, especially for the first time,
because they were unable to anticipate the surgery. Stress could be
caused by a few factors according to participants' experiences. First,
participants felt a sense of loss of confidence in interacting with dif-
ferent surgical teams, as many surgeons came from different hospitals,
and they felt inefficient in their work due to ineffective communica-
tion between teams, unfamiliar procedures, and stress. Nurses were
unfamiliar or unclear about the sequence of the surgery and some
instruments, as this was an uncommon procedure, as some instru-
ments were brought in by the procurement team. Furthermore, most
participants also used “stressful,” “fast”, and “busy” to describe this
fast speed of the procedure:
Oh my God, it's just too fast. It's scary! I had four sur-
geons and a perfusionist yelling instructions at me…
hoping that I have probably six hands trying to give to
everyone what they need. I felt very rushed. (Madelyn,
Malaysia)
3.3 | Becoming stronger
This theme included two subthemes: “this is my way of coping” and
“there is a special spiritual and emotional reward”.
3.3.1 | “This is my way of coping”
All participants articulated their own ways of managing feelings and
emotions when facing death, organ procurement procedures, and
post-mortem care, as well as their personal and professional under-
standings of the meaning of their participation. Most described trying
to distance themselves from donors to protect their own personal
well-being by shutting down their personal feelings:
I'm not emotionally involving myself anymore, it's just
a part of my cooperation; I don't want to get involved
too much, otherwise I will be affected. (Gemma,
Philippines)
However, some participants admitted that it was more difficult to dis-
tance themselves from pediatric patients as they would spontaneously
relate them to their own children:
I'm not really affected anymore with this, like seeing
that all the time, but with a child it's a different story…
my first exposure was a 5 year old boy…it's really hard,
because I can relate to that, seeing my kids the same
way. (Gemma, Philippines)
After the procedure and the “adrenaline rush” was a time that deeply
impacted these nurses' emotions, because they started to process
their thoughts and feel for the patient and family. Therefore, partici-
pants expressed the importance of having a break after the organ pro-
curement procedure. Nevertheless, having a break would not
guarantee that people would recover from the emotional experience
straight away. Other nurses might take longer or have different ways
to process their thoughts and digest their feelings, such as releasing
feelings privately or going home:
That was such a long 10 hour' shift…so I wasn't up to
talking about it. I was physically, emotionally, and men-
tally exhausted. (I) just wanted to go home to my fam-
ily and relax. (Violet, Philippines)
As time went by, nurses learnt from the experiences of their col-
leagues, friends, work, and personal life experiences. Participants
obtained support from their colleagues and supported each other by
giving hugs and comfort. When Nathan saw his colleagues being
8 GAO ET AL.
emotional and crying after a sad experience of viewing a family's grief
inside the theatre, he was very sympathetic to his colleague:
We have to console each other, the only comfort that I
can give is just to give them a hug. That's it. What are
you going to say? The patient (has) already died, so I
just give them a hug; it helps. (Nathan, Philippines)
During organ procurement procedures, participants described feeling
emotionally burdened, because the patient died regardless of what
they did, and they felt sadness and loss for the family. Some felt a
desire to pray for them. Sue, a Chinese nurse, would normally pray,
even if the body had left, because she believed the patient's soul was
still there: “
I feel strongly (that) I need to pray, because I still
believe that the soul is still there”.
3.3.2 | “There is a special spiritual and emotionalreward”
These coping strategies reflect these nurses' abilities to build resil-
ience in their personal lives and professional practice in these chal-
lenging times. Participants also felt honored and comforted when they
received a letter from the donation organization regarding the out-
come of transplantation after the procurement surgery. Interestingly,
one participant specifically mentioned a chance encounter with a
donor's family member in the hospital canteen. This recognition and
praise from the donor's relative was a significant reward and reassur-
ance for what they had done:
It was good feeling to hear that from him. That (is) big
to me, I have really thought hard about it…you've got
to love to do it…when someone recognize(s) and say(s)
“Thank you, well done”, you see good things. I like that.
(Ethan, Ghana)
3.4 | Personal beliefs and wishes
This theme included two subthemes: beliefs and wishes.
3.4.1 | Beliefs
After experiencing the organ procurement procedure, participants
revealed their deep personal and professional beliefs. They believed
that donors deserved to have the best patient-centered care during
their surgery. Although they addressed this belief of respect differ-
ently, meanings were similar and echoed across all their descriptions.
Violet reported caring for one little girl where she tried to accommo-
date the family's requests, such as putting a pink ribbon in her hair
and leaving her teddy bear with her:
We have to make sure to do all the proper cleaning
with no hesitation. We try our best to give them what
they need in the last moment of their life. (Gemma,
Philippines)
They believed that OR nurses should advocate for the patient's pri-
vacy and dignity. Some participants argued that retrieval teams should
be more mindful of their practice and behaviors in dealing with donors
and other team members, such as inappropriate conversations
between surgeons. There should be no difference in care between the
living and dead:
I just feel like you look after your patient when they
need you when they're alive; you have to give the
same dignity when they're dead. (Chloe, Philippines)
3.4.2 | Wishes
Furthermore, participants experienced the reality of organ procure-
ment procedures, so they expressed the desire for more respect, care,
and support to make their experience better in the future. A few
wishes arose from their experiences and expectations, which indicate
their cares and concerns for the rights, compassion, and well-being of
the patient, other nursing colleagues, and themselves. First, although
the patient was dead, Chloe felt strongly that people should not leave
the patient during the surgery. Her duty of care as a nurse drove her
to stay with the patient and other staff, such as making sure the
patient was cared for, maintaining their dignity, and supporting every-
one in need. Thus, when she saw her anesthetist leave the OR, she
thought:
Why are you leaving? This is still your patient! The
anesthetist is gone, surgeons are gone, I feel I need to
be there, help out (with) whatever they (donors) need.
(Chloe, Philippines)
Second, most participants expressed concern about the well-being of
new or junior staff during the procedure:
(A) junior nurse who has not experienced a death of a
patient before, there is no support after….It's pretty
much if you feel that you need to talk to somebody
then you have to look for somebody to talk to, there is
no support system in place….Procurement is not part
of something that we teach in a university…it's not the
same until you experience it. (Madelyn, Malaysia)
Therefore, they wished that inexperienced staff could have better
emotional and technical support at those critical points of time in
order to enhance the lifelong learning experience in their nursing
career.
GAO ET AL. 9
Third, debriefing after the organ procurement procedure could
help staff to express their emotional feelings, as well as share their
experiences, in order to assist staff to cope with stressful or emotional
situations. However, some participants believed that different cultural
backgrounds and language barriers limited their understanding of
“Westernized debriefing”, such as clarification and comforting. There-
fore, Kaylee would have preferred to have a debriefing in her own
language:
If someone is debriefing in (the) Korean language, it
hits me, but if it's translated to English, it won't hit
me. It doesn't help at all…counselling in English doesn't
help at all, even very simple word(s) (are) different.
(Kaylee, South Korea)
4 | DISCUSSION
From international OR nurses' descriptions of their experiences of
deceased organ procurement procedure, it became evident that they
struggled to face donors' deaths and became emotionally drained,
which could affect their health and well-being. These experiences are
consistent with research by Lambert (2004), who conducted a study
on workplace stressors in 1554 nurses in Japan, Thailand, South
Korea, and the USA, and found that dealing with death and dying was
one of the most stressful events in nursing, regardless of culture and
country. In fact, exposure to death and death-related issues could
evoke intense emotional responses that could lead to secondary trau-
matic stress, such as intrusive thoughts or disturbing dreams about
patients, powerlessness, and meaninglessness (Missouridou, 2017).
Moreover, nurses' early experiences with patient death can be a
salient event, especially for novice nurses (Anderson, Kent, &
Owens, 2015).
International OR nurses disclosed that their cultural consider-
ations, and limited experiences and knowledge in OR postmortem
care, caused them to feel distressed in performing postmortem care.
Some nurses, especially scrub nurses, admitted not wanting to partake
in preparing the dead body, and deliberately focused on doing
unrelated tasks, such as doing paperwork or cleaning instruments, to
avoid these unpleasant situations. The experiences of postmortem
care might influence their attitudes toward this practice in the future,
as well as the way they support junior nurses (Martin &
Bristowe, 2015).
Participants in this study spoke of different understandings and
beliefs about organ donation and related challenges when participat-
ing in organ procurement procedures in Australia. A study conducted
by Yang and Miller (2015) explored different perceptions toward brain
death and organ donation in Eastern and Western societies, and
found less acceptance of brain death and organ donation in Asia due
to deep-rooted cultural and religious traditions. There was consider-
able diversity in organ donation beliefs among these international OR
nurses. Healthcare professionals' personal beliefs could influence
individual attitudes regarding organ donation; subsequently their atti-
tudes towards organ donation could influence the organ donation
process (Ahlawat et al., 2013; Irving et al., 2012). Some participants in
this study were torn between their inner existing cultural beliefs about
organ donation and the reality of the procurement procedure in
Australia. International OR nurses' cultural values might affect their
way of expression or coping, and could affect their attitudes,
decision-making, and behaviors. This might cause challenges and con-
flicts with people from different cultural backgrounds during their
practice in the organ procurement procedure (Jose, 2011; Zhong,
McKenna, & Copnell, 2017).
Generally, a significant lack of emotional and professional educa-
tion in preparing OR nurses for organ procurement surgery was iden-
tified. Consistent with previous studies (Jose, 2011; Zhong et al.,
2017), some international OR nurses in this study noticed different
nursing practices between different countries, but to the best of our
knowledge, there is no existing literature exploring international OR
nurses' different practices in organ procurement procedures; for
example, postmortem set-up, different ceremonial or religious prac-
tices, and ways to present the body. Furthermore, effective profes-
sional communication is a complex practice that requires skills to
interact with each other. Communication barriers do not only involve
accents and pronunciation between those from non-English speaking
backgrounds and native-language speakers, but also include the way
people talk (Aveling et al., 2018).
Most participants in this study tried to keep their distance from
donors in order to cope with their deaths during the surgery. This was
mirrored in other studies (Regehr et al., 2004; Wang & Lin, 2009).
Peer support is a common and crucial strategy that nurses use to cope
with death experiences. OR nurses are not only expected to provide
emotional support to donors' families where possible during the pro-
cedure, they also care for other health professionals psychologically
and physically (Austin, Lovett, Moore, & Zuzarte, 2018).
In accordance with other studies, OR nurses in the current study
wanted to fulfil their nursing commitment or promise to donors and
their families by respecting donors' privacy, maintaining their dignity,
and acting as their advocates (Blomberg, Bisholt, Nilsson, & Lindwall,
2015; Munday, Kynoch, & Hines, 2015). Participants were urged to
approach the organ procurement process as person-oriented surgery,
instead of a task-oriented procedure, treating the donor as an individ-
ual person who needed surgery instead of a dead body with organs.
International OR nurses in this study strongly emphasized clinical
and emotional concerns for junior or inexperienced nurses during
organ procurement procedures, because they might not be experi-
enced with fast-paced surgical techniques or dealing with death,
which can have a negative impact on them. This echoed the findings
of Lomero, Jiménez-Herrera, Rasero, and Sandiumenge (2017) that
organ donation knowledge and training among nurses are lacking.
Clayton, Isaacs, and Ellende (2016) suggested that mentoring pro-
grams for experienced nurses with international cultural backgrounds
could be helpful for international nurses to acculturate into the host
country's workforce. Moreover, mentoring programs are common
practice in OR, where a mentor provides experiential learning
10 GAO ET AL.
opportunities to guide inexperienced nurses to learn and grow in their
practice (Smith, Leslie, & Wynaden, 2015b). However, Smith et al.
(2015b) identified that mentoring opportunities in organ procurement
procedures are limited due to staff shortages and a lack of suitably
experienced nurses. Furthermore, according to Norman (2015), men-
tors' personal and professional experiences might influence their
beliefs and perceptions over the years, which could shape their ways
of supporting other staff in organ procurement surgery. Therefore, it
is important to understand every mentor's beliefs and values about
their role in the procedure before giving professional and emotional
support and guidance to new or inexperienced nurses.
Debriefing is one strategy that nurses prefer to use to cope with
distressing situations (Wilson, Goettemoeller, Bevan, & McCord,
2013). Some participants expressed a wish to seek emotional support
from nurses with similar cultural backgrounds or experiences, as they
felt it would be easier to express feelings and be understood by them.
This finding which was similar to other studies (Kishi, Inoue,
Crookes, & Shorten, 2014; Yi & Jezewski, 2000; Zhou, 2014). From a
cultural aspect, they also felt that other international nurses could
understand their beliefs and perceptions of organ donation better.
Therefore, debriefing in different languages or groups could be con-
sidered to facilitate psychological process.
The implications for future practice include organ donation educa-
tion, which needs to consist of a structured orientation program in
donation hospitals to meet the needs of international OR nurses, com-
prising diverse cultural awareness, language and communication skills,
and organ donation policies and guidelines. This should be supported
by an in-service education program and tertiary international nursing
programs for practice transition into the Australian workforce and for
the cultural transition to death and organ donation. It would also be
necessary to establish a support program, such as coping strategies
and problem-solving skills, for international OR nurses so they can be
prepared for future practice in the organ procurement procedures.
Healthcare organizations should develop a mentoring or preceptor
program in organ donation that includes some experienced interna-
tional nurses for personalized emotional and technical support. This
could reduce their work-related stress and avoidance of certain
aspects of the role, and enhance their physical and psychological well-
being.
4.1 | Limitations
There are limitations identified and acknowledged in this study. First,
there was a geographical restraint, as all participants were recruited in
the same city, and all worked in the public health system. Second, data
were gathered through participants' memories. There was some time
distance between their experiences and the interviews: their experi-
ences might not have been as accurately or vividly recalled as they
would have been immediately after the event. Third, despite all partic-
ipants coming from different countries with diverse cultural back-
grounds, it is not possible to generalize the interpretations from this
study, nor to represent all international OR nurses' organ procurement
experiences in Australia due to the methodology of phenomenology.
4.2 | Conclusion
International OR nurses' powerful experiences and voices give
healthcare professionals and leaders opportunities to understand
these nurses' needs by seeing what they see, hearing what they hear,
and feeling what they feel, which were portrayed in the findings. Four
essential themes emerged from the data: the surreality of death, per-
sonal and professional challenges, becoming stronger, and personal
beliefs and wishes. Participants' valuable experiences and suggestions
will enhance awareness and considerations for international OR
nurses' in organ procurement procedures in Australia, as well as high-
light cultural awareness in dealing with death, organ procurement, and
interprofessional collaboration in the multi-cultural perioperative con-
text. With understanding and support, international OR nurses could
provide optimal nursing care to donors and their families, as well as
support to peers and colleagues, while maintaining their own health
and well-being during this sensitive practice.
ACKNOWLEDGMENT
The authors sincerely appreciate all the participants for sharing their
experiences.
AUTHOR CONTRIBUTIONS
Study design: W.G., V.P., and L.M.
Data collection: W.G.
Data analysis: W.G., V.P., and L.M.
Manuscript writing and revisions for important intellectual con-
tent: W.G., V.P., and L.M.
ORCID
Weili Gao https://orcid.org/0000-0001-6850-3681
Lisa McKenna https://orcid.org/0000-0002-0437-6449
REFERENCES
Ahlawat, R., Kumar, V., Gupta, A. K., Sharma, R. K., Minz, M., & Jha, V.
(2013). Attitude and knowledge of healthcare workers in critical areas
towards deceased organ donation in a public sector hospital in India.
National Medical Journal of India, 26(6), 322–326.Albright, C. L., Glanz, K., Wong, L., Dela Cruz, M. R., Abe, L., &
Sagayadoro, T. L. (2005). Knowledge and attitudes about deceased
donor organ donation in Filipinos: A qualitative assessment. Transplan-
tation Proceedings, 37(10), 4153–4158.Alexis, O. (2015). Internationally recruited nurses' experiences in England:
A survey approach. Nursing Outlook, 63(3), 238–244.Anderson, N. E., Kent, B., & Owens, R. G. (2015). Experiencing patient
death in clinical practice: Nurses' recollections of their earliest memo-
rable patient death. International Journal of Nursing Studies, 52(3),
695–704.Austin, E. A., Lovett, P., Moore, W. C., & Zuzarte, I. (2018). Pediatric peri-
operative nurses and the ethics of organ donation after cardiac death.
AORN Journal, 107(4), e1–e8.
GAO ET AL. 11
Aveling, E.-L., Stone, J., Sundt, T., Wright, C., Gino, F., & Singer, S. (2018).
Factors influencing team behaviors in surgery: A qualitative study to
inform teamwork interventions. The Annals of Thoracic Surgery, 106(1),
115–120.Blomberg, A. C., Bisholt, B., Nilsson, J., & Lindwall, L. (2015). Making the
invisible visible – Operating theatre nurses' perceptions of caring in
perioperative practice. Scandinavian Journal of Caring Sciences, 29(2),
361–368.Cantwell, M., & Clifford, C. (2000). English nursing and medical students'
attitudes towards organ donation. Journal of Advanced Nursing, 32(4),
961–968.Carter-Gentry, D., & McCurren, C. (2004). Organ procurement from the
perspective of perioperative nurses. AORN Journal, 80(3), 417–421,424–431. https://doi.org/10.1016/S0001-2092(06)60535-8.
Chan, Y. M., Po-lin, P. L., Lee, W. K., & Wong, N. H. (1997). Attitudes of
Hong Kong nurses toward cadaveric organ donation. ANNA Journal,
24(4), 413–419; discussion 420-411.
Chung, C., Ng, C., Li, J., Sum, K., Man, A., Chan, S., … Lee, P. (2008). Atti-
tudes, knowledge, and actions with regard to organ donation among
Hong Kong medical students. Hong Kong Medical Journal, 14(4),
278–285.Clayton, J., Isaacs, A., & Ellende, I. (2016). Perioperative nurses' experi-
ences of communication in a multicultural operating theatre: A qualita-
tive study. International Journal of Nursing Studies, 54, 7–15.Department of Health. (2012). Supporting international nurses & midwife
graduates. Retrieved from https://www2.health.vic.gov.au/Api/
downloadmedia/%7B879E3180-9A98-4573-AB2F-
9871BBE72365%7D
Fox, R. (1999). Organ procurement: What is our role and what do we need
to know? ACORN, 12(3), 19–22.Gao, W., Plummer, V., & Williams, A. (2017). Perioperative nurses' atti-
tudes towards organ procurement: A systematic review. Journal of
Clinical Nursing, 26(3–4), 302–319.Irving, M. J., Tong, A., Jan, S., Cass, A., Rose, J., Chadban, S., … Howard, K.
(2012). Factors that influence the decision to be an organ donor: A
systematic review of the qualitative literature. Nephrology Dialysis
Transplantation, 27(6), 2526–2533.Jones, C. B., & Sherwood, G. D. (2014). The globalization of the nursing
workforce: Pulling the pieces together. Nursing Outlook, 62(1), 59–63.Jose, M. M. (2011). Lived experiences of internationally educated nurses
in hospitals in the United States of America. International Nursing
Review, 58(1), 123–129.Kim, J. R., Elliott, D., & Hyde, C. (2004). Korean health professionals' atti-
tudes and knowledge toward organ donation and transplantation.
International Journal of Nursing Studies, 41(3), 299–307.Kishi, Y., Inoue, K., Crookes, P., & Shorten, A. (2014). A model of adapta-
tion of overseas nurses: Exploring the experiences of Japanese nurses
working in Australia. Journal of Transcultural Nursing, 25(2), 183–191.Konno, R. (2006). Support for overseas qualified nurses in adjusting to
Australian nursing practice: A systematic review. International Journal
of Evidence-Based Healthcare, 4(2), 83–100.Lambert, V. (2004). Cross-cultural comparison of workplace stressors,
ways of coping and demographic characteristics as predictors of physi-
cal and mental health among hospital nurses in Japan, Thailand, South
Korea and the USA (Hawaii). International Journal of Nursing Studies, 41
(6), 671–684. https://doi.org/10.1016/S0020-7489(04)00033-1Lomero, M. D. M., Jiménez-Herrera, M. F., Rasero, M. J., &
Sandiumenge, A. (2017). Nurses' attitudes and knowledge regarding
organ and tissue donation and transplantation in a provincial hospital:
A descriptive and multivariate analysis. Nursing & Health Sciences, 19
(3), 322–330.Marck, C. H., Weiland, T. J., Neate, S. L., Hickey, B. B., & Jelinek, G. A.
(2012). Personal attitudes and beliefs regarding organ and tissue dona-
tion: A cross-sectional survey of Australian emergency department cli-
nicians. Progress in Transplantation, 22(3), 317–322.
Martin, S., & Bristowe, K. (2015). Last offices: Nurses' experiences of the
process and their views about involving significant others. International
Journal of Palliative Nursing, 21(4), 173–178.Missouridou, E. (2017). Secondary posttraumatic stress and nurses emo-
tional responses to patients trauma. Journal of Trauma Nursing, 24(2),
E3–E4.Munday, J., Kynoch, K., & Hines, S. (2015). Nurses' experiences of advo-
cacy in the perioperative department: A systematic review. JBI Data-
base of Systematic Reviews and Implementation Reports, 13(8),
146–189.Norman, K. (2015). How mentors can influence the values, behaviours and
attitudes of nursing staff through positive professional socialisation.
Nursing Management (2014+), 22(8), 33.
Pan, X., Liu, L., Xiang, H., Ding, C., Ren, L., & Xue, W. (2014). Current atti-
tudes toward organ donation after cardiac death in northwest China.
Chinese Medical Journal, 127(5), 835–838.Regehr, C., Kjerulf, M., Popova, S. R., & Baker, A. J. (2004). Trauma and
tribulation: The experiences and attitudes of operating room nurses
working with organ donors. Journal of Clinical Nursing, 13(4),
430–437.Schneider, Z., Whitehead, D., LoBiondo-Wood, G., & Haber, J. (2013).
Nursing and midwifery research: Methods and appraisal for evidence-
based practice (4th ed.). Chatswood, Australia: Elsevier.
ShareLife. (2018). Australian organ donation performance. Retrieved from
http://www.sharelife.org.au/australian-organ-donation-performance
Shih, F., Chu, S., Hsu, R., Weng, H., & Wang, S. (2009). Ethical issues
of organ transplantation in Chinese community: Perspectives of
health professionals, legal professionals, and religious experts in
Taiwan and Mainland China. Transplantation Proceedings, 41(1),
17–19.Smith, Z., Leslie, G., & Wynaden, D. (2015a). Australian perioperative
nurses' experiences of assisting in multi-organ procurement surgery: A
grounded theory study. International Journal of Nursing Studies, 52(3),
705–715.Smith, Z., Leslie, G., & Wynaden, D. (2015b). Experiential learning not
enough for organ procurement surgery: Implications for perioperative
nursing education. Progress in Transplantation, 25(4), 339–350.Starzomski, R., & Curtis, B. (2010). Perspectives on organ and tissue dona-
tion among Chinese Canadians. CANNT Journal, 21(4), 22–25.Streubert, H. J., & Carpenter, D. R. (2011). Qualitative research in nursing:
Advancing the humanistic imperative (5th ed.). Philadelphia, PA: Wolters
Kluwer.
Taylor, B. (2005). The experiences of overseas nurses working in the NHS:
Results of a qualitative study. Diversity in Health & Social Care, 2,
17–27. Retrieved from http://diversityhealthcare.imedpub.com/the-
experiences-of-overseas-nurses-working-in-the-nhs-results-of-a-quali
tative-study.pdf
van Manen, M. (2014). Phenomenology of practice: Meaning-giving methods
in phenomenological research and writing. Walnut Creek, CA: Left Coast
Press.
van Manen, M. (2016). Researching lived experience: Human science for an
action sensitive pedagogy. London: Routledge.
Wang, Y. J., & Lin, C. Y. (2009). The experience of perioperative nurses
involved in organ procurement. Journal of Nursing Research, 17(4),
278–285.Williamson, G. (2007). Providing leadership in a culturally diverse work-
place. Workplace Health & Safety, 55(8), 329–335.Wilson, M. A., Goettemoeller, D. M., Bevan, N. A., & McCord, J. M. (2013).
Moral distress: Levels, coping and preferred interventions in critical
care and transitional care nurses. Journal of Clinical Nursing, 22(9–10),1455–1466.
Yang, Q., & Miller, G. (2015). East-west differences in perception
of brain death. Review of history, current understandings, and
directions for future research. Journal of Bioethical Inquiry, 12(2),
211–225.
12 GAO ET AL.
Yi, M., & Jezewski, M. A. (2000). Korean nurses' adjustment to hospitals in The
United States of America. Journal of Advanced Nursing, 32(3), 721–729.Zhong, Y., McKenna, L., & Copnell, B. (2017). What are Chinese nurses'
experiences whilst working overseas? A narrative scoping review.
International Journal of Nursing Studies, 74, 101–111.
Zhou, Y. (2014). The experience of China-educated nurses working in
Australia: A symbolic interactionist perspective. PLoS One, 9(9), e108143.
How to cite this article: Gao W, Plummer V, McKenna L.
Lived experiences of international operating room nurses in
organ procurement surgery: A phenomenological study. Nurs
Health Sci. 2020;22:5–13. https://doi.org/10.1111/nhs.12651
GAO ET AL. 13