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: weiligao6@gmail.com

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

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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