Ethical issues in the operating room: A scoping review

Abstract

Background

For the patients receiving care in the operating room, it emphasizes that the ethical behavior and attitude of health professionals should be aligned with patients’ basic human rights. Surgical ethics may provide an ethical alternative in a specific operating room context. However, it is unclear how actively research is being conducted in this regard.

Aim

This study determines the direction of future research by identifying ethical issues experienced in the operating room.

Method

This scoping review is based on the methodological framework suggested by Arksey and O’Malley in 2005. PubMed, CINAHL, EMBASE, WOS, Cochrane, KISS, and KMbase databases were searched from January 2012 to May 2022. Two researchers independently screened the searched articles by reviewing the titles, abstracts, and full texts. Consequently, 19 studies were selected.

Findings

Five categories were identified: Professional ethics, Organizational ethics, Patients’ rights, Patient safety, and Allocating resources. The derived categories covered all the same content as the International Council of Nurses’ (ICN) code of ethics, with the exception of one element, that is, global health.

Conclusions

This study highlights ethical issues in the operating theatre and emphasizes the need for individual and organizational strategies aligned with the ICN code of ethics. Future research should cover a wider range of issues, employ diverse perspectives and methodologies, and enhance ethical practices to improve understanding and ethical practices in the field.

Keywords

Ethics healthcare providers operating room patients’ rights scoping review surgical ethics

Introduction

The operating room (OR) is a self-contained environment where doctors and nurses collaborate to provide healthcare services to patients for a specific duration. In the OR, several environmental factors and unique circumstances lead to varied ethical situations. Surgical services are closely intertwined with scientific and technological advancements. Unlike other clinical settings, the OR is a highly demanding environment with a constant need for high concentration, delicate skills, and seamless collaboration.¹ Healthcare providers in the OR face significant ethical challenges arising from the characteristics of their work, which are closely related to patients’ lives, where even a minor error or lapse in judgment can have severe consequences for patient safety and well-being. Considering complex situations, healthcare providers in the OR have no choice but to possess a blend of ethical insights and clinical expertise to make choices that uphold both professional standards and the best interests of the patients.² In addition, since surgical patients are often unconscious and highly vulnerable, healthcare professionals who participate in the surgery bear ethical responsibility for the entire procedure. Addressing the ethical issues encountered in the OR becomes crucial for the professional growth of healthcare professionals.

Background

Surgical ethics is a subfield of bioethics that ensures an ethical approach to surgery, considering surgery’s unique context.³ Surgical ethics is developed from the morality in the OR based on the rights of patients receiving care.^3,4 It emphasizes that healthcare professionals’ ethical behavior and attitudes should be aligned to the patient’s basic human rights.^4,5 With the growing societal interest in patients’ rights in the OR, the healthcare field’s interest in approaching and managing ethical issues is increasing.

Ethical issues in the surgical field arise when individuals or organizations are faced with choosing between right (ethical) and wrong (unethical) alternatives, which can significantly impact patient care and well-being. There are various ethical issues that have been reported through research, including resource and time allocation,⁶ ghost surgery,⁷ patient safety,⁸ privacy,⁹ decision-making, and communication among staff members.¹⁰ Even surgical technology students encounter ethical dilemmas.^11–13 These ethical issues have been attributed to various factors, including a hierarchical structure that hinders effective communication and decision-making,¹⁴ intra-team conflict that creates tensions that may compromise patient care,¹⁵ and individual ethical practices that have significant implications for care integrity.¹⁶

Since ethical issues are inherent in surgical care, managing them can lead to improved quality of care, reduced staff burnout and decreased moral distress,¹⁷ for which a study that identifies actively researched issues and gaps in surgical ethics, thereby bridging the divide between theory, practice, and research, is necessary. While many studies have been conducted focusing on individual ethical issues in the OR, there remains a need to examine the current ethical issues from a comprehensive and synthesized standpoint. Therefore, this study’s primary objective is to comprehensively identify and analyze the ethical issues faced in the OR, providing valuable insights to improve ethical practices and patient care in surgical settings.

Methods

This study is a scoping review aimed at identifying ethical issues experienced in the OR. A scoping review is a suitable methodology for investigating the range and characteristics of research activities by mapping related literature. We followed the five scoping review steps outlined in the methodological framework of Arksey and O’Malley¹⁸ and adhered the Preferred Reporting Items for Systematic Reviews and Meta-Analyses extension for Scoping Reviews (PRISMA-ScR) Checklist.¹⁹

Step 1: Identifying the research questions

We used the Population-Concept-Context (PCC) model as a study design, in which “Population (P)” represents “patients, healthcare providers,” “Concept (C)” refers to “ethical issues,” and “Context (C)” denotes “operating room.” The research questions are as follows:

Research Question 1

What ethical issues have been the focus of research on surgical ethics?

Research Question 2

To what extent does the ethical scope of current research address the contents of the International Council of Nurses’ (ICN) code of ethics?

Step 2: Identifying relevant studies

Search strategy

Three researchers with expertise in literature reviews participated in the search strategy. The search period was from January 2012 to May 2022. The year 2012 was selected as the base year for the search, since this was when the ICN code was revised to include additional emphasis on patient dignity due to increasing social demand for patient rights and ethical awareness among healthcare providers.²⁰ The search query was finalized through a review by a librarian at the medical library.

The main keywords involved in the query were “ethics, surgical ethics, nursing ethics, medical ethics, clinical ethics, ethical” in the first category, “operative, surgical, operating room” in the second category, and “patients, healthcare provider, physician, nurse, doctor, surgeon” in the last category. PubMed, Cumulative Index to Nursing and Allied Health Literature (CINAHL), Excerpta Medica Database (EMBASE), Web of Science (WOS), Cochrane Library, Korean Studies Information Service System (KISS), and Korean Medical database (KMbase) were searched.

Data inclusion and exclusion criteria

Among the searched studies, we targeted original articles and excluded review articles, case reports, and grey literature. The language chosen was English. According to the designed PCC criteria, the population included studies that targeted healthcare providers or patients. As this study is about ethical issues in the OR, literature dealing with treatment and technical effects, such as surgical skills or methods and the use of preventive antibiotics, were excluded. The context was limited to the OR. Studies outside the OR, such as general wards and intensive care units, were excluded (Table 1).

Table 1.

Search strategy.

	Derived search terms	Inclusion criteria	Exclusion criteria
P “Population”	“patients” OR “healthcare provider” OR “physicians” OR “nurse” OR “doctor” OR “surgeon”	Healthcare providers or patients	Students
C “Concept”	“ethics” OR “surgical ethics” OR “nursing ethics” OR “medical ethics” OR “clinical ethics” OR “ethical”	Ethical issues in the operating room	Treatment and technical effects, such as surgical skills or methods and the use of preventive antibiotics.
C “Context”	“operative” OR “surgical” OR “ operating room”	The digital health technology applied to patient safety intervention	Outside the operating room, such as general wards and intensive care units.

Step 3: Study selection

The search result identified a total of 9497 articles. We excluded 2014 duplicates and only reviewed the titles and abstracts of 7483 articles. Of the 7483 articles, 7303 did not meet the criteria. Hence, only the full text of 180 articles were reviewed. From the 180 articles, we excluded 21 articles in which the original text was inaccessible. From the remaining 159 articles, we excluded 49 grey literature, eight articles that did not target healthcare providers and patients, 63 articles dealing with situations outside the OR, 21 articles unrelated to surgical ethics, and one article not written in English. After reviewing the references, two articles were added, giving a total 19 articles were used in this review (Figure 1).

Figure 1.

PRISMA diagram for ethical issues in the operating room. Cumulative Index to Nursing and Allied Health Literature (CINAHL); PubMed; Cochrane Library; Excerpta Medica Database (EMBASE); Web of Science (WOS); Korean studies Information Service System (KISS); Korean Medical database (KMbase).

Step 4: Charting the data

To determine the quality of the selected studies, we used the Mixed Methods Appraisal Tool (MMAT) as a research evidence tool.²¹ We then used an inductive approach to categorically summarize the ethical issues, research methods, and results. Two researchers independently reviewed each piece of literature and compared their review results several times to ensure research validity. The general and thematic characteristics of the derived literature were analyzed using Krippendorff’s content analysis, which offers a more profound understanding of the data and facilitates the generation of valuable insights.²² From Krippendorff’s content analysis, the year of publication, countries, research methods, and research subjects were identified for general characteristics while key meanings, sub-categories, and categories were derived for thematic characteristics. A specific study process was followed. First, two researchers reviewed the literature to confirm the contents related to surgical ethics. Second, two researchers with a deep understanding of the contents of the ICN code of ethics reviewed the results and discussions of the selected studies, extracted meaningful sentences, and grouped similar ones together to generate key meanings. Third, sub-categories were derived by grouping similar key meanings. Finally, the main category was derived by synthesizing the sub-categories. The main categories were compared and analyzed using the ICN code of ethics, considering key meanings and sub-categories. We then redefined the terms in the OR context and reviewed and cross-checked across the 19 studies.

Step 5: Collating, summarizing, and reporting results

The contents summarizing the study results and the number of articles on the analyzed items are presented in tables described in the Results section.

Results

General characteristics

Of the 19 studies, seven were published from 2012 to 2017 and 12 from 2018 to 2022, confirming that surgical ethics research has been actively conducted and trending in recent years. Most studies were conducted in Asia, followed by seven and five in America and Europe, respectively, and two in other countries. The research method involved nine quantitative studies, of which most were descriptive (n = 7), eight qualitative studies, and two mixed studies. The participants were healthcare providers (n = 12), teams (n = 4), patients (n = 2), and patients and nurses (n = 1). The quality of the studies was assessed, and 13 articles met or exceeded 80% of the MMAT quality criteria, while the remaining articles fell below this threshold. According to the criteria, weak areas were identified in the quantitative descriptive type, such as the risk of nonresponse bias and inappropriate statistical analysis. In the mixed methods type, the weak areas included a lack of rationale for using a mixed methods approach and a lack of adherence to traditional quality assessment criteria for each methodology. Details are listed in Tables 2 and 3.

Table 2.

General characteristics of the included studies (N=19).

Characteristics	Categories	Description
The year of publication	2012–2017	7
The year of publication	2018–2022	12
Countries^*	Asia	7
	America	5
	Europe	5
	Others (Egypt, international)	2
Methods	Quantitative	9
	Descriptive	7
	Experimental	2
	Qualitative	8
	In-depth interview	5
	Focus group interview	2
	Observation	1
	Mixed method	2
Population^†	Nurse	7
	Physician	6
	Operating team	4
	Patient	3

^*Countries are classified by continents.

^†Study with nurses and patients [A2] count in each category (multiple counts).

Table 3.

Description of included studies.

No	Authors	Year, countries	Aims	Methods	Samples	Sample size	Results	Categories	MMAT (%)
A1	Aghamohammadi, Imani, and Moghadari Koosha¹	2021, Iran	To investigate operating room nurses’ lived experiences of ethical codes.	Qualitative/In-depth interview	Operating room nurses (6) Anesthesia nurses (3) Operating room manager (1)	10	- Three main themes were revealed – Adherence to professional ethical principles; preserving patient dignity; respecting colleagues	Professional ethics	100
A2	Akyüz and Erdemir²³	2013, Turkey	To determine the opinions and expectations of patients and nurses about privacy during a hospital admission for surgery.	Mixed method	Nurses (47) Patients (102)	149	- 75.5% of patients have not experienced an uncomfortable situation and 24.5% of patients sometimes experienced an uncomfortable situation - Nurses do not share personal information and knock on the door for patients’ privacy - Patient expected nurses to respect their physical confidentiality	Professional ethics Patients’ rights	71.4
A3	Sepehrirad et al⁹	2021, Iran	To evaluate the relationship between moral sensitivity, ethical climate, and job strain with respect to patients’ privacy in operating room	Quantitative/descriptive	Nurses	132	- Moral sensitivity and ethical climate correlate with privacy - Job strain and privacy have negative correlation	Professional ethics Organizational ethics Patients’ rights	85.7
A4	Silas, Grassia, and Langerman²⁴	2015, U.S.	To determine whether video de-identification techniques alter health care workers’ perception of anonymity.	Mixed method	Attending surgeon (8) Resident surgeon (6) Attending anesthesiologists (9) Medical students (11) OR nurses or scrub (13) OR staff member (20)	83	- The unaltered video was best identified, followed by blurred faces, infrared, point cloud video - Participants suspected research and concerned about patient privacy	Patients’ rights	71.4
A5	Fanti Silva and Collleoni²⁵	2018, Brazil	To identify the most vulnerable health providers to share patient’s confidential data on social media in the surgical environment and their awareness of the confidentiality rules and laws.	Quantitative/descriptive	Medical students (52) Surgical residents (51) Attending surgeons (53)	156	- Residents shared patients’ information most, followed by medical students, attending surgeons - Most residents did not know about privacy policies	Professional ethics Patients’ rights	14.2
A6	Wichsova and Horakova²⁶	2018, Sweden	To determine violations of hygiene management and safety procedures during surgery and to understand the reason.	Qualitative/In-depth interview	Anesthesiologists Anesthetist nurses Surgeons Perioperative nurses	Unknown	- Anesthesiologists, surgeons and surgical nurses were usually wearing accessories - Anesthesiologist did not close the door well, did not observe the rule of clothing and masks - Surgeons did not observe the rule of hand washing and did not perform surgical safety checklist - Surgical nurses wore surgical gowns in the wrong way	Professional ethics Organizational ethics Patient safety	100
A7	Ekmekci, Kazak Bengisun, and Arda²⁷	2021. Turkey	To define the problems and develop solutions within the framework of ethical theories.	Mixed method	Anesthesiologists	226	- More than 80% of anesthesiologists took ethical education as required - Participants think that informed consent is written understandable but patients do not read it - Miscommunication with patients and colleagues, working burden, and lack of support and responsibility are legal issues	Professional ethics Patients’ rights	71.4
A8	Muensterer et al²⁸	2021, Germany	To evaluate whether purposefully introduced random errors during the timeout routine are reported by the team	Quantitative/experimental	Patients	120	- Half of the 120 cases with errors were reported - Anesthesiologists reported the errors most, followed by scrub nurses, residents or fellow, and medical students	Organizational ethics Patient safety	100
A9	Sydor et al²⁹	2012, Canada	To investigate how hierarchy in the operating theater team influences an anesthesia trainee’s ability to challenge an unethical decision.	Quantitative/experimental	Anesthesia trainees	49	- There were no significant difference between hierarchical and non-hierarchical group - Gender and personality did not affect to challenging authority	Organizational ethics Patient safety	85.7
A10	Hazaryan et al³⁰	2021, Iran	To assess the observance of patient’s rights by physicians and technicians	Quantitative/descriptive	Physicians (45): Surgeons (33), Anesthesiologists (12) Technicians (97): Anesthetists (17), operating room technicians (80)	142	- The patients’ rights observance scores were significantly higher for the anesthetists than for the operating room technicians and surgeons.	Professional ethics Patients’ rights	100
A11	Howard et al³¹	2012, Canada	To understand what staff surgeons think surgical trainees should learn and the ethical issues that trainees need to manage can strengthen surgical ethics education.	Qualitative/Focus groups interview	Ethics coordinators from the surgical staffs (13) Resident trainees (64)	77	- Most participants receive formal ethics education, but the form and content of education were diverse - Applicable experience, role playing, discussion were effective teaching ways - The ethical issues addressed in real clinical practice should be dealt - Listening experience of ethical issues and scoping to them will be more helpful to residents	Professional ethics	85.7
A12	Bakry, Sobhy, and Abdelmohty³²	2022, Egypt	Reporting the impact of the COVID-19 pandemic on cardiothoracic surgeon’s attitude and behavior	Quantitative/descriptive	Surgeons	77	- Most surgeons think that COVID-19 is risky for patients - Most elective surgeries had been postponed, and patients got COVID test before surgeries - Less than half of surgeons think high-risk surgeries need to be postponed	Professional ethics	57.1
A13	Fast et al³³	2020, 7 countries (Canada, USA, Brazil, UK, NZ, Australia, India	To investigate the reporting habits of clinicians who have been exposed to disruptive behavior in the operating room and assess their satisfaction with management’s responses to this issue.	Quantitative/descriptive	Anesthesiologists (2472) Nurses (1003) Nurse anesthetists (390) Surgeons (605) Other (student, technician) (305)	7465	- Most participants report disruptive behavior less than experience - Only 20% of participants satisfy their managers’ support	Professional ethics Organizational ethics Patient safety	85.7
A14	Miandoab et al³⁴	2015, Iran	To investigate the operating room staff attitude toward the ethical climate of educational hospitals	Quantitative/descriptive	Operating room staffs	71	- Demographic characteristics are not related to ethical climate - Attitude toward ethical climate is correlated with job experience	Organizational ethics	28.5
A15	DeKeyser Ganz and Berkovitz³⁵	2012, Israeli	To describe surgical nurses’ perceived levels of ethical dilemmas, moral distress and perceived quality of care and the associations among them.	Quantitative/descriptive	Nurses (including general surgery, urology, surgical intensive care, recovery, ophthalmology and orthopedic wards)	119	- Most nurses rarely or usually experience ethical dilemmas, which are intensive - Exposure to frequent ethical dilemmas negatively affect to level of nursing skill, meeting patients’ need, and total quality of care	Professional ethics	85.7
A16	Willassen, Jacobsen, and Tveiten³⁶	2018, Norway	To elucidate operating room nurses’ and operating room nursing students’ experiences and opinions about execution of and compliance with checklists.	Qualitative/Focus groups interview	Nurses (19) Nursing students (2)	21	- The surgical safety checklist can promote teamwork and prevent safety incident - The surgical safety checklist contributes to clinical and ethical responsibility	Professional ethics Organizational ethics Patient safety	100
A17	Gunaratnam and Bernstein³⁷	2016, Canada	To examine patients’ perspective on the accountability for reasonableness prioritization system for operating theater time	Qualitative/In-depth interview	Patients	37	- Patients think prioritization needs to be improved - Patients think that patients who need help should be considered - Patients trust their doctor related to cancelation or step down - More communication makes patient comfort - Patients strongly trust doctors to be their advocators	Patients’ rights Allocating resources	85.7
A18	Hanssen, Smith Jacobsen, and Skråmm¹⁶	2020, Norway	To learn what ethical issues operating room nurses perceive as important regarding non-technical skills	Qualitative/In-depth interview	Nurses	11	- Three main themes were revealed – Respect and care for the patient; Making the patient feel safe and in good hands; respect within the perioperative team	Professional ethics Organizational ethics Patient safety	85.7
A19	Blomber, Bisholt, and Lindwall³⁸	2019, Sweden	To describe operating theatre nurses’ experiences of ethical value conflicts in perioperative practice.	Qualitative/In-depth interview	Nurses	15	- Two main themes were revealed – Obstacles to being involved in the perioperative nursing process; Health professionals do not see and listen to each other	Professional ethics Organizational ethics	100

Thematic characteristics

By analyzing 19 studies, 33 key meanings and 12 sub-categories were identified, and finally, five categories—Professional ethics, Organizational ethics, Patients’ rights, Patient safety, and Allocation resources—were derived (Table 4). A comparative review of the ICN’s code of ethics revealed that the derived topics covered the overall contents of the ICN’s principal code except for the fourth element, global health (Table 5). The derived categories were redefined to clarify their scope considering the OR context (Table 6).

Table 4.

Categories, sub-categories, and key meanings.

Key meanings	Sub-categories	Categories
Implementing the code of ethics is the basic duty of healthcare providers.	Ethical duty	Professional ethics
Ethical conflicts arise from the risks faced in a public health crisis.
The operating room staff must protect the dignity of the patients.
The operating room staff must be familiar with ethical principles and laws on patient rights.
The operating room staff must experience strong moral obligations and responsibilities for patient safety.
The operating room staff must be supportive as patients’ advocates.	Ethical practice
The operating room staff must practice the virtues of care.
The operating room staff must cope appropriately with any ethical situation to maintain the quality of care.
Healthcare providers must be sensitive to the risks of patient vulnerability.	Ethical perception
The moral sensitivity of healthcare providers is an important factor in patient respect.
Healthcare providers must increase awareness of patient rights.
The ability to solve ethical problems is important in the professional development of healthcare providers.	Ethical education
The operating room staff must be trained on legal and ethical issues in the operating room and the rights and responsibilities of the patient.
Appropriate ethical education is needed to cope with ethical dilemmas.
The ethical behavior of healthcare providers reflects the organizational decision-making process and attitude.	Ethical climate	Organizational ethics
The organization must provide active education and management to improve the ethical attitude of its members.
The organizational climate of the operating room affects the relationships between team members.
Ethical decision-making in the operating room reflects the hierarchy of the organization.	Hierarchy
Horizontal relationships are required for effective communication in the operating room.
Positive communication within the organization is important to protect the well-being of patients.
Nurses and patients must interact to protect personal information shared in the care processes.	Privacy/confidentiality	Patients’ rights
With the development of information and communication technology, more sensitive attention is required to protect patient’s personal information.	Privacy/confidentiality
Incapacitated patients in the operating room must be guarded by healthcare providers.	Respect
Patients must be provided with appropriate therapeutic communication with their healthcare providers to share their ethical perspectives.	Respect
False ethical decisions pose a risk to patient safety.	Decision-making/communication	Patient safety
Open decision-making enables appropriate responses for patient safety.
In the operating room, structured procedures such as checklists to assist communication must be established as strategies.
Harmonious cooperation among team members should be emphasized for patient safety in the operating room.	Teamwork
Patient safety in the operating room is the responsibility of the team, not the individual.	Teamwork
The problem of how to utilize limited resources often arises.	Equity	Allocating resources
For a patient to be respected, everyone should be given equal opportunities.	Equity
Medical institutions must have a priority system for surgical assignments.	Priority of surgery
Priority criteria for surgery must be fair and continuously improved.	Priority of surgery

Table 5.

The matrix of categories – ICN code.

ICN code	Categories
ICN code	Professional ethics	Organizational ethics	Patients’ rights	Patient safety	Allocating resources
Nurses and patients or other people requiring care or services			∨	∨	∨
Nurses and practices	∨		∨	∨
Nurses and the profession		∨			∨
Nurses and global health					∨

Table 6.

Definitions of categories.

Categories	Definitions
Professional ethics	Responsibility and duty for a professional role, the value of clinical practice, and professional competence of healthcare providers as moral agents on behalf of the patients in the operating room.^39,40
Organizational ethics	Patients’ interests in the operating room are linked to the organizational characteristics in the surgical part based on the team approach. Organizational ethics is the organization’s values and moral position with its holistic view of ethical practices.^41,42
Patients’ rights	An operating room has a special condition in which the patient is alone. Respect for individual dignity on the patient’s care journey is the basic value; caring with dignity, privacy, and confidentiality is present.^43,44
Patient safety	Activities to prevent errors—wrong site, wrong procedure, wrong person, and retained foreign body—that are unique to the operating room environment.⁴⁵
Allocating resources	Surgical prioritization; a decision-making process considering health equity in the surgical care services delivery.^46,47

Based on the redefinitions, 19 articles were reviewed, and multiple categories were selected for each study (Table 7). The most frequently addressed category was “Professional ethics” (n = 4), followed by “Organizational ethics” (n = 9) and “Patients’ rights” (n = 7). On average, each article dealt with two categories, and a maximum of three categories were covered.

Table 7.

Relations with categories.

Articles	A1	A2	A3	A4	A5	A6	A7	A8	A9	A10	A11	A12	A13	A14	A15	A16	A17	A18	A19	Total
Categories
Professional ethics	∨	∨	∨		∨	∨	∨			∨	∨	∨	∨		∨	∨		∨	∨	14
Organizational ethics			∨			∨		∨	∨				∨	∨		∨		∨	∨	9
Patients’ rights		∨	∨	∨	∨		∨			∨							∨			7
Patient safety						∨		∨	∨				∨			∨		∨		6
Allocating resources																	∨			1
Total	1	2	3	1	2	3	2	2	2	2	1	1	3	1	1	3	2	3	2	37

Category 1: Professional ethics

As the most frequently addressed topics, six studies involving nurses [A1, A2, A3, A15, A18, A19], four studies for doctors [A5, A7, A11, A12], three studies for teams [A6, A10, A13], and one patient and nurse study [A2] were identified. The studies covered the ethical duties of surgical staff [A2, A5, A6, A10, A12], ethical practice [A3, A13, A16, A19], ethical perception [A15, A18], ethical education for health professionals [A7, A11], and the experience of nurses in the code of ethics [A1].

Category 2: Organizational ethics

Four studies were conducted involving nurses [A3, A16, A18, A19], two for physicians [A9, A14], two for surgical teams [A6, A13], and one comprising patients [A8]. The studies dealt with hierarchy from the perspective of organizational authorities and relationships [A13, A18], hierarchy related to decision-making and communication [A8, A9, A19], organizational culture such as patient respect and safety regarding ethical climate [A3, A6, A14], and organizational perspective in ethical practice and responsibility [A16].

Category 3: Patients’ rights

Two studies involving physicians [A5, A7], two studies for surgical teams [A4, A10], one nurse and patient study [A2], one nurse study [A3], and one study comprising patients [A17] were identified. These studies covered healthcare providers’ attitudes and perceptions about patients’ rights [A7, A10] and protecting those rights and therapeutic interaction [A2]. Some studies identified factors affecting one’s attitudes towards protecting patient privacy [A3], privacy related to video recording in the OR and healthcare staff’s perceptions of it [A4], social media and patient privacy protection [A5], and protecting patient rights in resource allocation [A17]. Primarily, these studies dealt with ample privacy.

Category 4: Patient safety

Two studies involving nurses [A16, A18], two studies for teams [A6, A13], one for physicians [A9], and one for patients [A8] were identified. According to the contents of the studies, patient safety considers organizational communication and environment [A9, A13, A18], compliance with healthcare staff [A6, A16], and reporting system for patient safety [A8]. As most studies were considered from the perspective of communication and teamwork, many covered organizational ethics.

Category 5: Allocating resources

One study focused on the prioritization of surgery from a fair resource distribution perspective [A17]. The study identified improvements in a system of surgical priority that ensures fairness with limited resources for patients requiring surgical services through interviews with patients.

Discussion

The study provides a comprehensive overview of the ethical issues faced in the OR reviewing the studies published in academic journals over the past 10 years. A total of 19 studies were identified through the systematic analysis process, and five categories—Professional ethics, Organizational ethics, Patients’ rights, Patient safety, and Allocating resources—were identified.

This study found that more than half of the research on ethical issues is focused on professional ethics, followed by organizational ethics. These results reflect the two representative characteristics of the OR: “healthcare providers caring for patients who are more vulnerable than other departments”⁴ and “the organizational structure that shapes procedures and methods in performing their tasks.”⁴⁸ Numerous research covered the four main elements of the ICN code of ethics.

The first major category, Professional ethics, pertains to the ethical conduct of individuals within their respective professions. It included ethical duty, practice, perception, and education. In this category, various ethical issues linked to the “Nurses and practice” section of the ICN code have been identified. This section emphasizes the importance of individual knowledge, competence, and professional growth in fostering ethical nursing attitudes, and behaviors. Possessing these attributes enables effective functioning when ethical issues arise or need resolution.^9,23 Conversely, a lack of ethical knowledge and competence hampers practical resilience and hinders collaboration.⁴⁹

The next category, Organizational ethics, focused on ethical climate and hierarchy. This category aligns with the contents of the “Nurses and the profession” section of the ICN code, which emphasizes the creation of a constructive organizational environment. It also delves into the organizational aspects of ethical issues. The OR is a small community with its own rules and order within the hospital. Ethical culture is influenced by organizational values, policies, and beliefs.⁹ Additionally, managerial factors, such as work distribution and support, can contribute to ethical issues.²

In the Patients’ rights and Patient safety categories, the ethical issues primarily revolve around the patients. Patients’ rights included privacy/confidentiality and respect, highlighting the importance of safeguarding patient autonomy and dignity. Patient safety encompassed decision-making/communication and teamwork, emphasizing the significance of ensuring a safe and reliable healthcare environment for patients. These categories were associated with two sections of the ICN code: “Nurses and patients or other people requiring care or services,” which highlights the significance of patient-centered care and effectively encompasses the values and responsibilities of the professionals delivering it, and “Nurses and professions.” Our findings indicate that ethical issues are linked to surgical patients’ autonomy in the OR, examining both the ethical decision-making process of the team and the individual capabilities of the beneficence and non-maleficence principles. Surgical ethics emphasize patients’ rights and safety because patients undergoing surgery are in a state of reduced competency, and their vulnerability is increased more than usual.^4,5 Hence, the healthcare environment focuses on the shared decision-making practice, emphasizing patient participation to balance autonomy and best interests. However, there are limitations to applying this concept in the OR, as the interaction between the patient and healthcare staff is limited and often paternalistic. For instance, a healthcare staff member determines the necessary procedures according to changes in a patient’s condition during an operation; however, the patient is only notified of the changes after the procedure. In this situation, the healthcare staff should act as “advocates of patients” who practice virtue ethics to prevent mistreatment of patients and maintain the patients’ best interests.³⁹ Therefore, the surgical staff must make good ethical judgments while maintaining transparency and confidentiality for the entire process in the OR.

This study also revealed that research was conducted mainly on healthcare providers, with a few cases involving patients. Research on healthcare providers, who act as patients’ advocates, is certainly important. However, examining the ethical experiences of patients within the OR is of equal importance. Their experiences can help cultivate the sensitivity and empathy of healthcare personnel towards patients by comprehending their perspectives and vulnerabilities. This not only enhances individual ethical competence but also empowers organizations to formulate effective strategies. Therefore, studies on patients should be actively performed in the field of surgical ethics to emphasize patients’ rights and safety.

Lastly, the Allocating resources category identified the ethical issues of equity and priority of surgery. This category is closely linked to the following sections of the ICN code: “Nurses and patients or other people requiring care or services,” “Nurses and the profession,” and “Nurses and global health.” However, it is worth noting that the coverage of “Nurses and global health” is only relevant to the principle of justice as it pertains to the fair distribution of health resources. The partial coverage of this section indicates the potential for further exploration and research in this area.³⁷ Furthermore, ensuring equitable allocation of resources in the OR is significantly considered to promote global health. For example, the COVID-19 pandemic revealed the justice problem of resource distribution, particularly selective surgery.⁵⁰ It also raised ethical conflicts between the professionals’ obligations and individual autonomy due to the risk of infection for the healthcare staff.⁵¹ Similarly, the ethical issues in the OR are sensitive to changes in the international health and social environment. Global public health requires clear priority protocols to reduce the gap in access to surgery between countries.^52,53 To maintain equity in the face of unexpected changes in the global health environment, a clear ethical framework and protocols are needed to help prioritize decisions about the allocation of resources.^49,54 The development of ethical strategies for ensuring care for global health requires a revitalization of theoretical and empirical research, as well as a transition towards evidence-based practice.

The five categories are not independent but rather complement each other. While ethical issues naturally arise due to the work and environmental characteristics in the OR,² the causes can be identified at the individual and organizational levels. At the individual level, there is a lack of awareness regarding ethical principles, including patient rights and the virtue of caring, the ability to manage and resolve ethical issues, and an understanding of collaboration, which is attributed to the absence of proper training and support to foster ethical practice. At an organizational level, there is a lack of support for ethical training in the work environment, particularly in caring for incapacitated patients. Additionally, vertical hierarchies hinder effective communication, and the absence of decision support protocols exacerbates the problem. These issues fundamentally stem from the organizational system. Thus, actively addressing these problems by providing organizational support and implementing strategic planning to enhance ethical awareness and practice among individuals who form the collaborative core becomes imperative. To truly uphold the values of the nursing profession, expanding opportunities that not only enhance clinical knowledge but also deepen ethical understanding is crucial. Furthermore, the implementation of a decision-making support system can help alleviate moral stress during the decision-making process. Constructive communication and coordination are vital aspects that need to be fostered, and a shift towards a more egalitarian hierarchy led by an inclusive leader is essential to promoting mutual respect among colleagues.^1,55 Therefore, designing an organizational strategy based on the ICN code will help create a conducive environment for improving cooperation in the OR, as well as for fostering the ethical growth of individuals.

All identified studies took a normative ethical perspective, concerned with moral principles that underpin practice.⁵⁶ The normative ethical approach is largely divided into empirical and theoretical perspectives.⁵⁶ The selected studies were dominated by an empirical perspective. Scientific research from an empirical perspective aims to change policies by observing real-world practices. However, showing the complete reasoning process without a theoretical perspective is difficult.⁵⁷ Empirical research that includes theoretical perspectives should also be conducted in the future to develop an ethical strategy for the operating theatre that bridges theory, research, and practice.

Limitations

Although our study targeted ethical issues for healthcare staff and patients in the OR and showed the future research direction of surgical ethics by examining research trends compared to theory and practice, it did not cover the entire field of surgical ethics. For instance, “informed consent,” which is a preoperative stage that occurs outside the OR and is an act to protect patients’ rights while undergoing surgery due to the patient’s limited decision-making ability.^58–60 Nevertheless, our study is valuable for identifying ethical issues that are intensively discussed in the main surgical care place, that is, the OR. We meaningfully explored humanistic aspects and prepared practical implications. However, the technical and therapeutic aspects of surgery, such as new drugs or equipment, were not addressed. We also limited our focus to literature available in English. In other languages, a Q methodology study explored the ethical perception of OR nurses,⁶¹ and the applicability of various research methodologies was confirmed. Such design research must be actively conducted internationally.

Conclusion

With the continuous advancement in science and technology, ethical skills within the healthcare environment have become increasingly crucial. This study provides a comprehensive examination of ethical issues in surgical ethics and suggests directions for future research. The identified ethical issues in the OR are attributed to individuals and organizations, and many of these issues align with the principles outlined in the ICN code. Therefore, it is essential to improve strategies at the individual and organizational levels based on the ICN code to effectively address ethical concerns in the OR. This calls for active engagement in theoretical and empirical studies. To further progress the field of surgical ethics, future research should aim to explore a broader and more profound range of ethical issues specific to the OR. Additionally, encouraging research that examines different ethical perspectives will contribute to the advancement of knowledge in this area. To conclude, the dynamic nature of healthcare necessitates ongoing exploration and investigation into surgical ethics. By expanding the scope of research topics, employing diverse research methodologies, and promoting empirical studies, we can deepen our understanding of ethical considerations in surgery and enhance ethical practices within the field.

Supplemental Material

Supplemental Material - Ethical issues in the operating room: A scoping review

Supplemental Material for Ethical issues in the operating room: A scoping review by Heejung Jeon, Sanghee Kim, and Yuha Shon in Nursing Ethics

Footnotes

Authors’ contributions

Heejung Jeon, Yuha Shon, and Sanghee Kim identified the research question and selected the scope of the review for the study. Heejung Jeon and Yuha Shon conducted a comprehensive literature search, screened and selected the studies for review. Heejung Jeon, Yuha Shon, and Sanghee Kim synthesized the findings, and analyzed patterns and themes. Heejung Jeon and Yuha Shon drafted the article and critically revised it for important intellectual content. All authors have participated sufficiently in the work and take full responsibility for the accuracy and integrity of the study.

Declaration of conflicting interests

The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Funding

The author(s) received no financial support for the research, authorship, and/or publication of this article.

Ethics considerations

The study maintained scientific integrity in all processes.

ORCID iDs

Heejung Jeon

Sanghee Kim

Yuha Shon

Supplemental Material

Supplemental material for this article is available online.

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