APRIL 1985, VOL 41, NO 4 AORN J O U R N A L

Managing Stress in the OR A COLLABORATIVE APPROACH

Andrea L. Marcus, RN; Slobodan Popovic, MD

perating room suites are typically intense, complex environments that require 0 sophisticated management techniques.

Traditional administrative goals and issues of efficiency, productivity, finances, and physician satisfaction are emphasized while OR personnel's feelings and concerns are ignored, resulting in stress. Therefore, providing avenues through which OR personnel may express themselves and participate in decisions that affect their clinical practice setting may help alleviate some of the stressors.

Problem

inai Hospital's (Detroit) 14-OR suite was experiencing problems in the recruitment S and retention of well-qualified nurses. Staff

morale appeared low, and there was confusion about supervisory responsibilities, staff expecta- tions, and reporting relationships.

The director of the surgical suite contacted Sinai Hospital's Problems of Daily Living Clinic (PDLC) in the psychiatry department to seek assistance in developing an instrument to assess problematic areas, as well as a mechanism for OR' personnel to express their attitudes, concerns, and feelings. The associate chief of the PDLC agreed to help design a survey that would provide information necessary to plan organizational changes with the OR staff.

To determine causes of stress, the OR staff was asked to keep a one-week personal log in which they would identify any events they found stressful. Eleven OR staff members maintained the logs.

Using the information from the logs, stressors and problems were identified, grouped, and catego- rized, and a 57-item questionnaire was designed (Fig 1). All OR nurses and technicians were asked to complete the questionnaire. The responses were scaled on a range of one to ten, depending upon the severity of the stresses, with ten being most severe.

Methodology

or each question, a Stress (SIN) was determined by F average response to the

example, the responses to each compiled as follows:

Index Number calculating the question. For question were

ProfessionaMnterdisciplinary Relationships with surgeons

rank: 1 2 3 4 5 6 7 8 9 1 0 frequency of response: 7 5 4 3 4 2 4 2 1 4

A weighted average rank of the responses to the question was then calculated by multiplying

Andrea L. Marcus, RN, MS, is director of the surgical suite at Sinai Hospital of Detroit. She earned her bachelor's degree in nursing and master's degree in nursing health services administration from the University of Michigan, Ann Arbor.

Slobodan Popovic, MD, is associate chief of the Problems of Daily Living Clinic, Department of Psychiatry, Sinai Hospital Detroit. He is a graduate of the medical school of Rijeka , Yugoslavia

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I I I I I I I :

Fig 1 OR Questionnaire

RN LPN ORT

After spending considerable time analyzing the current situation in the OR and carefully reviewing personnel logs completed by the OR staff, the following is a list of the problems that might exist there. We would appreciate your input by rating them as they apply to you; that way we will learn the areas of importance to you and we will use that information to plan appropriate topics for an all-day workshop planned for the OR in the near future. Using the scale from one to ten, (ten being most problematic) please rate the following:

ProfessionaNlnterdisciplinaly Relarionships with surgeons with anesthesiologists with residents with supervisors and head nurses with RNs with OR technicians with others (identify 1 Level of professionalism in relating Overall cooperation among staff Coworkers’ accountability

1 2 3 4 5 6 7 8 9 1 0

Service rotation or assignment (identify 1

1 2 3 4 5 6 7 8 9 1 0 Professional Relations between RNs and LPNs and OR Technicians (circulating vs scrub)

Level of professionalism in relating Overall cooperation

Junior vs Senior OR Stafl Orientation of new staff New staffs’ adjustments to new procedures Old staffs’ adjustment to new staff Overall cooperation

Racial Issues Black vs white Overall cooperation

Staffing Staff turnover Breaks Vacation time Overtime Insufficient room staffing

Equipment Lack of (unavailable) Outdated and defective Overall organization

1 2 3 4 5 6 7 8 9 1 0

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I I I I I I I I -

Boarding Procedures Time between cases Changes in scheduling Delay due to incomplete pre-ops Delay due to staff tardiness Add-on or emergency boardings

I I I I I I I 1 1 1 1 1 1 1 1 1 .

Communication Patterns Personal issues Professional issues (specify)

Administrative Hierarchy within OR (confusion about who is responsible for what to whom)

StaflDevelopment and Growth Proper orientation of new personnel Expectations of OR staff Outdated case cards Inservice training Knowledge about electrical hazards in OR Knowledge about contamination and infection control Knowledge about the care of instruments Knowledge about legal aspects of OR nursing

Participation in Decision Making Opportunity to give input Opportunity to express feelings

Stresses (Related to the actual type of work)

Working with very ill people Complex procedures Unpredictable outcomes Deaths Feelings of inadequate preparation Feelings of personal responsibility Feeling isolated in the OR Feeling overworked Adequate facilities Opportunity for on the job relaxation Responsive supervisors use of tapes

Other (add your own)

I 2 3 4 5 6 7 8 9 1 0

I 2 3 4 5 6 7 8 9 1 0 lxnmIEm

1 2 3 4 5 6 7 8 9 1 0

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each rank by its frequency, yielding a frequency score for response, and then summing up all of the frequency scores.

rank X frequency: 1 2 3 4 5 6 7 8 9 10 7 10 12 12 20 12 28 16 9 40=166 total

Finally, this number was divided by the number of people who answered the question to obtain the SIN for each item.

Example: Sum of frequency scores divided by number of responses = SIN 166 divided by 36 = 4.6

Findings

hirty-six staff members (23 nurses and 13 technicians) representing approximately T 80% of the total OR staff completed the

questionnaire. Ninety-two percent of all the questions were answered. Based on the SIN, a list was composed with items ranked in order from most to least stressful (Fig 2). Items were grouped into four categories: (1) definite problems (SIN > 6.0); (2) probable problems (SIN = 5.0 to 6.0); (3) possible problems (SIN = 4.0 to 5.0); and (4) apparently problem- free areas (SIN < 4.0).

Evaluation

he major problem areas identified were: (1) orientation and ongoing inservice educa- T tion; (2) work scheduling and patient

assignments; (3) supervisor-employee relation- ships; and (4) communication patterns. Orienta- tion of new staff was stressful mainly because there was no formal orientation program. New employees were often assigned haphazardly to different operating rooms with different services and personnel; there was no planned program for rotating in an orderly fashion through all the services. New staff felt left too much on their own. This created feelings of inadequate preparation and difficulties in adjusting to Sinai Hospital’s procedures and policies. The staff (especially new

employees) were confused about what was expected of them. Their roles and procedures were not clearly and consistently explained, and as a consequence, senior staff members felt burdened with the responsibility of training the new nurses and sometimes would not share complete information with them.

Implementing Change

fter reviewing the findings, an all-day workshop was designed as the starting A point for implementing changes. The

associate chief of the PDLC participated in designing the workshop and in selecting, orienting, instructing, and supervising facilitators for small group discussions. He held meetings with the facilitators before, during, and after the workshop to coach and evaluate the progress of the small groups.

At the workshop, the associate chief of the PDLC shared the survey results, and explained the study’s methodology and scoring system. Two additional formal presentations were made. The clinical director of OR services from St Joseph’s Mercy Hospital, Ann Arbor, Mich, explained the philosophy behind a team approach to patient assignments in the OR. She explained why and how the team approach was implemented at her hospital and pointed out the benefits that were achieved by the OR staff, supervisory personnel, and physicians.

The second presentor, a clinical psychologist from the PDLC, addressed communication, stress, and relaxation. She explained the need for all stress management skills in any working situation and specifically how they could be applied in Sinai Hospital’s OR. Identification of effective commun- ication skills and intervention techniques were presented to the staff to help them reduce stressful situations in their work setting. These included

listening when another person is talking discussing one thing at a time using short and clear expression leaving the past in the past and dealing with the “here and now” using “I statements” when expressing personal feelings, thoughts, or opinions.

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36 Participants 2.052 Potential responses 1,886-91.9% Questions answered 166-8% Questions not answered

Definite Problem (to be corrected immediately) 1. 6.2 orientation of new staff 2. 6.2 expectations of OR staff 3. 6.2 proper orientation of new

personnel 4. 6.1 old staffs adjustment to new staff

Probable Problem (to be corrected immediately) 5. 5.7

6. 5.7 7. 5.7

8. 5.7 9. 5.7 10. 5.6 11. 5.6

12. 5.5 13. 5.4 14. 5.2 15. 5.2

16. 5.2 17. 5.1 18. 5.1 19. 5.0

20. 5.0 21. 5.0 22. 5.0

new staffs adjustment to new procedures insufficient room staffing level of professionalism in relating RNs/ORTs responsive supervisors service rotation outdated case cards knowledge about legal aspects of OR nursing changes in scheduling delay due to incomplete pre-ops opportunity to give input administrative hierarchy within OR overall cooperation RNs/ORTs opportunity to express feelings staff turnover overall cooperation juniorlsenior Staff overall cooperation among staff add-on or emergency boardings knowledge about the care of instruments

Possible Problem (worth looking into) 23. 4.9 overall organization of equipment 24. 4.9 inservice training 25. 4.9 feelings of inadequate preparation 26. 4.9 level of professionalism in relating 27. 4.8 lack of equipment 28. 4.8 feeling overworked 29. 4.8 opportunity for on-the-job

30. 4.7 31. 4.7 32. 4.7 33. 4.7 34. 4.7

35. 4.7 36. 4.7 37. 4.7 38. 4.7 39. 4.6 40. 4.5 41. 4.5 42. 4.4

43. 4.3 44. 4.3 45, 4.2 46. 4.2 47. 4.1 48. 4.1 49. 4.1

relaxation feeling isolated in the OR communication-personal issues breaks relationships with ORTs knowledge about electrical ha- zards in O R use of tapes feelings of personal responsibility knowledge about contamination coworker's accountability relationship with surgeons time between cases adequate facilities communication-professional issues relationship with anesthesiologists relationship with others relationship with head nurse complex procedures outdated and defective equipment unpredictable outcomes deaths

Apparently Problem-ji-ee Areas 50. 3.8 overall cooperation blacks/whites 51. 3.8 delays due to staff tardiness 52. 3.7 working with very ill people 53. 3.7 vacation time 54. 3.6 relationship with RNs 55. 3.5 racial issues-blackdwhites 56. 3.3 overtime 57. 3.1 relationship with residents

Suggestions for on-the-job relaxation exercises were also discussed.

After each presentation, small discussion groups were formed. To provide an open, yet confidential atmosphere for exchange, the group discussions were facilitated by RNs from other departments of the hospital. Thus, the discussions proved meaningful and provided the opportunity for staff to communicate personal attitudes, feelings, and concerns about daily O R stressors they expe-

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rienced with their peers. A task force composed of registered and

practical nurses and technicians was organized to continue this sharing of feelings and ideas and to begin planning for future change and direction in Sinai's OR. The task force implemented the team approach in the OR and recommended that specialty services be grouped into the following four teams:

Team I: moat, general surgery Team 11: Cardiovascular, peripheral

vascular, plastic, thoracic Team 111: Ear, nose 8c throat, ophthal-

mology, oral surgery, orthopedics

Team IV Neurosurgery, gynecology, urology.

One head nurse was assigned to each team based on clincial expertise and specialty preference. Head nurses now have 24-hour accountability for personnel management, scheduling, financial management, physician relations, quality nursing care activities, etc. They are more involved in coordinating inservice activities and orientation programs for new staff members. Physicians relate directly with the head nurse in charge of each group of services when making decisions relative to equipment needs, personnel concerns, follow up on new procedures, problems, requests, and ongoing inservice education needs of team members. Also, each head nurse has weekly meetings with hidher staff to problem solve, share ideas and information about procedures, and provide a forum to discuss new policies and procedures within the OR or the hospital. Physicians are also invited to provide inservice education at these team meetings. Any updates needed on surgeon preference cards are also communicated at these meetings.

Head nurses now report directly to the director of the surgical suite. Head nurses meet biweekly both individually and together with the director to solve problems for the surgical department and to share information, which is then conveyed to the service team. These meetings are also used to announce promotions, staff changes, and to introduce nurses newly hired.

Staff inservice education meetings are held

monthly and are coordinated by the OR clinical nursing instructor. Improvements in both com- munications and supervisor-employee relations resulted from these formalized education meetings by establishing clearer role expectations and mechanisms for interchange.

Conclusion

pproximately nine months after the OR questionnaire was administered, a post- A survey was conducted to evaluate the

impact of the changes. The associate chief of the PDLC shared the results of the post-survey with the staff and explained the differences between the results of the first questionnaire and the second questionnaire. The staff saw him as an expert on feelings and communication skills and was very receptive to his input. At the same time, he was seen as a neutral, objective person outside the OR.

Forty-seven staff members, consisting of 29 nurses and 18 technicians, responded to the post- survey. (Thirteen had not attended the all-day workshop and/or were not employed in the OR at the time the first survey was conducted.) Ninety- three percent of the questions were answered. The same method was used to calculate the SIN, and the responses were grouped into the same four categories used with the first questionnaire.

The post-survey revealed no problems in the first category, and only four items were ranked as probable problems in the second category. Thirteen of the most stressful original problems were reduced significantly, showing a decrease of greater than 1.0 in their SIN. These included:

orientation of new staff new staffs adjustment to procedures inadequate preparation old staffs adjustment to new staff expectations of OR staff professionalism in relating RNs/OR technicians overall cooperation of RNs/OR technicians relationship with surgeons responsive supervisors service rotations.

Overall, the results demonstrate that a tremendous level of satisfaction among the OR

APRIL 1985, VOL 41, NO 4 A O R N J O U R N A L

staff had been achieved. We feel the reason for this achievement was administration’s sensitivity

workshops, and specific changes, such as the addition of a clinical instructor, team approach, and staff meetings.

This project also stands as a positive example of the multiple benefits that can be gained as a result of cooperative efforts between a hospital’s

medical and psychiatric departments. Through this interdisciplinary approach, a solution toward a

to the OR stars concerns, expressed through the complex management problem emerged.

Notes 1. D 0 Spurr, H Ehnis, and J Feldkamp, “A team

approach to patient assignments,” AORN Journal 4

2. J Paquet, “Stress and the OR Make it work for March 1981) 783-792,

you,” Part 2, Today’s OR Nurse 5 (March 1983).

Study to Identify Top-ranked Schools The National League for Nursing (NLN) has an- nounced that it will fund a nationwide study to delineate what makes up a top-ranked school of nursing. The plan for the study will be similar to that of the American Academy of Nursing’s 1983 study, “Magnet Hospitals-Attraction and Retention of Professional Nurses.”

Wandelt of the University of Texas at Austin School of Nursing. Wandelt was a member of the task force that conducted the magnet hospital study. Codirectors of the project will be Drs Betsy Bowman, Mary Duffy, and Susan Pollack, of the same school.

The six schools selected for the study are the University of Washington, Seattle; Catholic Uni- versity of America, Washington, DC; Boston Uni- versity, University of Maryland, College Park; University of Illinois, Urbana; and Wayne State University, Detroit.

Interviews will be conducted with deans and their associates, professors and associate profes- sors, assistant professors and instructors, graduate students, and baccalaureate students at each school. These interviews will help the researchers identify the organizational, faculty, student, and resource variables that compose a top-ranked school of nursing.

Study results will be reported at the upcoming NLN biennial convention June 2-5, 1985, in San Antonio, and will be published by the NLN.

The principal investigator will be Dr Mabel A.

Freestanding Centers Increasing in Number The National Association for Ambulatory C re (NAFAC) in Dallas predicted that by the end of 1984,2,500 freestanding emergency centers would be operating in the United States. That would rep resent a growth of 1,400 fadties over 1983, accord- ing to author Joyce W e r in the Dec 16 issue of Hospitals.

As the number of freestanding emergency centers grew during 1984, their activities came under the scrutiny of regulatory agencies that sought licensure standards. The NAFAC resisted, saying that regula- tion would inhibit the growth of the industry. Members of the National Association of Freestand- ing Emergency Centers voted to change their name to the National Asmiation for Ambulatory Care. They hope that by eliminating the word emergency, the centers will not be burdened with state regulations.

The number of freestanding surgery centers also i n c r d last year. One survey showed there were 356 centers in existence, 249 of which were open, and 107 that were under development or construc- tion. Eightyeight centers were scheduled to open in 1984, a 37% increase in the total number of centers.

The same survey indicated that OB/GYN proce- dures are the most common type of surgery per- formed at freestanding surgery facilities, representing 37% of all suqgcal procedures done at the centers. A total of 375,266 procedures were done in outpa- tient surgery centers in 1983, and the survey indi- cates that 275 surgical procedures can be performed in the facilities. The survey also estimated that 30% to 40% of all surgeries can be performed on an out- patient basis.

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