Open access peer-reviewed chapter
Abstract
Healthcare is facing new challenges today; accordingly, staffing and work environment are important for healthcare to work smoothly. The limitations in the perioperative physical work environment, for employees to not have an impact, are unique. Thus, the psychosocial work environment becomes even more important, where colleagues and nurse managers, relational justice and organisational justice play an important role in staff’s well-being and decision to leave or stay. Moreover, interest in those who train to work in perioperative settings is decreasing for various reasons. It is, therefore, important to make perioperative departments healthy and attractive workplaces, where the demands and control in one’s work are in balance, where support is offered by colleagues and managers as well as good salary, possibility for development in the profession and satisfactory work schedules with respect to recovery.
Keywords
- perioperative
- psychosocial
- organisational
- work environment
- nurses
- anaesthesiologists
- work demands
- healthy workplace
1. Introduction
Shortage of specialist nurses in perioperative settings has been a commonly discussed issue during the past years and is of larger significance today; furthermore, it affects quality of patient care [1], as planned surgeries may be cancelled [2, 3]. Perioperative settings or operating departments offer unique and demanding working conditions for perioperative nurses, that is, nurse anaesthetists, operating room nurses, nurse assistants, and anaesthesiologists, due to which some of them decide to leave [4]. The pressure to work quickly is high and stressful in perioperative settings due to high patient turnover [5].
The decreasing interest in training to become specialist nurses in perioperative settings makes it even more urgent to address the issues in connection with the perioperative work environment. Studies show that colleagues and nurse managers, among others, are important in perioperative nurses’ decision to stay or leave [4]. Moreover, female gender, younger age and parents with children are reasons for burnout among anaesthesiologists [6]. Studies also show that when there is a peak in demand, employees need recovery the most. This chapter provides insights into the unique challenges in the work environment faced by the perioperative staff and how the perioperative environment can be a better workplace by just implementing some simple measures. This chapter comprises three main parts presenting: a) the uniqueness of perioperative work environment, b) psychosocial and organisational work environment and c) how the work environment can be improved by simple means. In the first part, the chapter explains the work of the perioperative nurses, including their education. Moreover, it describes the work environment of nurse assistants and anaesthesiologists. In the second part, insights are given into challenges in psychosocial and organisational work environments, the nurse managers’ role in perioperative nurses’ satisfaction with work, and how job demand-control affects work for professionals in perioperative settings. The final part describes measures that can be taken to make the psychosocial work environment better for the employees working in the perioperative context.
1.1 Methodology
To write each part of this chapter, a literature search was conducted in the database PUBMED with different combinations of the following keywords: perioperative settings or departments, perioperative care, perioperative dialogue, work environment, air temperature in operating room, noise level in operating room, regulations, nurse anaesthetist, scrub nurse, operating room nurse, assistant nurse, formal education (Europe, Nordic and the USA), work tasks, professional responsibilities, role description, skills, non-technical skills, competences, person-centered care, anaesthesiologists, experience, burnout, work place incivility, work stress, work-life balance, psychological work environment, nurse turnover (global and perioperative), nurse shortage, leave one’s workplace, stay or remain at workplace, job satisfaction/dissatisfaction, organisational justice, nurse managers, caritative leadership, caritative caring, digitalization, job-demand-control- support model, organisational justice and relational justice. The inclusion criteria were articles about perioperative staff (nurses, nurse assistants, and anaesthesiologists) or nursing and perioperative environment. Research articles after year 2000 were used, with the exception of key references in specific areas, for example, in perioperative dialogue, where articles published before year 2000 were also included. In conclusion, this chapter reminds of an integrative review as research using multiple methodologies were utilised.
2. Perioperative work environment and working conditions: why is it unique?
2.1 Perioperative settings and perioperative care
A perioperative setting refers to operating departments where multidisciplinary teams, comprising perioperative nurses, nurse assistants, anaesthesiologists, surgeons and surgical assistants work together. Perioperative nurses are specialist nurses, that is, nurse anaesthetists (NA) and operating room nurses (OR nurses), who provide care to patients during the perioperative period: pre- (before), intra- (during) and post (after) operative phases of anaesthesia and surgery. Special training is required for those who work in perioperative settings, which varies in different countries [7].
2.2 The physical work environment
The physical work environment in operating departments and operating rooms is unique. These are special rooms requiring a clean environment, with the least number of microorganisms in the air; therefore, the airflow is regulated to minimise airborne microorganisms and to reduce the occurrence of infections. In other words, operating rooms are closed rooms, sometimes without windows; thus not always allowing access to daylight, where the air is exchanged 15–20 times per hour [8, 9], with an air temperature between 20°C to 23°C and as low as 17°C [10]. This can result in operating rooms being experienced as cold rooms for those working in them. As Golvani and Roos [11] described, access to daylight can lead to feelings of joy and a sense of time, whereas a lack thereof contributes to feelings of fatigue and stress among OR nurses. Moreover, perceived incompetence, lack of confidence, relational problems with regard to the surgeon, and team members’ disruptive behaviour were described as sources of stress for OR nurses.
Operating rooms are high-tech environments. There are several devices and apparatus in the environment, for example, a ventilator/respirator to help the anaesthetised patient breathe; equipment to monitor the patient’s vital parameters, such as blood pressure, heart rate and saturation; a device for blood suction; a tourniquet; a device to burn the micro blood vessels and control the blood loss and a device that keeps the patient warm by blowing hot air into a blanket that is placed on the patient. Each device has its own alarm system to give a warning when, for example, the vital signs are not in the normal range and when something is wrong with the device; they also make a noise when turned on for use. There are also computers used for documentation, x-ray devices and other apparatus needed for specific surgeries. Despite the World Health Organisation’s (WHO) recommendations regarding maximum noise levels at workplaces (including ORs) of 55 decibels (dB), operating rooms reach mean, median and maximum decibel levels of 71.7 dB, 69.4 dB and 90.3 dB, respectively, as shown in a study by Dornbusch, Boston [12]. In their study, the author collected data from surgical oncology surgery, soft tissue surgery, ophthalmologic procedures and orthopaedic and neurologic surgeries, among which the neurologic surgeries were associated with higher levels of noise. The authors indicated that in operating rooms where music was played, greater noise levels (mean 73.3 and median 71.3 dB) were measured compared to those without music (mean 70.6 dB and median 68.2 dB). It is also important to consider that besides the type of surgery, the number of people in the room, comprising scrubs and anaesthesia personnel, also adds to the noise levels [12].
2.3 Nurse anaesthetist and operating room nurses and their professional responsibilities
In 40 low- and middle-income countries, NAs provide induction, maintenance and emergence of anaesthesia, independently, and in close collaboration with anaesthesiologists [13]. The International Federation of Nurse Anaesthetists (IFNA) identified the following components, among others, in the role described as “Nurse anaesthetist expert”: anaesthetic management, pre-anaesthetic pain management, risk management, advanced life support, monitoring, termination of anaesthesia, post-operative care and pain management, infection control, communication, collaboration and teamwork, task and quality management, patient information, patient education, patient advocacy, continuous professional development, research and education. IFNA is a global organisation, representing over 40 member countries and is an affiliate of the International Council of Nursing (ICN) [14].
The roles and education of nurse anaesthetists vary. The Nordic countries have different types of anaesthesia nursing education, ranging from non-degree supplementary programmes to master’s degree programmes [15]. In Sweden, to become a specialist nurse in anaesthesia care or operating room nursing care requires a university training of 60 credits at an advanced level (in addition to a registered nurse degree, which is a three-year bachelor’s degree in university education), and a master’s degree in nursing. According to the competence description for nurse anaesthetists, they should have good knowledge in both nursing and medical sciences, ethics, medical technology, pedagogy, scientific theory, laws and regulations and working during major crises. According to their competency description, two nurse anaesthetists may independently start a case or terminate the anaesthesia when the patient is healthy (ASA 1–2), with approval from the responsible anaesthesiologist. Furthermore, the nurse anaesthetist may assess the patient’s airway and intubate the patient. ASA stands for the American Society of Anaesthesiologists: ASA 1 is a healthy patient and ASA 2 stands for patients with a mild systemic disease without significant functional limitations. In Switzerland, the role of a nurse anaesthetist requires a 2-year nurse anaesthesia programme, and a nurse diploma is also mandatory. The education includes at least 900 h of additional didactic training. To become a Certified Registered Nurse Anaesthetist (CRNA) in the US, a master’s degree from an accredited nurse anaesthesia educational programme is required [16].
According to the European Operating Room Nurse Association (EORNA), education for OR nurses should contain the following five core competencies: professional, ethical and legal practice; nursing care and perioperative nursing practice; interpersonal relationships and communication; organisational, managerial and leadership skills; and educational, research and professional development. As stated in the competence description for OR nurses (also called scrub nurses), their responsibilities include ensuring that the operating room is aseptic; being responsible for correct ventilation in the operating room; patient preparation and safety; control of instruments and instrumentation; infection prevention and complication prevention measures in connection with surgery and handling of biological material. OR nurses may work in operating rooms, ambulatory day surgery units, and in other fields where invasive techniques are used (Endoscopy Unit, interventional radiology, etc) [17]. OR nurses possess unique non-technical skills (which are decision-making, situation awareness, communication, teamwork and leadership); thus by listening to the tone of someone’s voice, observing expressions in surgeon’s eyes or paying attention to the changing sounds of the instruments, they anticipate what the surgeon will do next. NAs and OR nurses must work according to six competencies, besides verifying patient id, and ensuring that the correct body part is marked for surgery (NAs also verify fasting): a) person-centred care, b) teamwork, c) evidence-based care, d) improvement knowledge and quality development, e) safe care for the patients and f) informatics (IT and digitalisation).
2.4 How do perioperative nurses work?
The work of perioperative nurses starts when the patient arrives in the operating room. From preparation and start of anaesthesia till termination, and handover of responsibility of care to the post-operative ward nurse, NAs oversee anaesthesia care. They work independently, consulting anaesthesiologists and providing the patient with analgesia and anaesthesia. OR nurses are responsible for aseptic procedures and assisting the surgeons with suitable surgical instruments during surgeries. Both the professions are equally responsible for the patient’s nursing care, for example, positioning the patient on the operating bed and patient safety. This means that perioperative nurses are locked in the operating room. Breaks are planned for lunch. NAs may have short coffee breaks, but OR nurses take their coffee breaks between patients or during preparation of anaesthesia. Work schedules include day work, afternoon and night shifts and during unsocial hours (e.g. between 4 p.m. and 7 a.m. and during weekends). The number of cases per operating room varies from one to multiple cases; also, during a work shift, perioperative nurses usually are responsible for one operating room, including all the cases planned for that room, but they can be removed to other operating rooms whenever needed. These unique working conditions in this unique environment, during long hours of work along with high demands on concentration, place high demands on both specialist nurses.
2.5 Anaesthesiologists
According to Matsusaki and Sakai [16], in 1910, in the USA, a campaign was started by physician anaesthetists in order for anaesthesia to become solely physicians’ work, where NAs had already been working for 150 years in their profession. Studies indicate that specific knowledge and skills are required for anaesthesiologists to undertake perioperative patient care [18] and that a majority believe that their current training must advance to support this aspect of their professional development. Being airway experts, providing vascular access, performing triage and resuscitation, and managing hemodynamic triage are some of the work tasks performed by anaesthesiologists [19]. Moreover, Zacharowski and Filipescu [20] stated that anaesthesiologists in Europe care for approximately 70% and in Scandinavia for 100% of ICU patients, whereas the remaining 30% of the ICU patients are being managed by other medical or surgical specialities.
In perioperative settings in Sweden, anaesthesiologists are located outside the operating rooms [21], and they are responsible for more than one patient or operating room at the same time; in other words, they carry a heavy responsibility for patients’ lives during anaesthesia and surgery [22]. They are responsible for assessment, preparation, maintenance and termination of anaesthesia and monitoring the patients. Moreover, they apply blockades. Anaesthesiologists work closely with nurse anaesthetists who are with the patient in the operating room. Parallel with their work in the operating room, anaesthesiologists assess new patients who are scheduled for surgery on the same day or in advance. In addition to working in operating departments and intensive care units, anaesthesiologists work in the radiology department, pos-toperative departments, acute and chronic pain management departments and emergency departments [21, 23]. In other countries, for example in the UK and in Germany, anaesthesiologists are the ones who stay with the patients in the operating rooms. Thus, the work tasks of anaesthesiologists vary in different countries.
The work environment for anaesthesiologists is characterised by working under time pressure, delayed or cancelled breaks, frequent overtime, high levels of stress and high risk of emotional exhaustion [24]. Burnout among anaesthesiologists and intensivists (who work in intensive care units) is one issue studied by Vittori and Marinangeli [25], who emphasised that one-third of the respondents scored at high risk of emotional exhaustion, and that anaesthesiologists who practised in intensive care had the highest rate of burnout. Female gender, high workload, younger physicians with children, academic physicians [6] and anaesthesiology residents [26] are, according to literature, at high risk of burnout. Female gender seems to be more at risk of higher stress levels than males; nonetheless, they tend to prioritise home/work commitments better than males [27]. Besides stress, burnout and high emotional exhaustion, high levels of depersonalisation, and low levels of achievement have been reported among anaesthesiologists [28]. On a more psychosocial level, anaesthesiologists reported fatigue, lack of collegiality and respect and lack of training, as areas of job satisfaction, of which lack of respect was a contributor to burnout [29].
2.6 Nurse assistants
There is a lack of literature studying nurse assistants, who are also called unlicensed assistive personnel (in Sweden) or nursing support workers. Nurse assistants provide basic care to patients and work under the direction of registered nurses. In Sweden, the training period is 1.5 years of high school education. Also, Nurse assistants may work in operating rooms as circulating nurses, assisting the operating room nurse with additional instruments needed during surgery (as the OR/scrub nurse cannot open nonsterile packages such as autoclaved packages with sterile tools inside), documentation, patient positioning, preparing the operating room or table and assisting with draping the patients. In anaesthesia care, the assistant nurse assists NAs and anaesthesiologists with the preparation and termination of anaesthesia. They do not have formal responsibility for patient care and work under delegation of the perioperative nurses. In operating room care, they always stay in the operating room together with the OR nurse. If they work with nurse anaesthetists, they leave the room after preparation and start of anaesthesia, and they come back for termination and transportation of the patient to the post-operative ward. During the maintenance of anaesthesia, nurse assistants supply the nurse anaesthetist with what is needed in the operating room and help with the analysis of blood samples taken/arterial gases. Additional training is offered on-site, in the department, where the nurse assistants work.
In summary, strict regulations of the work environment in operating rooms make it difficult for the perioperative nurses to open a window (if there is one) when it is hot or increase the room temperature when it is cold, or take a break when one feels the need for it. One eats or goes to the restroom when someone else decides or takes a break when it is allowed. As the perioperative nurses have too little to say about their physical environment in the operating rooms, the psychosocial environment becomes even more important in the nurses’ and other staff’s well-being.
3. Psychosocial and organisational work environment
Job satisfaction and dissatisfaction are concepts frequently discussed to describe how satisfied healthcare workers are with their work environment and working conditions. The endpoint of these discussions is voluntary or non-voluntary turnover, or adequate staffing within the organisation. Organisations such as operating departments, which are complex adaptive systems, should always be prepared, making the workplace as attractive as possible, as turnover and training of new staff are costly and require thoughtful planning and resources from the organisation. Turnover within the organisation is common, for example, when employees change their residence (voluntary turnover), choose to study further (voluntary turnover) or retirements (could be voluntary or non-voluntary turnover). However, voluntary turnover, when nurses with good skills, competencies, experiences and of working age leave their workplace due to job dissatisfaction, is serious and needs to be addressed.
Psychosocial and organisational factors in the healthcare environment interact, and they may contribute to nurses’ and other professionals’ decisions to stay or leave. On a psychosocial level, personal health [30] and possibilities to develop one’s skills and knowledge at one’s workplace, feeling that one’s work has a meaning and relationships [31] with colleagues and managers are some factors, which affect job satisfaction. Lee and MacPhee [32] explained that nurse-physician relationship in perioperative settings was related to nurses’ job satisfaction, and emotional exhaustion was the key predictor for nurses’ job satisfaction and intention to leave. Furthermore, perioperative nurse-to-nurse violence [33] and physician-to-nurse mistreatment [34] have been shown to cause high-stress levels [34] and depressive symptoms [33] in perioperative settings. Incivility or bullying leads to stress at work, impacting patient safety [35]. In contrast, perioperative nurses report that resolving issues leads to better patient outcomes, greater satisfaction in the workplace and heightens organisational commitment [36]. Villafranca and Hiebert [37] stated that the young clinicians who were inexperienced, female, non-heterosexual, worked as a nurse and worked in private care were groups that were more likely to be exposed to disruptive behaviour in their workplace.
On a personal level, Clausen and Burr [38] pointed out that not finding any meaning in one’s work and not having any organisational commitment were associated with long-term sickness. Moreover, demanding work schedules, working night shifts and unsocial hours have been shown to have a negative impact on sleep [39]. According to Zhao and Bogossian [40], shift worker nurses are 1.15 times more likely to develop low back pain. In a more organisational level, factors such as re-organisation, meaning (ever-) changing structure in the organisation versus stability in the organisation, working schedule or hours [41] and recovery [42, 43], salary [30], number of people working at one’s workplace [44] and leadership have further impact on whether one feels satisfied with his or her work. In summary, operating rooms are complex systems. Preventing perioperative nurses, nurse assistants or anaesthesiologists from leaving their workplace prematurely often requires several parallel measures.
3.1 Nurse managers’ role in staff’s well-being
As studies by Logde, Rudolfsson [4] and Arakelian, Rudolfsson [45] pointed out, the first-line manager can be someone who, by his or her actions or lack thereof, is experienced as a facilitator and someone who contributes to staff’s well-being or someone who is the reason for perioperative nurses leaving their workplace. This is valuable knowledge for leaders and managers in healthcare in perioperative departments, namely knowing that their role is crucial and that they can prevent loss of personnel. Leaving one’s workplace was described as a process, where perioperative nurses had considered talking to their closest managers about it for a while. Nonchalance on the part of the managers and feeling that they were not needed in the organisation made the nurses take the step to quit their jobs. However, the nurses argued that when the decision was made to leave one’s workplace, nothing, not even the best salary in the world, could change their mind. That is why nurse managers should be present and in close contact with their staff, being aware of their staff’s needs on a personal level.
Nurse managers are important for both quality of patient care [46] and the staff’s well-being [45, 47]; they desire to become nurse managers to do their best for the patients and their fellow employees, finding strength in their employees [47]. Nurse managers have described challenges they encounter, which are unique to perioperative settings [48]. Some challenges mentioned were that the nurse manager felt burdened by tasks that could be performed by other professions, for example, planning staff work schedules and lunch breaks, working as clinical nurses, being in the middle of the staff’s personal needs and the organisational needs, challenges described with the ever-changing organisation and need to find tasks suitable for staff who physically were not able to work with the physical demands of static work of, for example, operating room nurses (this is the case of nurses who are getting closer to retirement).
Unfortunately, not all nurse managers have the proper university education in management. This is a serious issue that should be addressed in health care, namely, to educate and require that they have proper education and training in future. From a caring science perspective, Bondas [49] discussed the concept of “caritative leadership”, which is derived from Eriksson’s theory of “caritative caring” [50]. The core of caritative leadership is the Caritas concept of human love and mercy, which in caritative leadership is directed towards both patients and employees. In other words, it means seeing the uniqueness of the employees and their abilities to “minister to” or help the patients. Fredriksson and Eriksson [51] pointed out the importance of a caritative conversation between the nurse managers and their employees, by creating a room or space between them. Such a conversation metaphorically serves as “compassionate love” in professional commitment and organisational tasks [49]. Solbakken and Bergdahl [52] emphasised the importance of reflection, time and space and a balance between these for nurse managers, which metaphorically was discussed as rooms in the “house of leadership”. The rooms were the patients’ room, the staff room, the organisational room, the superior’s room and the secret room. Caring in caritative leadership, according to Solbakken and Bergdahl [52], is a conscious movement or a metaphoric walk between the different rooms, as described above, to create a caring atmosphere. The secret room is a place where the managers have the opportunity to be alone with their own reflections and think things over.
3.2 Job demand-control-support and organisational and relational justice
Karasek [53] introduced the demand-control-support model, explaining that employees that receive support (both managerial and collegial) and feel high control and have low demands in their work are more likely to be healthy, or are in a healthy workplace. In contrast, those who do not receive support and feel high demands with no control, are in the high strain and more likely to become sick (burnout and other physical diseases). The latter presents risks for unhealthy or dangerous work. Those individuals who reported low well-being, low zest for work (meaning emotions about one’s work, low means feeling discomfort or aversion towards work) and high intention to leave are the ones in the high strain field, experiencing high demands and low control. These individuals are, in other words, in unhealthy environments. Moreover, Karasek and Theorell [54] pointed out that employee health is positively related to feelings of high job control and to receiving social support in the workplace and is negatively influenced by high work demands [53]. Job demand, job control and perceived fairness in the organisation (in organisational and social work environment) are important in the work environment [55, 56]. These factors affect sleep quality and short-term recovery. Furthermore, high work demands and low sense of control affect the blood pressure negatively [57, 58]. Moreover, effort-reward imbalance may lead the nurses to quit their jobs [59]. Perioperative nurses, nurse assistants and anaesthesiologists have an imbalance in their job demand and job control, as they do not have control over the physical work environment or working conditions (for example, lunch breaks, which patients they care for, order of patients and anaesthesia methods changing with short notice); perioperative nurses and nurse assistants must adapt to changes in anaesthesiologists and the surgeons’ decisions in patient care, and the changes occurring in the organisation. The workload is often high due to the growing number of surgeries, long work hours and personnel loss [4, 60], now more than ever, after COVID-19.
A study using Karasek’s demand-control-support model [61], performed in perioperative settings, emphasised that 30% of the approximately 955 respondents (perioperative nurses, nurse assistants and anaesthesiologists) sometimes had thoughts of leaving their workplace during at least one month in the last year. Lower social support, lower zest for work or feelings about one’s work, and thoughts about leaving one’s workplace were interconnected. None of the perioperative nurses, nurse assistants, nor anaesthesiologists was in the high strain (low support, high demands and low control). Operating room nurses were in the “active field”, according to the model, which means they felt they were in high control, despite feeling high demands. Nurse anaesthetists and nurse assistansts nurses were in a passive field with low demands and low control, and the anaesthesiologists, younger employees, and those with good well-being and high zest for work reported feeling low demands and high control (thus, being in the low-strain field).
Relation with one’s superior manager is one of several factors in the work environment affecting employee health, and organisational justice and relational justice describe two of them [62]. There are four dimensions in organisational justice (or fairness in the organisation or being treated fairly), and interpersonal justice or relational justice (also referred to as interactional justice) is one of them. It highlights the superior’s relationship with his or her employees, or how superior managers treat their employees. In other words, it means how employees’ personal views and rights are treated by superior managers, or whether the employees are treated impartially, truthfully and with kindness. Relational justice or being treated fairly at the workplace is also linked to employee health in the workplace [63, 64, 65, 66, 67].
First-line managers, who offer support to their nurse employees, play an important role in their well-being [68] and job satisfaction [45], and employees who are content with their work are more engaged in their workplace [54, 69]. Employees with higher organisational justice also have higher well-being [64, 65]. On the other hand, low organisational justice affects quality of sleep negatively [55], causing stress and employee’s possibility for recovery [70]. Working with work environment management systematically, a cohort of 500 employees in perioperative settings indicated higher scores of organisational justice, which means positive or good organisational justice (a higher number of total scores between 6 and 30 indicates good organisational justice, and the group had 25 and 26 at measurement in two-time points). A closer look at relational justice in the same cohort showed that timely feedback about decisions and being treated kindly by one’s supervisors who showed consideration had the most impact on employees’ well-being [71]. It is essential that supervisors treat their employees with fairness and create a friendly, welcoming workplace, where employees feel a balance in work demands and control of their work tasks, receive support from supervisors and colleagues and want to remain, and newcomers want to come and stay. Supervisors have the power to affect their employees’ health and well-being.
4. How can work environment be improved by simple means?
To increase work attractiveness, according to Bjorn and Josephson [41], special attention should be paid to salary, organisation and physical work environment. Logde, Rudolfsson [4] and Arakelian, Rudolfsson [45] indicated that simple means, such as creating a non-violent atmosphere between colleagues and professionals, the first-line managers being present, stressing everyone’s value in the team, giving timely feedback to one’s employees, providing healthy work schedules and working with employees’ salaries and allowing time to develop in one’s profession in the workplace were important steps in working in the right direction.
On a psychosocial level, a friendly and permissive atmosphere can be created by making a workplace a safe place, where one wants to be oneself and develop, namely a homelike place. Simple acts of knowing one’s colleagues on a personal level and creating relations, greeting each other every morning when coming to work and thanking each other before going home also played an important role. In such a workplace, where one has a voice, there is joy, a positive learning culture and creativity, all of which impact patient care positively.
Because of the nature of work in perioperative environments, small and smart planned breaks [72], microbreaks (short breaks) and passive- (just for rest) or active breaks (to walk or do small physical exercises) [73], which give an opportunity to change focus between two patients, are very important. In turn, breaks require planning and relevant staffing with relevant competencies to allow the NA or OR nurse to leave the operating room to change focus and be able to drink some water or use the restrooms. Operating settings and aviation settings have been compared in literature. Whereas in aviation, shifts and breaks are strictly regulated, as the staff’s focus and full concentration are always required during the flight, there is no consensus about breaks in operating rooms. Even in the transportation sector, there are also rules about taking breaks during a work shift. One has the right to have a meal or lunch 4 hours after starting to work in operating departments, which is not always followed due to hygiene regulations (the rule of not opening doors in, for example, orthopaedic surgery, where prostheses are being operated into patient’s body), safety reasons (the risk of missing information when reporting the patient to another nurse, so that one can leave the room) or staff shortage. This directly affects staff’s long-term well-being and ability to work.
Healthy work scheduling, with a focus on safety and recovery, is another measure that should be communicated to the staff, teaching them the benefits of correct planning of one’s work schedule so that one can feel a work-life balance and recovery, for example, not planning early morning shifts after late evening shifts, which gives less than 11 hours of sleep/recovery or to spread out days off, instead of working more than six or seven days in a row and taking a week off thereafter. According to research results, personal preferences in the workforce should be in balance with the organisational needs of staffing [42, 43]. There have been attempts to shorten the workday from eight to six hours for the workforce in operating departments, by planning the breaks at the end of the work shift, instead of spreading them out during the work shift. This, in the long run, tires the workforce, placing maximal demand on them during the shift. In other words, the idea is to reduce the tips of the iceberg (the peaks of high workload), with smartly placed breaks. It is also important to take into consideration that the staff need breaks more when the workload is the highest. Breaks can be planned during each work shift, but they can also be planned, for example, by mixing multiple tasks so that, for example, OR nurses do not statically stand and assist the surgeon with surgical instruments throughout their entire career every week, but to give the person an opportunity during the week to work with other tasks or responsibilities, for example, to work with students, to work with hygiene issues or to contact different firms and order and pack surgical instruments. This way, the person does not have to work statically every day, preserving his/her back, neck and shoulders for more years to come. For NAs, other tasks can include developing nursing care for the patients, taking responsibility for students and organising internal competence development for nurse anaesthetists or nurse assistants. Another way to both offers breaks and allow for competence development is to give time for reflection, where experienced nurses can guide newcomers in their professional development. As almost every minute of perioperative nurses’ workday is planned with tasks and the fact that working as a NA or OR nurse is a solitary work (there is just one nurse anaesthetist or operating room nurse per operating room), they need to process and reflect together with other colleagues about nursing care for the patients and how it can be improved, sharing knowledge together. This is a part of one’s development process in the profession, needing time and space from one’s clinical work.
Perioperative dialogue is a model, a way of working, to guarantee continuity, patient safety and person-centred care in perioperative settings. The model was first described by von Post [74] and developed further [75, 76, 77, 78]. According to perioperative dialogue, the same NA or OR nurse should meet the patient before, during and after surgery and anaesthesia. The purpose of this meeting before (pre) is to assess, to have a dialogue, to take in the patient’s story and experiences in planning the nursing actions during and after surgery and anaesthesia and give the patient a voice. These are the cornerstones in person-centred care, as described by Ekman [79]. Thereafter, a care plan is formed together with the patient. Meeting the same nurse during surgery and anaesthesia guarantees continuity, a familiar face who welcomes the patient into the operating room, and a nurse who guarantees that she/he is and will be there for the patient, seeing to the patient’s best interests [80]. During (perioperatively) surgery and anaesthesia, the nurse guarantees that the plan that was agreed upon with the patient will be carried out. After termination of surgery and anaesthesia (post-operatively), the nurse follows up on the plan with his/her patient. The departments that give the perioperative nurses the opportunity to perform perioperative dialogue will have better-prepared patients and more satisfied nurses, and benefits of perioperative dialogue are known for both patients and nurses who perform it [75, 76, 78, 81, 82, 83, 84, 85]. Moreover, perioperative nurses will feel that their unique and specific nursing knowledge will be a force to count on in patient care in perioperative departments. This will lift their pride and increase joy at work, and perioperative nurses will feel less like a secretary for electronic documentation, putting additional demands on their work [86]. The focus has changed in recent years towards digitalisation, and electronic documentation, with systems that do not always interact with each other. Hence, perioperative nurses, especially, must log into different systems, sometimes documenting the same information in several IT journal sights/systems. Furthermore, they have to struggle to find correct information [86, 87] when working with their patients in the operating room. The perioperative nurses describe this shift in focus from the valuable patient care to being forced to act as a secretary for electronic documentation. Working with and increasing the perioperative nurses’ pride and joy, lifting their specific competence and specific knowledge in nursing care of the patients should be the number one priority of the operating departments.
Possibilities to continuously develop one’s competence at work is another factor to increase job satisfaction. There should be paths of development in one’s workplace, both in the academic field and in the clinical field. In the academic field, there should be a plan (three-year or five-year plan) for how many NAs or OR nurses should study on PhD-level, or how many perioperative nurses, who also are associate professors or professors, should be employed and active within each operating department. Furthermore, to be an attractive workplace, nurses with high(er) academic grades should be involved in research and education of the departments, and in management from department levels to the highest level of the organisation at the hospital. There should be a carefully considered competence development plan and tools for assessing everyone’s competence and how it can be improved further at the workplace. The competence plan should be connected to and work hand in hand with a salary development plan, and the message should be “development pays off”. Salary is costly, but it is an incentive for the workforce to remain in the workplace. While employing new employees is associated with financial challenges, losing staff and being forced to hire temporary staff are even more costly, and training new staff also requires human and financial recourses. Economic means should be invested in the existing staff, as it pays off in the long run when they remain in the workplace. Not everyone is interested in developing an academic career. There should, therefore, be paths to work clinically, and in leadership, and reach the “next level”. For example, perioperative nurses or assistant nurses may work in different operating departments, with adult patients or children, and develop their clinical skills, meeting new challenges with new patient groups. Intensive care units and airborne intensive care (used for care of patients, for example, during transportation from one hospital to another and from the scene of injury to hospital) are other clinical work developments, which can be offered to nurse anaesthetists. The third path of development is in leadership and management.
Shortage of time is frequently discussed at the hospitals, and to compensate for that, mandatory education or meetings, which are essential for patient safety are shortened. For example, yearly training in CPR (cardiopulmonary resuscitation), important meetings about changes in surgical routines, instruments or new routines or medications in how to anaesthetise a pregnant woman have a direct impact on the outcome of care and should be prioritised in the organisation. This is not a matter of ‘whether we should’ but ‘how should it be done’ systematically! In addition, team training that increases psychosocial well-being, bonds the staff who work together on an everyday basis and gives them a well-deserved break from monotonous work are important means. During team training, time should be allotted for reflection and improvements in care for patients.
Finally, systematic work environment management can improve work environments in perioperative settings for perioperative nurses, nurse assistants [88] and anaesthesiologists [89]. Using a support model for systematic environment management gives the staff (nurses and assistant nurses) in the perioperative context an opportunity to discuss problems with collaboration, work organisation and how to treat each other. Moreover, it gives them the opportunity to be engaged in their work environment issues, helping first-line managers in work environment management [90].
5. Conclusion
Despite the challenges in perioperative work environment, many choose to work in such an environment. As the physical environment is difficult to affect, the psychosocial and organisational environment become more important in the staffs’ work life. There are several simple measures that can be used, and actions must be taken today to make perioperative settings healthy and attractive. Actions should be taken against incivility or bullying at work; nurse managers should have proper university education and training to be able to conduct caritative caring for their staff members; salaries for perioperative staff, among the nurses, should be revised and increased; and they should be given the opportunity to use their full competence and advanced nursing knowledge in patient care, and possibilities to develop in their profession in their workplace. This way, newcomers and ordinary staff may choose to stay, develop themselves and their workplace further, as losing perioperative nurses results in cancelled surgeries and suffering for patients.
Thanks
Ann Lögde, we will always remember you for your engagement and for your input in your colleagues’ work environment. Thank you!
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