We can address fundamental issues from quality of care to work environment by focusing on two areas: teamwork and communication.
The COVID era has tested hospitals and healthcare professionals in unfathomable ways. The strain on resources and personnel continues to affect both hospital efficiency and patient care.
How do we pull ourselves out of the COVID funk to improve the environment — and the outcomes — for doctors, nurses, support staff, and patients?
For the past few years, we’ve been in survival mode, making do with available personnel, operating rooms, and changing schedules, trying to help as many people as possible as quickly as possible. Now is a good time to reset — not because there is any less need but because we’re facing a real crisis.
According to Health Affairs, the number of RNs dropped by more than 100,000 over the course of 2021 alone. That’s the biggest exodus that’s been observed in four decades of tracking. An Epic Research study also found that the median tenure of nurses working 12-hour shifts fell 19.5% from March 2021 to March 2022, so the number of nurses coming into the field is dropping, and the ones in the field are not staying as long.
This creates a host of issues that were intently discussed at the HLTH conference. The nursing shortage is only one aspect of what’s going on in our ORs — but it is this shortage of essential workers that may be the impetus for change.
If we take a step back to consider what’s going on, we can address fundamental issues from quality of care to work environment to increasing efficiency by focusing on two areas: teamwork and communication. Both areas involve respecting the humanity and expertise of everyone in the OR.
Let’s look at teamwork first because it ultimately feeds communication. In most hospitals today, teams are constantly changing based on who’s available and what is happening around them. It is not uncommon for team members to swap out during procedures, even cases of short duration. This causes disruption and a lack of cohesion that many doctors find unsettling, while nurses are constantly running between patients, leaving them mentally and physically exhausted.
Importantly, this persistent movement limits situational awareness. Without fully knowing what’s going on around them, decision-makers lack data points that could impact the course of care, whether it’s which instrument to pick up or which drug to administer. There are safety procedures in place that minimize the likelihood of mistakes, but even the slightest pause or well-intentioned interruption can be costly. Suppose a nurse is preparing for surgery and someone asks him or her a question, distracting their focus. If a mistake is made, it can be extremely difficult to rectify.
By building consistent teams that get used to working together, situational awareness dramatically increases. While not always practical, these units not only get in sync with one another, but they also come up with solutions and improvements that would be impossible to conceive if a group were mashed together for the first time.
For example, an expert team brainstorming ways to decrease distractions at the end of a case when critical activities take place (for example, counting) could look for innovative ideas from other parts of the hospital and may adapt the concept of “red zones” from best practices in medication management.
Prior to the start of the counting process, the nurse announces, “We are going into the red zone. Do you need anything before we start counting?” While in red zone time, only questions related to the count or a critical event are discussed.
Core to establishing effective teams is expertise. It’s not just about having knowledge — it’s having the right knowledge.
Often, the person (or machine) in charge of staffing tries to pair a less experienced nurse with someone who has more years on the job. This seems logical.
But what if a veteran nurse is assigned to a procedure in which a robot is leveraged, and what if that nurse had never worked with a robot? Despite 20 years in the OR, she or he could be considered a novice, whereas someone fresh out of nursing school could be remarkable with robots. The lines are not always clear-cut, but an attempt at balance should be made. Once skills are fully understood, it becomes much easier to consistently pair the teams together for similar procedures.
We’ve all been on good teams — and on bad ones. Putting together a group of people that makes sense on paper or in a computer system doesn’t always translate to something that works in the OR.
So, what makes a team functional? Extensive, clear communication.
Suppose there’s a cardiac arrest in the OR. The circulating nurse says, “Can someone push the code button?” In this scenario, no one knows who the nurse is talking to, and they don't know if somebody else has done it. Everybody expects somebody else to do it, and in that delay, precious time is lost. What the nurse really needs to say is, “David, would you please push the code button,” and then David does it and says something along the lines of “done,” or “pushed,” so that the fact that the task was completed is communicated to everyone.
This seems obvious, and yet many times it doesn’t happen. Obstacles exist to clear communication. One of the biggest is the traditional OR hierarchy in which the surgeon is generally situated at the pinnacle. Often, no one feels comfortable speaking up if they notice something — anything — is amiss. They don’t want to come across as critical or worry about the impact on their careers if one of their “higher ups” takes a comment the wrong way.
For maximum efficiency, quality patient care, and a better work environment altogether, we must do a better job of developing cultures of psychological safety. That means we have to believe we will not be punished or humiliated for speaking up with ideas, questions, or concerns.
In this type of culture, instead of hearing, “We always do it the same way,” in response to a question, using phrases such as “Thank you for that information/question/suggestion,” or “This case is actually slightly different than I usually do it, and I’ll explain to you why” is a better way to go.
If a surgeon says, “Here’s some additional information about the patient/the procedure that might help you better understand why I’m doing something out of the ordinary,” it becomes a learning experience as well as a team-building experience. This is a subtle, yet powerful, mindset shift in which expert teams are born rather than one that glorifies individual experts.
Cultures are built over time, and in today’s ORs, it can seem like this is a luxury we don’t have, but other industries in which lives are on the line realize that we must prioritize people’s needs in our processes. It starts with small steps. New technologies and better processes can help.
With a mindset and culture of respect, communication, and collaboration, everyone wins. We showcase that we are an industry of compassion that people want to join and where they are proud to stay.
Jeff Robbins is the founder and CEO of LiveData