Surgery and Central Processing Relationships: A Survey
By Jack Donaldson, BSN, CNOR, CSPDM and Kathy Donaldson, RN, CNOR, CSPDT
A survey designed to explore Central Processing Department (CPU) staff attitudes regarding their relationship with the Operating Rooms (OR) of their respective institutions was conducted at the annual conference of the Golden West Central Service & Healthcare Chapter held in Reno, Nev, September 27-29, 2000. Sixty-six conference attendees responded to a 19-question multiple-choice survey. Of those responding, 30 also wrote short statements addressing the one thing they would do to improve CPU-OR relations (Addendum A).
In general, the survey finds that the current state of CPU-OR relationships is good. No significant themes or patterns are identified as contributory factors to poor relationships. Some data results are cause for concern and written comments centered around two major themes. The following will report on the survey findings, discuss areas of concern, and share recommendations expressed in the written comments.
Two survey questions asked participants to rate both their department's and their personal relationship with the OR. Rating choices were excellent, very good, good, fair, poor, and very poor. For the purposes of this survey, ratings of good to excellent were considered positive and ratings of very poor to fair were considered negative. Forty-nine respondents (74%) rated the current state of CPU and OR relationships as positive while 17 rated them as negative. Thirteen respondents (20%) gave excellent ratings while only one very poor rating was recorded. These responses were explored for influencing factors: numbers of operating rooms, acuity of surgical practice, hospital type, management structure, management credentialing, intradepartmental credentialing requirements, personal status of respondents credentials, departmental educational practices, departmental orientation practices, physical location of the department relative to the OR, interdepartmental communication tools, staffing design, experience levels, age, and staffing schedules. The survey response data is presented in Table A. The following is a review of each category response and how it may contribute to excellent or poor ratings.
Review of Findings
CPU complexity results from two primary influences, facility size (numbers of operating rooms) and the "CPU-Acuity" of the surgical services practiced in the OR. CPU-Acuity is influenced by instrumentation volume and complexity relative to requirements for decontamination, assembly, and sterilization. Thus, a facility performing multiple total joint, spinal fixation, and laparoscopic procedures will earn a higher CPU-Acuity score than a similar sized institution performing large volumes of general surgery.
Staff from small facilities (1-6 Rooms) responded positively 89% of the time. Moderate size facilities (7-11 Rooms) report a 52% positive rating. Staff from large facilities (12-23 Rooms) responded positively 78 %of the time. Facilities with higher acuities were rated positively 77% of the time while less acute facilities were given positive a 55% positive rating.
A review of facility types found that outpatient surgery center staff gave a 100% positive rating. Other facilities gave the following ratings:
- Teaching hospitals: 81% positive
- Private hospitals: 75% positive
- Clinics and other settings: 66% positive rating.
Management structure does not appear to influence approval ratings. Staff under material's management gave a 72% positive rating, while those under surgical services gave 70% positive ratings. Those classifying their management structure as "other" gave 100% positive ratings.
Management credentialing appears to influence ratings. Nurse managers received 80% positive ratings. Certified sterile processing technicians were rated positive 66% of the time. Non-certified managers received a 50% positive rating.
Departmental certification requirements and personal certification do not appear to influence positive or negative ratings. It is important to note that while only 43% of the departments require certification, 80% of the survey respondents were certified.
There is no indication that the frequency of education programs influences positive or negative relations. However, given the ongoing technological changes challenging sterile processing professionals, it is disconcerning that 78% of the respondents report that they have education programs monthly or less frequently. However, it is encouraging that 74% of the respondents report that their departments have structured orientation programs.
The responses do not show that structured orientation programs influence positive or negative ratings.
The physical relationship of the CPU to the OR does not seem to impact relations. Those located in the OR gave an 81% positive rating. Those respondents most removed--on a different floor and without direct access to the OR--gave a 77% positive rating.
Communication does not appear to influence ratings. Direct verbal communication received a 77% positive score, while phone communication received 75%.
The relationship does not appear to be affected by staffing design, experience, or age. It is important to note that the average experience of the survey respondents was over six years and that the average age was 48 years. There were no respondents under 30 years of age and only five respondents were entry-level employees. These figures match well with current nursing data and do not bode well for the future staffing of central processing departments. If they are a reflection of national trends, central processing units will be facing a shortage of experienced workers in an era of advancing technological challenge.
CPU staff who work days, are required to take calls, and work weekends gave the highest cluster of "Excellent" ratings of any related category in the survey.
The more negatively a staff member perceived their personal relationship with the OR, the more negatively they rated their department's relationship with the OR. However:
- 8% of the respondents who rated their personal relationship as excellent gave negative ratings to their department's relationship with the OR.
- 16% of those with very good personal relationships rated their department's relationship as negative.
- 40% of those with good personal relationships considered their department's relationship as negative.
- 66% of those with fair personal relationships with the OR gave their department negative marks.
Survey participants were asked to suggest the one thing they would do to improve OR and CPU relations. Their comments focused on two themes: inter-department cross-training/cross-orientation and improved communication. The orientation of new nursing staff in the OR to the functions of the CPU is highly recommended by CPU staff. It is viewed as a means of providing the OR staff with knowledge that will assist them to appreciate the workings of the CPU and how to best work with the CPU staff to achieve their needs. Conversely, comments strongly recommend rotation of CPU staff into the OR to provide for enhanced understanding of OR functions and how the CPU may be better able to improve services. Other comments addressed the need for more intradepartmental education.
One person surveyed found that "the weak or negligible influences on the quality of worklife of OR nurses are: organizational structure, leadership, and organizational learning." He states that the "things that matter to OR Nurses and that influence their quality of worklife are: collaborative decision-making, multiskilled workers, change, organizational culture, focus of control: and the most important influence of all- Teamwork."1 These same influences seem apparent in this survey. The survey did not find any major institutional influences on the quality of worklife. However, in their personal comments CPU staff consistently called for collaboration in training, education, and team building. Efforts in this direction are supported by Wurstner and Koch, who found that a staffing patterns redesign process employed to create multiskilled worker roles within self-managed perioperative specialty teams resulted in "reduced potential interdepartmental barriers and instilled a spirit of support and cooperation."2 A surveyed woman recommends bi-monthly staff meetings combining CPU staff and OR licensed staff to prevent the "we--they" scenario."3 Comments recommending interdepartmental cross orientation are supported by Schultz, who states: "Reality orientation might be facilitated by having CS workers float to the OR, perhaps to staff the central core, and, conversely, OR staff need to spend a couple of shifts in CS, including at least one in Decontam. In today's stressed economic environment, this may be difficult to accomplish for many healthcare institutions. But action speaks so much louder than words and learning will occur faster with hands-on experience than with talk alone."4
The aging of the CPU workforce identified in this survey poses a need for further investigation. Downsizing, increasing technology, and the natural physical deterioration that comes with aging presents a complex problem for CPU managers in the future. For example, a complex revision of a total joint knee surgery may require as many as 25 trays of instruments averaging 20 pounds for each tray. Assume that each tray is handled once for assembly, autoclave loading and unloading, storage, case picking, and following the case washer-sterilizer loading and unloading. A downsized and older CPU staff will handle a total of 3,500 pounds of instruments for one total joint surgery. Add to that the pushing and pulling of loaded autoclave carts, case carts, washer-sterilizer carts, and incidental handling of the trays to organize work and the figure can easily exceed 5,000 pounds for one case.
The survey did not identify any aspect of institutional design that significantly (positively or negatively) influences interdepartmental relations between the OR and CPU. Survey data suggests that CPUs may be facing the same staffing issues as nursing units--an experienced, educated, and aging workforce facing diminishing membership. The data suggests that younger workers are not entering the field and that institutional commitment to the educational needs of CPU staff needs to be enhanced.
Lastly, personal comments recommending actions that would enhance OR-CPU relations centered around two themes, interdepartmental cross training, and improved communication. These comments are supported in literature as positive change agents to improved relations.
Jack Donaldson, BNS, CNOR, CSPDM is the Nurse Manger for Sterile Processing at Sutter Medical Center in Sacramento, Calif. He is also the editor of the Interned Nursing Education Site, nurseceu.com. Kathy Donaldson, RN, CNOR,CSPDT is the Clinical Nurse Educator, Surgery at the University of California Medical Center, Davis (Sacramento, Calif.).
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