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By Jack Donaldson, BSN, CNOR, CSPDM and KathyDonaldson, RN, CNOR, CSPDT
A survey designed to explore Central Processing Department (CPU)staff attitudes regarding their relationship with the Operating Rooms (OR) oftheir respective institutions was conducted at the annual conference of theGolden West Central Service & Healthcare Chapter held in Reno, Nev,September 27-29, 2000. Sixty-six conference attendees responded to a 19-questionmultiple-choice survey. Of those responding, 30 also wrote short statementsaddressing the one thing they would do to improve CPU-OR relations (AddendumA).
In general, the survey finds that the current state of CPU-OR relationshipsis good. No significant themes or patterns are identified as contributoryfactors to poor relationships. Some data results are cause for concern andwritten comments centered around two major themes. The following will report onthe survey findings, discuss areas of concern, and share recommendationsexpressed in the written comments.
Two survey questions asked participants to rate both their department's andtheir personal relationship with the OR. Rating choices were excellent, verygood, good, fair, poor, and very poor. For the purposes of thissurvey, ratings of good to excellent were considered positive and ratings ofvery poor to fair were considered negative. Forty-nine respondents (74%) ratedthe current state of CPU and OR relationships as positive while 17 ratedthem as negative. Thirteen respondents (20%) gave excellentratings while only one very poor rating was recorded. These responseswere explored for influencing factors: numbers of operating rooms, acuity ofsurgical practice, hospital type, management structure, managementcredentialing, intradepartmental credentialing requirements, personal status ofrespondents credentials, departmental educational practices, departmentalorientation 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. Thefollowing is a review of each category response and how it may contribute to excellentor poor ratings.
Review of Findings
CPU complexity results from two primary influences, facility size (numbers ofoperating rooms) and the "CPU-Acuity" of the surgical servicespracticed in the OR. CPU-Acuity is influenced by instrumentation volume andcomplexity relative to requirements for decontamination, assembly, andsterilization. Thus, a facility performing multiple total joint, spinalfixation, and laparoscopic procedures will earn a higher CPU-Acuity score than asimilar 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 fromlarge facilities (12-23 Rooms) responded positively 78 %of the time. Facilitieswith higher acuities were rated positively 77% of the time while less acutefacilities were given positive a 55% positive rating.
A review of facility types found that outpatient surgery center staff gave a100% positive rating. Other facilities gave the following ratings:
Management structure does not appear to influence approval ratings. Staffunder material's management gave a 72% positive rating, while those undersurgical services gave 70% positive ratings. Those classifying their managementstructure as "other" gave 100% positive ratings.
Management credentialing appears to influence ratings. Nurse managersreceived 80% positive ratings. Certified sterile processing technicians wererated positive 66% of the time. Non-certified managers received a 50% positiverating.
Departmental certification requirements and personal certification do notappear to influence positive or negative ratings. It is important to note thatwhile only 43% of the departments require certification, 80% of the surveyrespondents were certified.
There is no indication that the frequency of education programs influencespositive or negative relations. However, given the ongoing technological changeschallenging sterile processing professionals, it is disconcerning that 78% ofthe respondents report that they have education programs monthly or lessfrequently. However, it is encouraging that 74% of the respondents report thattheir departments have structured orientation programs.
The responses do not show that structured orientation programs influencepositive or negative ratings.
The physical relationship of the CPU to the OR does not seem to impactrelations. Those located in the OR gave an 81% positive rating. Thoserespondents most removed--on a different floor and without direct access to theOR--gave a 77% positive rating.
Communication does not appear to influence ratings. Direct verbalcommunication received a 77% positive score, while phone communication received75%.
The relationship does not appear to be affected by staffing design,experience, or age. It is important to note that the average experience of thesurvey 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 wereentry-level employees. These figures match well with current nursing data and donot bode well for the future staffing of central processing departments. If theyare a reflection of national trends, central processing units will be facing ashortage of experienced workers in an era of advancing technological challenge.
CPU staff who work days, are required to take calls, and work weekends gavethe highest cluster of "Excellent" ratings of any related category inthe survey.
The more negatively a staff member perceived their personal relationship withthe OR, the more negatively they rated their department's relationship with theOR. However:
Survey participants were asked to suggest the one thing they would do toimprove 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 ishighly recommended by CPU staff. It is viewed as a means of providing the ORstaff with knowledge that will assist them to appreciate the workings of the CPUand 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 forenhanced understanding of OR functions and how the CPU may be better able toimprove services. Other comments addressed the need for more intradepartmentaleducation.
One person surveyed found that "the weak or negligible influences on thequality of worklife of OR nurses are: organizational structure, leadership, andorganizational learning." He states that the "things that matter to ORNurses and that influence their quality of worklife are: collaborativedecision-making, multiskilled workers, change, organizational culture, focus ofcontrol: and the most important influence of all- Teamwork."1These same influences seem apparent in this survey. The survey did not find anymajor institutional influences on the quality of worklife. However, in theirpersonal comments CPU staff consistently called for collaboration in training,education, and team building. Efforts in this direction are supported byWurstner and Koch, who found that a staffing patterns redesign process employedto create multiskilled worker roles within self-managed perioperative specialtyteams resulted in "reduced potential interdepartmental barriers andinstilled a spirit of support and cooperation."2 A surveyedwoman recommends bi-monthly staff meetings combining CPU staff and OR licensedstaff to prevent the "we--they" scenario."3 Commentsrecommending interdepartmental cross orientation are supported by Schultz, whostates: "Reality orientation might be facilitated by having CS workersfloat to the OR, perhaps to staff the central core, and, conversely, OR staffneed to spend a couple of shifts in CS, including at least one in Decontam. Intoday's stressed economic environment, this may be difficult to accomplish formany healthcare institutions. But action speaks so much louder than words andlearning 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 forfurther investigation. Downsizing, increasing technology, and the naturalphysical deterioration that comes with aging presents a complex problem for CPUmanagers in the future. For example, a complex revision of a total joint kneesurgery may require as many as 25 trays of instruments averaging 20 pounds foreach tray. Assume that each tray is handled once for assembly, autoclave loadingand unloading, storage, case picking, and following the case washer-sterilizerloading and unloading. A downsized and older CPU staff will handle a total of3,500 pounds of instruments for one total joint surgery. Add to that the pushingand pulling of loaded autoclave carts, case carts, washer-sterilizer carts, andincidental handling of the trays to organize work and the figure can easilyexceed 5,000 pounds for one case.
The survey did not identify any aspect of institutional design thatsignificantly (positively or negatively) influences interdepartmental relationsbetween the OR and CPU. Survey data suggests that CPUs may be facing the samestaffing issues as nursing units--an experienced, educated, and aging workforcefacing diminishing membership. The data suggests that younger workers are notentering the field and that institutional commitment to the educational needs ofCPU staff needs to be enhanced.
Lastly, personal comments recommending actions that would enhance OR-CPUrelations centered around two themes, interdepartmental cross training, andimproved communication. These comments are supported in literature as positivechange agents to improved relations.
Jack Donaldson, BNS, CNOR, CSPDM is the Nurse Manger for SterileProcessing at Sutter Medical Center in Sacramento, Calif. He is also the editorof the Interned Nursing Education Site, nurseceu.com. Kathy Donaldson, RN,CNOR,CSPDT is the Clinical Nurse Educator, Surgery at the University ofCalifornia Medical Center, Davis (Sacramento, Calif.).
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