- Email: [email protected]
What Do Surgical Nurses Know About Surgical Residents?
2009 APDS SPRING MEETING
What Do Surgical Nurses Know About Surgical Residents? Lisa L. Schlitzkus, MD, Steven C. Agle, MD, Michael M. McNally, MD, Kimberly D. Schenarts, PhD, and Paul J. Schenarts, MD Division of Surgical Education, Department of Surgery, East Carolina University, Brody School of Medicine, Greenville, North Carolina OBJECTIVE: A fundamental premise of establishing collabo-
rative relationships between residents and nurses is a basic understanding of the attributes of each group. The intent of this study was to determine what surgical nurses know about surgical residents. DESIGN: A piloted survey tool was administered to a cross-
section of nurses working in 3 surgical intensive care units, a surgical intermediate unit, and 2 general surgical floors. Surgical residents completed the same survey tool. The percentage of residents giving the most frequent response was compared with the percentage of nurses giving the same response. SETTING: A university, teaching hospital. PARTICIPANTS: One hundred twenty-four of 129 surgical nurses and 24 of 25 surgical residents who completed the survey tool. RESULTS: The response rate for nurses on the 2 survey days was 94%, or 54% of all surgical nurses employed by the hospital, and 96% for residents. The nurses surveyed were equally distributed between the units. Ninety-nine percent of nurses did not have a surgical resident as a significant other, 55% of nurses had greater than 5 years experience, and 95% were licensed registered nurses. Seventy-eight percent of nurses correctly indicated that a medical doctorate is the highest degree required to start residency (p ⫽ 0.01), but only 57% accurately identified the length of surgical residency (p ⫽ 0.02). Nurses perceived residents devoted less time to patient care (p ⬍ 0.01) and more time to studying (p ⬍ 0.01). Forty percent of nurses do not think interns are legally physicians (p ⬍ 0.01) or hold a medical license (p ⬍ 0.01). Forty percent of nurses are aware of the 80-hour work week restriction (p ⬍ 0.01). Eighteen percent of nurses have the perception that residents are not allowed to
Correspondence: Inquiries to Paul J. Schenarts, MD, FACS, Director, General Surgery Residency Program, Associate Professor of Surgery, Department of Surgery, East Carolina University, Brody School of Medicine, 600 Moye Blvd, Greenville, NC 27858; fax: (252) 847-8208; e-mail: [email protected] Presented as a podium presentation at the 2009 Meeting of the Association of Program Directors in Surgery, Salt Lake City, Utah, April 2009.
perform bedside procedures without an attending physician present (p ⫽ 0.03), while 56% have the perception that residents are not allowed to perform any part of an operation without an attending physician (p ⬍ 0.01). There is a misperception among 32% of nurses that residents pay tuition for residency (p ⬍ 0.01), while only 52% accurately identified the range of a resident’s salary (p ⫽ 0.01) and 11% the amount of resident debt (p ⬍ 0.01). CONCLUSIONS: Despite the importance of the collabora-
tive relationship in surgical patient care, surgical nurses have a limited understanding of surgical residents. Educating nurses about the education, roles, and responsibilities of surgical residents might improve collaborative relationships and ultimately patient care. (J Surg 66:383-391. © 2009 Association of Program Directors in Surgery. Published by Elsevier Inc. All rights reserved.) KEY WORDS: ACGME competencies, nursing, resident evaluation, surgical education, surgical residents COMPETENCY: Interpersonal Skills and Communication,
Professionalism, Systems-Based Practice
INTRODUCTION Effective teamwork, collaboration, and communication have become emphasized in improving the quality of patient care1-5 and in surgical education.6-12 A fundamental premise of a productive, collaborative relationship is that members of each team understand the basic attributes of other team members. With regard to the care of the surgical patient, surgical residents and surgical nurses are required to work together more so than any other 2 groups. Failure to establish a collaborative relationship and misperceptions of the basic attributes of team members can lead to conflict resulting in poor patient care. In a survey13 of over 6000 residents about conflict with other professional colleagues, 20% of residents reported a serious conflict with another staff member, 8.9% of whom were nurses. As the number of reported conflicts increased, the number of serious medical errors and
Journal of Surgical Education • © 2009 Association of Program Directors in Surgery Published by Elsevier Inc. All rights reserved.
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adverse patient outcomes also increased. The report of conflict with 1 versus 2 professional colleagues increased serious medical errors from 36.4% to 51%, and adverse patient outcomes from 8.3% to 16%. While the causality of this relationship cannot be determined from the data, the findings are sobering. The importance of learning this collaborative approach is reflected by the Accreditation Council for Graduate Medical Education’s (ACGME) core competencies of communication, professionalism, and systems-based practice.14 Mastery of these competencies may be verified on surgical resident evaluations, such as the 360 degree evaluation, described in the ACGME’s Toolbox Assessment15 which incorporates surgical nurses into the evaluation process. The 360 degree evaluation further meets the Residency Review Committee’s (RRC) program requirement of evaluating and documenting resident performance utilizing multiple evaluators, highlighting the RRC’s mission of objectivity and fairness.16 Given the importance of effective collaborative relationships between surgical residents and surgical nurses and the potential consequences of poor clinical outcomes as well as poor resident evaluations resulting from misperceptions, we sought to define what surgical nurses know about the educational goals, scope of practice, and lifestyles of surgical residents.
METHODS This study was approved by the Biomedical Institutional Review Board at East Carolina University. Nursing management is part of this approval process and agreed to participate in this study. Participation in the survey was voluntary and without compensation. Individual nurses and surgical residents consented by completing the survey. The survey consisted of an introductory statement explaining the purpose of the survey and queried participants regarding demographic information, and their individual knowledge of the educational goals, scope of practice, and lifestyles of surgical residents at our University Hospital. The survey tool is provided in Appendix A. Our general surgery residency program is ACGMEapproved and graduates 4 chief residents each year after 5 clinical years and 1 year of research training. Our institutional policy states that residents may perform bedside procedures and certain parts of operations without an attending physician present.
Face and Content Validity Face and content validity of the survey tool was confirmed by a pilot survey of 8 nurses who work closely with internal medicine residents on a nonsurgical floor. Following completion of the pilot survey, 1 investigator discussed the survey tool with the pilot participants to ensure that the survey questions and answers were understandable. 384
Survey Methodology The survey tool was distributed to the nurses in our 3 surgical intensive care units (SICU), the surgical intermediate Unit (SIU), and our 2 general surgical floors. The survey was handed directly to each nurse and collected several hours later. At our institution, nurses work either day or night shifts (not both), and the staffing pattern is such that nurses work Monday through Thursday or Friday through Sunday, although there is occasionally some crossover. As a result, the survey was distributed on 1 weekday and 1 weekend day to both day and night shifts to ensure that the sample was a representative crosssection of the entire surgical nursing staff. If a nurse happened to be present during more than 1 survey time, they were asked to participate only once. Data collected included demographics about the nursing staff regarding clinical experience, education, and time spent working with surgical residents. The nursing staff was also asked about residents’ levels of education, licensing, roles in patient care and procedures, patient coverage, work hours, salary, and debt. Our nursing staff is exposed to all levels of residents, but we did not ask the nurses which level of residents they were exposed to the most. Surgical residents were also asked to complete the same survey tool, and the most frequent response was considered the control answer. Comparisons were then made between the percentage of residents giving the most frequent response and the percentage of nurses giving the same response to each question. If a question was left blank or multiple answers given, that question response was removed from the analysis. Statistical analyses were performed using the statistical software package SPSS for windows 16.0 (Chicago, IL). All univariate analysis employed the Student t test, analysis of variance (ANOVA), or 2-test as appropriate. Two-tailed tests were used for every analysis, and statistical significance was set a priori at p ⬍ 0.05.
RESULTS A total of 226 surgical nurses are employed by the hospital; 136 (54%) were available at the 4 time points the survey was performed. Of the nurses available to participate, the survey response rate was 94% (124 surveys returned). The weekday response rate was 95%, and the weekend response rate was 92%. The nurses surveyed were equally distributed between the SICU (37%), SIU (26%), and the general surgical floors (37%). Ninety-nine percent of nurses did not have a surgical resident as a significant other. Fifty-five percent of nurses had greater than 5 years experience, and 95% were licensed registered nurses. Twenty-four out of 25 surgical residents (96%) completed the survey as well. Demographic data for both groups are summarized in Table 1. Comparisons between the most frequent resident response and the percentage of nurses giving the same response to ques-
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while on call (p ⬍ 0.01), show a wide variance in the responses by the nurses (Figure 2).
TABLE 1. Demographics Nurses (n ⴝ 124) Female Age 22–35 Caucasian African American Spouse member of opposite cohort?
81% 56% 69% 19% 1%
Residents (n ⴝ 24) 25% 100% 67% 17% 12.5%
p Value ⬍0.001 0.003 NS 0.014
NS, not significant.
tions relating to education, roles, licensing, and lifestyle are presented in Table 2. There was a distinct discrepancy in the perceived amount of time devoted to patient care and studying. Most residents (83%) felt that over 76% of their time is spent devoted to patient care. Conversely, only 27% of nurses perceived residents devote more than 76% of their time to patient care (p ⬍ 0.01). Figure 1 demonstrates that there was no clear consensus among the nursing staff as to how much resident time is allocated to patient care. It appears that the perceived percent of resident time devoted to patient care was underestimated by the nursing staff. A similar discrepancy occurred in response to the amount of resident time allocated to study; most residents (96%) felt that less than 30% of their time is spent studying compared with 21% of the nursing staff giving this response (p ⬍ 0.01). While there was fewer variation of the nursing response, the perceived amount of resident time devoted to studying is overestimated (Figure 1). Data regarding resident lifestyle variables, such as length of residency (p ⫽ 0.01), work hours per week (p ⬍ 0.01), the number of hours on call at a time (p ⬍ 0.01), and hours of sleep
DISCUSSION The results of our study find that there are serious misunderstandings between the nursing staff and surgical residents with regard to education, roles, licensing, and lifestyles of surgical residents. This degree of misunderstanding has important implications for patient safety, clinical outcomes, and resident evaluations. When comparing organization climate safety factors with outcomes for surgical services, Davenport et al found that perceived positive communication and collaboration with resident doctors correlated with lower risk-adjusted morbidity.5 Failure of effective communication has also been reported by the Joint Commission for the Accreditation of Health Care Organizations as the leading cause of sentinel events during the perioperative period.17 As part of the World Health Organization’s Safe Surgery Saves Lives program, facilitation of communication by use of a surgical safety checklist in the operating room decreased the rate of any complication from 11% to 7% (p ⬍ 0.001) and reduced mortality from 1.5% to 0.8% (p ⫽ 0.003).18 Similarly, patients whose surgical teams frequently displayed teamwork behavior were at a lower risk of death and complications.19 Safety checklists and briefing periods force all members of the operative team to communicate, and concentrate on the patient and procedure at hand. However, outside the operating room no checklist or briefing period exists, so that members of the team are not introduced and expectations are not clearly stated, setting the stage for error and conflict. Despite our institutional policies to the contrary, we found that 40% of surgical nurses
TABLE 2. Response Results Question Asked
Most Frequent Response
Residents
Nurses
p Value
Highest degree to start residency Residency duration, years Residency required to practice % Resident time devoted to patient care % Resident time devoted to study Mandatory education conferences Know when conferences are held Pass examination to be promoted to next year Are interns legally doctors Are residents legally doctors Do interns hold medical licenses Maximum work hours per week Maximum hours on call Hours slept while on call Bedside procedures without attending Portions of operations without attending Do residents pay tuition Average resident salary per year, US$ Average resident debt, US$
Medical doctor 5–6 yes 76–90 15–30 yes yes no yes yes yes 80 30 1–2 yes yes no $31,000–$45,000 $126–$150,000
100% 100% 100% 54% 63% 100% 100% 58% 100% 100% 92% 100% 100% 92% 100% 75% 100% 79% 29%
78% 57% 89% 20% 16% 96% 40% 13% 60% 93% 59% 40% 5% 43% 82% 44% 68% 52% 11%
0.01 0.02 NS ⬍0.01 ⬍0.01 NS ⬍0.01 ⬍0.01 ⬍0.01 NS ⬍0.01 ⬍0.01 ⬍0.01 ⬍0.01 0.03 ⬍0.01 ⬍0.01 0.01 ⬍0.01
NS, not significant. Journal of Surgical Education • Volume 66/Number 6 • November/December 2009
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FIGURE 1. Comparison of nursing and resident responses to how much time residents devote to patient care and studying.
do not recognize interns as physicians who can give orders, and 18% presume that residents are not allowed to perform bedside procedures without an attending present. While our study did not specifically investigate patient outcomes, it is reasonable to assume that such discrepancies and misunderstandings may lead to conflict and be detrimental to patient care. In addition to patient safety and outcomes, the misperceptions between surgical nurses and residents also have implications for resident evaluations. The influence of effective communication and teamwork on patient outcome is further supported by incorporation of these concepts into resident training. Three competencies as established by the ACGME — interpersonal and communication skills, professionalism, and systems-based practice—require that the resident “communicate effectively . . . with other health professionals . . . and work effectively as a member or leader of a health care team.”16 To demonstrate competency in these areas, the RRC requires that residents be evaluated in numerous settings by multiple evaluators who typically include nurses.16 One example of such an evaluation tool is the 360 degree evaluation. Given the lack of understanding of surgical residents by surgical nurses, the nurses’ role in the evaluation process needs to be reconsidered. It should be remembered that the initial intent of the 360 degree evaluation was for managers and executives to receive feedback for their own career development—not annual performance evaluations of subordinates.20 Increasing the number of evaluator constituencies does not automatically improve the 386
quality of feedback. In order for the recipient in the evaluation to benefit from multiple data sources, the data gathered must add value beyond traditional evaluator sources.20 In assessing the validity of the 360 degree evaluation of surgical residents, different evaluators such as surgical nurses provided equivalent information to traditional surgical faculty evaluations with no significant statistical difference between evaluator groups with regards to any ACGME competency, offering no new information compared with traditional faculty evaluations.21 Given the degree of misperceptions found in our study, nurses must be trained about the job description they are evaluating. Ghorpade also found that evaluators must be trained about the 360 degree evaluation and receive guidance about who is being evaluated and their job description.20 In “The Dark Side of 360 degree Feedback”, Wimer describes the pitfalls of 360 degree evaluation which include straining work relationships with negative evaluations from peers or lower personnel managed by the person being evaluated; feedback that is not constructive, and the origin is unclear; loss of anonymity of the evaluator; fostering distrust and defensive behavior; and providing negative feedback with no follow up support or development tools and guidance.22 The evaluation of a resident by nursing staff with little understanding of residency goals and challenges not only has a negative impact for the resident personally by fostering feelings of resentment, but actually works against collaborative teamwork and in turn, quality patient care. Our findings support that residency programs should not incorporate nursing evaluations of residents until they can document that the evaluating nurse understands the basic attributes of a resident. Based on our data, there appears to be a fundamental misunderstanding of the contribution of patient care and independent study to resident education. Resident responses indicated that most of their time is dedicated to patient care and a small fraction of their time to studying, the nursing staff by contrast perceived the residents to spend more time studying than devoted to patient care and may not consider patient care an opportunity for learning. These results suggest that residents view their education during residency as a process of “learning through doing” as opposed to traditional educational formats such as didactic lectures, independent study, and testing. The depth of misunderstanding of surgical residents by surgical nurses is illustrated by the contradictory finding that 100% of the nursing staff knew the residents were paid a salary, but then 68% believed the residents pay tuition for residency. In a critique of more objective findings, the nursing staff’s perception of the length of residency, the number of hours a resident works in a week, the number of hours on call at a time, and hours of sleep while on call demonstrate a wide variance in the responses, further indicating a true misunderstanding of the residency goals with relation to patient care, studying, and time allocation (Figure 2).
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FIGURE 2. Comparison of nursing and resident responses to length of residency, work hours, on call hours, and sleep while on call.
Baggs and Schmitt compared the perceptions of medicine intensive care unit nurses and medicine residents about the process of nurse/physician collaboration.23 The residents described 3 circumstances when collaboration failed: (1) when they were too busy and just had to tell the nurses what to do; (2) when the nurse was aggressive and told the resident what to do, so the resident in turn became defensive and withdrawn; and (3) when the resident made a decision the nurse disagreed with thus the order was not carried out or the nurse told others the resident was wrong. The residents felt that at times the nursing staff did not understand their multiple responsibilities or why a certain decision was made, and at that point the resident felt challenged “inappropriately and personally.” Our data support that the relationship of surgical nurse and surgical resident is fraught with serious misperceptions in which many nurses do not understand the fundamental characteristics of surgical residents. Our study has several limitations. To begin, this work was conducted at a single institution, and it is possible that findings may be different elsewhere. In addition, our results are based on the unique policies and practices of our residency program and may not translate to other surgical training programs. Our survey only involved surgical residents and surgical nurses, and as such, our results may be not hold true across different types of residency programs or be applicable to other members of the team such as attending physicians or fellows. Another limitation is that despite a greater than 90% response rate of available
nurses, we ultimately only surveyed 54% of all surgical nurses employed by the hospital. While we attempted to account for weekend option scheduling and day versus night shifts, it is possible that those not surveyed may have responded to survey questions differently. Despite this limitation, our survey population of 124 nurses out of a possible 226 likely represents an accurate cross-section. In the survey tool, we did not specifically define what constituted patient care, studying, intern, or resident. Not defining these terms allowed nurses to answer the questions based on their own understanding of these terms. However, our pilot survey of internal medicine nurses did not identify this as a problem area. While defining an intern may have altered the results, it further demonstrates the lack of understanding of resident terminology and appreciation of the surgical hierarchy. Finally, our survey tool was 1-sided in that we only sought to identify the nursing perceptions about surgical residents. Certainly, the reverse is as equally important with regard to forming a collaborative team. It is likely that the surgical residents would have significant misperceptions about the nursing staff as well, which would also affect team dynamics and needs to be addressed. In conclusion, a greater understanding of surgical residents by surgical nurses may result in more effective collaboration, communication, and improved patient care. With respect to resident evaluation, the degree of misunderstanding of surgical residents by surgical nurses emphasizes the
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need for nurses to be oriented to the specific attributes of residents. Identification of misperceptions alone does not improve collaborative teamwork. Much of this misunderstanding can be corrected by communicating basic information to the nursing staff. Because of our study, our hospital has implemented this information as a session on “The Basics of Resident Education” into its nursing orientation of all nurses, both surgical and nonsurgical. This educational opportunity has been easy to implement and may immediately ameliorate potential areas of conflict and miscommunication.
11. Ponzer S, Hylin U, Kusoffsky A, et al. Interprofessional
training in the context of clinical practice: Goals and students’ perceptions on clinical education wards. Med Educ. 2004;38:727-736. 12. Undre S, Koutantji M, Sevdalis N, et al. Multidisciplinary
crisis simulations: The way forward for training surgical teams. World J Surg. 2007;31:1843-1853. 13. Baldwin DC, Daugherty SR. Interprofessional conflict
and medical errors: Results of a national multi-specialty survey of hospital residents in the US. J Interprof Care. 2008;22:573-586.
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Appendix A. Nursing Perceptions of Surgical Residents Survey All answers are anonymous. Unit where you spend the most clinical time: e SICU e SIU e 2 East e 1 South e ASU e OR e PACU e ED e Other _________________________________ Demographic Information. Please answer the following questions about yourself. Age: e Under 22 e 22–28 e 29 –35 e 36 – 42 e 43– 49 e 50 –56 e 57– 63 e Over 63 Gender: e Male e Female Ethnicity: e Caucasian e African American (Non-White) e Asian American e Hispanic e Other Is your spouse or significant other a resident? e Yes e no Entry level into Nursing Practice: e ADN e diploma e BSN Type of licensure: e LPN e RN Highest level of Nursing education completed: e ADN e diploma e BSN e MSN e PhD Number of years you have been a clinical nurse. e 5 or less e 6 –10 e 11–15 e 16 –20 e 21–25 e 26 –30 e 31–35 e over 35 How many years have you worked with surgical residents? e 5 or less e 6 –10 e 11–15 e 16 –20 e 21–25 e 26 –30 e 31–35 e over 35 Please list any non-nursing degrees you hold: _______________________________________________________________ Please list any nursing certifications you hold: _______________________________________________________________ Please respond to the following questions regarding surgical resident training. Check only one answer or fill in the blank. What is the highest level of education before starting a surgical residency? Check only one answer. e High School e Associate’s Degree e College Degree (BS or BA) e Medical School Degree (MD or DO) How many years does it take to complete a surgical residency? e 1 e 2 e 3 e 4 e 5 e 6 e 7 e 8 e 9 e 10 Are surgical residents certified in Basic Life Support (CPR)? e yes e no Are surgical residents certified in Advanced Cardiac Life Support (ACLS)? e yes e no Are surgical residents certified in Pediatric Advanced Life Support (PALS)? e yes e no Are surgical residents certified in Advanced Trauma Life Support (ATLS)? e yes e no Is completion of residency a requirement to practice surgery? e yes e no What is the primary purpose of residency? Check only one answer. e Providing patient care e Education e Both patient care and education What percent of time does a resident devote to patient care? e less than 15% e 15–30% e 31– 45% e 46 – 60% e 61–75% e 76 –90% e greater than 90% What percent of time does a resident devote to studying? e less than 15% e 15–30% e 31– 45% e 46 – 60% e 61–75% e 76 –90% e greater than 90% Is conducting research a requirement for surgery residents? e yes e no Journal of Surgical Education • Volume 66/Number 6 • November/December 2009
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Are educational conferences (M&M, Grand Rounds, Friday morning conferences) mandatory for surgical residents? e yes e no Do you know when educational conferences (M&M, Grand Rounds, Friday morning conferences) are held? e yes e no Should a nurse page a resident during a mandatory conference? Check only one answer. e yes e no e only in an absolute emergency Do residents take exams or tests during their residency training? e yes e no Do residents have to pass an exam to be promoted from one year to the next? e yes e no Are medical students legally considered doctors? e yes e no Are interns legally considered doctors? e yes e no Are residents legally considered doctors? e yes e no Do interns hold medical licenses? e yes e no Do residents hold medical licenses? e yes e no What is the maximum number of hours a week a surgical resident is permitted to work? e 50 e 55 e 60 e 65 e 70 e 75 e 80 e 85 e 90 e 95 e 100 e 105 e 110 What is the maximum number of consecutive hours that a surgical resident is permitted to be ‘on call’? e 10 e 12 e 14 e 16 e 18 e 20 e 22 e 24 e 26 e 28 e 30 e 32 e 34 e 36 e 38 e 40 When a surgical resident starts being “on call,” what time do they arrive at the hospital? e 3.00 a.m. e 4.00 a.m. e 5.00 a.m. e 6.00 a.m. e 7.00 a.m. e 8.00 a.m. e 9.00 a.m. e 10.00 a.m. e 11.00 a.m. e 12.00 p.m. e 1.00 p.m. e 2.00 p.m. e 3.00 p.m. e 4.00 p.m. e 5.00 p.m. e 6.00 p.m. e 7.00 p.m. e 8.00 p.m. When a surgical resident leaves the hospital after being “on call” during the night, what time does he or she leave the next day? e 3.00 a.m. e 4.00 a.m. e 5.00 a.m. e 6.00 a.m. e 7.00 a.m. e 8.00 a.m. e 9.00 a.m. e 10.00 a.m. e 11.00 a.m. e 12.00 p.m. e 1.00 p.m. e 2.00 p.m. e 3.00 p.m. e 4.00 p.m. e 5.00 p.m. e 6.00 p.m. e 7.00 p.m. e 8.00 p.m. When “on call” in the hospital, are residents allowed to sleep? e yes e no If a resident does sleep while “on call,” on average, how many hours of sleep does a surgical resident get? e 1 e 2 e 3 e 4 e 5 e 6 e 7 e 8 e 9 e 10 e 11 e 12 During an “on call” period, what is the average number of new patients one surgical resident will evaluate? e 0 e 1 e 2 e 3 e 4 e 5 e 6 e 7 e 8 e 9 e 10 e 11 e 12 How many patients is a surgical resident responsible for while “on call” during the night? e 1–10 e 11–20 e 21–30 e 31– 40 e 41–50 e 51– 60 e 61–70 e 71– 80 e More than 80 How many surgical residents are “on call” and in the hospital during the night? e 0 e 1 e 2 e 3 e 4 e 5 e 6 e 7 e 8 e 9 e 10 How many patients is a surgical resident responsible for during the day when not “on call”? e 1–10 e 11–20 e 21–30 e 31– 40 e 41–50 e 51– 60 e 61–70 e 71– 80 e More than 80 On average, how many patients are on a surgical service at a time? e 1–10 e 11–20 e 21–30 e 31– 40 e 41–50 e 51– 60 e 61–70 e 71– 80 e More than 80 What is the junior surgical resident’s primary role at a cardiac arrest or other emergency? Check only one answer. e No Role e Calling Rapid Response Team e Perform procedures e Running the Code e Call the Attending What is the senior surgical resident’s primary role at a cardiac arrest or other emergency? Check only one answer. e No Role e Calling Rapid Response Team 390
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e Perform procedures e Running the Code e Call the Attending What is the surgical resident’s role in updating families? Check only one answer. e No Role e Only during rounds with an attending e Only patients they know/on their team e Available at any time for any patient What is the surgical resident’s role in patient’s care? Check only one answer. e No independent decision making role e Transcribing what Attendings order e Making suggestions to Attendings e Responsible for all aspects of patient care Are surgical residents allowed to perform bedside procedures (central lines, chest tubes, etc.) without an Attending being present? e yes e no Are surgical residents allowed to perform some parts of operative procedures without an Attending in the room? e yes e no In an emergency, can a chief surgical resident start an operative procedure without an Attending present? e yes e no Can a surgical resident perform the “time out” before starting a procedure? e yes e no How many pagers does a surgical resident usually carry when on call? e1 e2 e3 e4 e5 e6 e7 e8 When on call, on average, how many pages does a surgical resident get in one night? e 1–10 e 11–20 e 21–30 e 31– 40 e 41–50 e 51– 60 e 61–70 e 71– 80 e More than 80 What is the primary role of the nurse when working with a surgical resident on patient care? Check only one answer. e Protect the patient from resident errors e Work in collaboration with the resident e Educate the resident e Follow only the instructions of the attending surgeon e Follow whatever orders a resident gives Does a resident have to pay tuition to the hospital for his/her training during residency? e yes e no What is the average yearly salary of a surgical resident? e none e less than $15,000 e $15–US$30,000 e $31–US$45,000 e $46 –US$60,000 e $66 –US$85,000 e $86 –US$100,000 e greater than $100,000 What is the average debt a surgical resident has at the beginning of residency? e none e less than $25,000 e $26 –US$50,000 e $51–US$75,000 e $76 –US$100,000 e $101–US$125,000 e $126 –US$150,000 e $151–US$175,000 e $176 –US$200,000 e greater than $200,000 How many days does a surgical resident take off in one month? e 0 e 1 e 2 e 3 e 4 e 5 e 6 e 7 e 8 e 9 e 10 How many sick days does a surgical resident take in one year? e 0 e 1 e 2 e 3 e 4 e 5 e 6 e 7 e 8 e 9 e 10 e 11 e 12 What questions do you have about surgical residents? What would improve the effective working relationship between residents and nurses?
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What Do Surgical Nurses Know About Surgical Residents? Lisa L. Schlitzkus, MD, Steven C. Agle, MD, Michael M. McNally, MD, Kimberly D. Schenarts, PhD, and Paul J. Schenarts, MD Division of Surgical Education, Department of Surgery, East Carolina University, Brody School of Medicine, Greenville, North Carolina OBJECTIVE: A fundamental premise of establishing collabo-
rative relationships between residents and nurses is a basic understanding of the attributes of each group. The intent of this study was to determine what surgical nurses know about surgical residents. DESIGN: A piloted survey tool was administered to a cross-
section of nurses working in 3 surgical intensive care units, a surgical intermediate unit, and 2 general surgical floors. Surgical residents completed the same survey tool. The percentage of residents giving the most frequent response was compared with the percentage of nurses giving the same response. SETTING: A university, teaching hospital. PARTICIPANTS: One hundred twenty-four of 129 surgical nurses and 24 of 25 surgical residents who completed the survey tool. RESULTS: The response rate for nurses on the 2 survey days was 94%, or 54% of all surgical nurses employed by the hospital, and 96% for residents. The nurses surveyed were equally distributed between the units. Ninety-nine percent of nurses did not have a surgical resident as a significant other, 55% of nurses had greater than 5 years experience, and 95% were licensed registered nurses. Seventy-eight percent of nurses correctly indicated that a medical doctorate is the highest degree required to start residency (p ⫽ 0.01), but only 57% accurately identified the length of surgical residency (p ⫽ 0.02). Nurses perceived residents devoted less time to patient care (p ⬍ 0.01) and more time to studying (p ⬍ 0.01). Forty percent of nurses do not think interns are legally physicians (p ⬍ 0.01) or hold a medical license (p ⬍ 0.01). Forty percent of nurses are aware of the 80-hour work week restriction (p ⬍ 0.01). Eighteen percent of nurses have the perception that residents are not allowed to
Correspondence: Inquiries to Paul J. Schenarts, MD, FACS, Director, General Surgery Residency Program, Associate Professor of Surgery, Department of Surgery, East Carolina University, Brody School of Medicine, 600 Moye Blvd, Greenville, NC 27858; fax: (252) 847-8208; e-mail: [email protected] Presented as a podium presentation at the 2009 Meeting of the Association of Program Directors in Surgery, Salt Lake City, Utah, April 2009.
perform bedside procedures without an attending physician present (p ⫽ 0.03), while 56% have the perception that residents are not allowed to perform any part of an operation without an attending physician (p ⬍ 0.01). There is a misperception among 32% of nurses that residents pay tuition for residency (p ⬍ 0.01), while only 52% accurately identified the range of a resident’s salary (p ⫽ 0.01) and 11% the amount of resident debt (p ⬍ 0.01). CONCLUSIONS: Despite the importance of the collabora-
tive relationship in surgical patient care, surgical nurses have a limited understanding of surgical residents. Educating nurses about the education, roles, and responsibilities of surgical residents might improve collaborative relationships and ultimately patient care. (J Surg 66:383-391. © 2009 Association of Program Directors in Surgery. Published by Elsevier Inc. All rights reserved.) KEY WORDS: ACGME competencies, nursing, resident evaluation, surgical education, surgical residents COMPETENCY: Interpersonal Skills and Communication,
Professionalism, Systems-Based Practice
INTRODUCTION Effective teamwork, collaboration, and communication have become emphasized in improving the quality of patient care1-5 and in surgical education.6-12 A fundamental premise of a productive, collaborative relationship is that members of each team understand the basic attributes of other team members. With regard to the care of the surgical patient, surgical residents and surgical nurses are required to work together more so than any other 2 groups. Failure to establish a collaborative relationship and misperceptions of the basic attributes of team members can lead to conflict resulting in poor patient care. In a survey13 of over 6000 residents about conflict with other professional colleagues, 20% of residents reported a serious conflict with another staff member, 8.9% of whom were nurses. As the number of reported conflicts increased, the number of serious medical errors and
Journal of Surgical Education • © 2009 Association of Program Directors in Surgery Published by Elsevier Inc. All rights reserved.
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adverse patient outcomes also increased. The report of conflict with 1 versus 2 professional colleagues increased serious medical errors from 36.4% to 51%, and adverse patient outcomes from 8.3% to 16%. While the causality of this relationship cannot be determined from the data, the findings are sobering. The importance of learning this collaborative approach is reflected by the Accreditation Council for Graduate Medical Education’s (ACGME) core competencies of communication, professionalism, and systems-based practice.14 Mastery of these competencies may be verified on surgical resident evaluations, such as the 360 degree evaluation, described in the ACGME’s Toolbox Assessment15 which incorporates surgical nurses into the evaluation process. The 360 degree evaluation further meets the Residency Review Committee’s (RRC) program requirement of evaluating and documenting resident performance utilizing multiple evaluators, highlighting the RRC’s mission of objectivity and fairness.16 Given the importance of effective collaborative relationships between surgical residents and surgical nurses and the potential consequences of poor clinical outcomes as well as poor resident evaluations resulting from misperceptions, we sought to define what surgical nurses know about the educational goals, scope of practice, and lifestyles of surgical residents.
METHODS This study was approved by the Biomedical Institutional Review Board at East Carolina University. Nursing management is part of this approval process and agreed to participate in this study. Participation in the survey was voluntary and without compensation. Individual nurses and surgical residents consented by completing the survey. The survey consisted of an introductory statement explaining the purpose of the survey and queried participants regarding demographic information, and their individual knowledge of the educational goals, scope of practice, and lifestyles of surgical residents at our University Hospital. The survey tool is provided in Appendix A. Our general surgery residency program is ACGMEapproved and graduates 4 chief residents each year after 5 clinical years and 1 year of research training. Our institutional policy states that residents may perform bedside procedures and certain parts of operations without an attending physician present.
Face and Content Validity Face and content validity of the survey tool was confirmed by a pilot survey of 8 nurses who work closely with internal medicine residents on a nonsurgical floor. Following completion of the pilot survey, 1 investigator discussed the survey tool with the pilot participants to ensure that the survey questions and answers were understandable. 384
Survey Methodology The survey tool was distributed to the nurses in our 3 surgical intensive care units (SICU), the surgical intermediate Unit (SIU), and our 2 general surgical floors. The survey was handed directly to each nurse and collected several hours later. At our institution, nurses work either day or night shifts (not both), and the staffing pattern is such that nurses work Monday through Thursday or Friday through Sunday, although there is occasionally some crossover. As a result, the survey was distributed on 1 weekday and 1 weekend day to both day and night shifts to ensure that the sample was a representative crosssection of the entire surgical nursing staff. If a nurse happened to be present during more than 1 survey time, they were asked to participate only once. Data collected included demographics about the nursing staff regarding clinical experience, education, and time spent working with surgical residents. The nursing staff was also asked about residents’ levels of education, licensing, roles in patient care and procedures, patient coverage, work hours, salary, and debt. Our nursing staff is exposed to all levels of residents, but we did not ask the nurses which level of residents they were exposed to the most. Surgical residents were also asked to complete the same survey tool, and the most frequent response was considered the control answer. Comparisons were then made between the percentage of residents giving the most frequent response and the percentage of nurses giving the same response to each question. If a question was left blank or multiple answers given, that question response was removed from the analysis. Statistical analyses were performed using the statistical software package SPSS for windows 16.0 (Chicago, IL). All univariate analysis employed the Student t test, analysis of variance (ANOVA), or 2-test as appropriate. Two-tailed tests were used for every analysis, and statistical significance was set a priori at p ⬍ 0.05.
RESULTS A total of 226 surgical nurses are employed by the hospital; 136 (54%) were available at the 4 time points the survey was performed. Of the nurses available to participate, the survey response rate was 94% (124 surveys returned). The weekday response rate was 95%, and the weekend response rate was 92%. The nurses surveyed were equally distributed between the SICU (37%), SIU (26%), and the general surgical floors (37%). Ninety-nine percent of nurses did not have a surgical resident as a significant other. Fifty-five percent of nurses had greater than 5 years experience, and 95% were licensed registered nurses. Twenty-four out of 25 surgical residents (96%) completed the survey as well. Demographic data for both groups are summarized in Table 1. Comparisons between the most frequent resident response and the percentage of nurses giving the same response to ques-
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while on call (p ⬍ 0.01), show a wide variance in the responses by the nurses (Figure 2).
TABLE 1. Demographics Nurses (n ⴝ 124) Female Age 22–35 Caucasian African American Spouse member of opposite cohort?
81% 56% 69% 19% 1%
Residents (n ⴝ 24) 25% 100% 67% 17% 12.5%
p Value ⬍0.001 0.003 NS 0.014
NS, not significant.
tions relating to education, roles, licensing, and lifestyle are presented in Table 2. There was a distinct discrepancy in the perceived amount of time devoted to patient care and studying. Most residents (83%) felt that over 76% of their time is spent devoted to patient care. Conversely, only 27% of nurses perceived residents devote more than 76% of their time to patient care (p ⬍ 0.01). Figure 1 demonstrates that there was no clear consensus among the nursing staff as to how much resident time is allocated to patient care. It appears that the perceived percent of resident time devoted to patient care was underestimated by the nursing staff. A similar discrepancy occurred in response to the amount of resident time allocated to study; most residents (96%) felt that less than 30% of their time is spent studying compared with 21% of the nursing staff giving this response (p ⬍ 0.01). While there was fewer variation of the nursing response, the perceived amount of resident time devoted to studying is overestimated (Figure 1). Data regarding resident lifestyle variables, such as length of residency (p ⫽ 0.01), work hours per week (p ⬍ 0.01), the number of hours on call at a time (p ⬍ 0.01), and hours of sleep
DISCUSSION The results of our study find that there are serious misunderstandings between the nursing staff and surgical residents with regard to education, roles, licensing, and lifestyles of surgical residents. This degree of misunderstanding has important implications for patient safety, clinical outcomes, and resident evaluations. When comparing organization climate safety factors with outcomes for surgical services, Davenport et al found that perceived positive communication and collaboration with resident doctors correlated with lower risk-adjusted morbidity.5 Failure of effective communication has also been reported by the Joint Commission for the Accreditation of Health Care Organizations as the leading cause of sentinel events during the perioperative period.17 As part of the World Health Organization’s Safe Surgery Saves Lives program, facilitation of communication by use of a surgical safety checklist in the operating room decreased the rate of any complication from 11% to 7% (p ⬍ 0.001) and reduced mortality from 1.5% to 0.8% (p ⫽ 0.003).18 Similarly, patients whose surgical teams frequently displayed teamwork behavior were at a lower risk of death and complications.19 Safety checklists and briefing periods force all members of the operative team to communicate, and concentrate on the patient and procedure at hand. However, outside the operating room no checklist or briefing period exists, so that members of the team are not introduced and expectations are not clearly stated, setting the stage for error and conflict. Despite our institutional policies to the contrary, we found that 40% of surgical nurses
TABLE 2. Response Results Question Asked
Most Frequent Response
Residents
Nurses
p Value
Highest degree to start residency Residency duration, years Residency required to practice % Resident time devoted to patient care % Resident time devoted to study Mandatory education conferences Know when conferences are held Pass examination to be promoted to next year Are interns legally doctors Are residents legally doctors Do interns hold medical licenses Maximum work hours per week Maximum hours on call Hours slept while on call Bedside procedures without attending Portions of operations without attending Do residents pay tuition Average resident salary per year, US$ Average resident debt, US$
Medical doctor 5–6 yes 76–90 15–30 yes yes no yes yes yes 80 30 1–2 yes yes no $31,000–$45,000 $126–$150,000
100% 100% 100% 54% 63% 100% 100% 58% 100% 100% 92% 100% 100% 92% 100% 75% 100% 79% 29%
78% 57% 89% 20% 16% 96% 40% 13% 60% 93% 59% 40% 5% 43% 82% 44% 68% 52% 11%
0.01 0.02 NS ⬍0.01 ⬍0.01 NS ⬍0.01 ⬍0.01 ⬍0.01 NS ⬍0.01 ⬍0.01 ⬍0.01 ⬍0.01 0.03 ⬍0.01 ⬍0.01 0.01 ⬍0.01
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FIGURE 1. Comparison of nursing and resident responses to how much time residents devote to patient care and studying.
do not recognize interns as physicians who can give orders, and 18% presume that residents are not allowed to perform bedside procedures without an attending present. While our study did not specifically investigate patient outcomes, it is reasonable to assume that such discrepancies and misunderstandings may lead to conflict and be detrimental to patient care. In addition to patient safety and outcomes, the misperceptions between surgical nurses and residents also have implications for resident evaluations. The influence of effective communication and teamwork on patient outcome is further supported by incorporation of these concepts into resident training. Three competencies as established by the ACGME — interpersonal and communication skills, professionalism, and systems-based practice—require that the resident “communicate effectively . . . with other health professionals . . . and work effectively as a member or leader of a health care team.”16 To demonstrate competency in these areas, the RRC requires that residents be evaluated in numerous settings by multiple evaluators who typically include nurses.16 One example of such an evaluation tool is the 360 degree evaluation. Given the lack of understanding of surgical residents by surgical nurses, the nurses’ role in the evaluation process needs to be reconsidered. It should be remembered that the initial intent of the 360 degree evaluation was for managers and executives to receive feedback for their own career development—not annual performance evaluations of subordinates.20 Increasing the number of evaluator constituencies does not automatically improve the 386
quality of feedback. In order for the recipient in the evaluation to benefit from multiple data sources, the data gathered must add value beyond traditional evaluator sources.20 In assessing the validity of the 360 degree evaluation of surgical residents, different evaluators such as surgical nurses provided equivalent information to traditional surgical faculty evaluations with no significant statistical difference between evaluator groups with regards to any ACGME competency, offering no new information compared with traditional faculty evaluations.21 Given the degree of misperceptions found in our study, nurses must be trained about the job description they are evaluating. Ghorpade also found that evaluators must be trained about the 360 degree evaluation and receive guidance about who is being evaluated and their job description.20 In “The Dark Side of 360 degree Feedback”, Wimer describes the pitfalls of 360 degree evaluation which include straining work relationships with negative evaluations from peers or lower personnel managed by the person being evaluated; feedback that is not constructive, and the origin is unclear; loss of anonymity of the evaluator; fostering distrust and defensive behavior; and providing negative feedback with no follow up support or development tools and guidance.22 The evaluation of a resident by nursing staff with little understanding of residency goals and challenges not only has a negative impact for the resident personally by fostering feelings of resentment, but actually works against collaborative teamwork and in turn, quality patient care. Our findings support that residency programs should not incorporate nursing evaluations of residents until they can document that the evaluating nurse understands the basic attributes of a resident. Based on our data, there appears to be a fundamental misunderstanding of the contribution of patient care and independent study to resident education. Resident responses indicated that most of their time is dedicated to patient care and a small fraction of their time to studying, the nursing staff by contrast perceived the residents to spend more time studying than devoted to patient care and may not consider patient care an opportunity for learning. These results suggest that residents view their education during residency as a process of “learning through doing” as opposed to traditional educational formats such as didactic lectures, independent study, and testing. The depth of misunderstanding of surgical residents by surgical nurses is illustrated by the contradictory finding that 100% of the nursing staff knew the residents were paid a salary, but then 68% believed the residents pay tuition for residency. In a critique of more objective findings, the nursing staff’s perception of the length of residency, the number of hours a resident works in a week, the number of hours on call at a time, and hours of sleep while on call demonstrate a wide variance in the responses, further indicating a true misunderstanding of the residency goals with relation to patient care, studying, and time allocation (Figure 2).
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FIGURE 2. Comparison of nursing and resident responses to length of residency, work hours, on call hours, and sleep while on call.
Baggs and Schmitt compared the perceptions of medicine intensive care unit nurses and medicine residents about the process of nurse/physician collaboration.23 The residents described 3 circumstances when collaboration failed: (1) when they were too busy and just had to tell the nurses what to do; (2) when the nurse was aggressive and told the resident what to do, so the resident in turn became defensive and withdrawn; and (3) when the resident made a decision the nurse disagreed with thus the order was not carried out or the nurse told others the resident was wrong. The residents felt that at times the nursing staff did not understand their multiple responsibilities or why a certain decision was made, and at that point the resident felt challenged “inappropriately and personally.” Our data support that the relationship of surgical nurse and surgical resident is fraught with serious misperceptions in which many nurses do not understand the fundamental characteristics of surgical residents. Our study has several limitations. To begin, this work was conducted at a single institution, and it is possible that findings may be different elsewhere. In addition, our results are based on the unique policies and practices of our residency program and may not translate to other surgical training programs. Our survey only involved surgical residents and surgical nurses, and as such, our results may be not hold true across different types of residency programs or be applicable to other members of the team such as attending physicians or fellows. Another limitation is that despite a greater than 90% response rate of available
nurses, we ultimately only surveyed 54% of all surgical nurses employed by the hospital. While we attempted to account for weekend option scheduling and day versus night shifts, it is possible that those not surveyed may have responded to survey questions differently. Despite this limitation, our survey population of 124 nurses out of a possible 226 likely represents an accurate cross-section. In the survey tool, we did not specifically define what constituted patient care, studying, intern, or resident. Not defining these terms allowed nurses to answer the questions based on their own understanding of these terms. However, our pilot survey of internal medicine nurses did not identify this as a problem area. While defining an intern may have altered the results, it further demonstrates the lack of understanding of resident terminology and appreciation of the surgical hierarchy. Finally, our survey tool was 1-sided in that we only sought to identify the nursing perceptions about surgical residents. Certainly, the reverse is as equally important with regard to forming a collaborative team. It is likely that the surgical residents would have significant misperceptions about the nursing staff as well, which would also affect team dynamics and needs to be addressed. In conclusion, a greater understanding of surgical residents by surgical nurses may result in more effective collaboration, communication, and improved patient care. With respect to resident evaluation, the degree of misunderstanding of surgical residents by surgical nurses emphasizes the
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need for nurses to be oriented to the specific attributes of residents. Identification of misperceptions alone does not improve collaborative teamwork. Much of this misunderstanding can be corrected by communicating basic information to the nursing staff. Because of our study, our hospital has implemented this information as a session on “The Basics of Resident Education” into its nursing orientation of all nurses, both surgical and nonsurgical. This educational opportunity has been easy to implement and may immediately ameliorate potential areas of conflict and miscommunication.
11. Ponzer S, Hylin U, Kusoffsky A, et al. Interprofessional
training in the context of clinical practice: Goals and students’ perceptions on clinical education wards. Med Educ. 2004;38:727-736. 12. Undre S, Koutantji M, Sevdalis N, et al. Multidisciplinary
crisis simulations: The way forward for training surgical teams. World J Surg. 2007;31:1843-1853. 13. Baldwin DC, Daugherty SR. Interprofessional conflict
and medical errors: Results of a national multi-specialty survey of hospital residents in the US. J Interprof Care. 2008;22:573-586.
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Appendix A. Nursing Perceptions of Surgical Residents Survey All answers are anonymous. Unit where you spend the most clinical time: e SICU e SIU e 2 East e 1 South e ASU e OR e PACU e ED e Other _________________________________ Demographic Information. Please answer the following questions about yourself. Age: e Under 22 e 22–28 e 29 –35 e 36 – 42 e 43– 49 e 50 –56 e 57– 63 e Over 63 Gender: e Male e Female Ethnicity: e Caucasian e African American (Non-White) e Asian American e Hispanic e Other Is your spouse or significant other a resident? e Yes e no Entry level into Nursing Practice: e ADN e diploma e BSN Type of licensure: e LPN e RN Highest level of Nursing education completed: e ADN e diploma e BSN e MSN e PhD Number of years you have been a clinical nurse. e 5 or less e 6 –10 e 11–15 e 16 –20 e 21–25 e 26 –30 e 31–35 e over 35 How many years have you worked with surgical residents? e 5 or less e 6 –10 e 11–15 e 16 –20 e 21–25 e 26 –30 e 31–35 e over 35 Please list any non-nursing degrees you hold: _______________________________________________________________ Please list any nursing certifications you hold: _______________________________________________________________ Please respond to the following questions regarding surgical resident training. Check only one answer or fill in the blank. What is the highest level of education before starting a surgical residency? Check only one answer. e High School e Associate’s Degree e College Degree (BS or BA) e Medical School Degree (MD or DO) How many years does it take to complete a surgical residency? e 1 e 2 e 3 e 4 e 5 e 6 e 7 e 8 e 9 e 10 Are surgical residents certified in Basic Life Support (CPR)? e yes e no Are surgical residents certified in Advanced Cardiac Life Support (ACLS)? e yes e no Are surgical residents certified in Pediatric Advanced Life Support (PALS)? e yes e no Are surgical residents certified in Advanced Trauma Life Support (ATLS)? e yes e no Is completion of residency a requirement to practice surgery? e yes e no What is the primary purpose of residency? Check only one answer. e Providing patient care e Education e Both patient care and education What percent of time does a resident devote to patient care? e less than 15% e 15–30% e 31– 45% e 46 – 60% e 61–75% e 76 –90% e greater than 90% What percent of time does a resident devote to studying? e less than 15% e 15–30% e 31– 45% e 46 – 60% e 61–75% e 76 –90% e greater than 90% Is conducting research a requirement for surgery residents? e yes e no Journal of Surgical Education • Volume 66/Number 6 • November/December 2009
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Are educational conferences (M&M, Grand Rounds, Friday morning conferences) mandatory for surgical residents? e yes e no Do you know when educational conferences (M&M, Grand Rounds, Friday morning conferences) are held? e yes e no Should a nurse page a resident during a mandatory conference? Check only one answer. e yes e no e only in an absolute emergency Do residents take exams or tests during their residency training? e yes e no Do residents have to pass an exam to be promoted from one year to the next? e yes e no Are medical students legally considered doctors? e yes e no Are interns legally considered doctors? e yes e no Are residents legally considered doctors? e yes e no Do interns hold medical licenses? e yes e no Do residents hold medical licenses? e yes e no What is the maximum number of hours a week a surgical resident is permitted to work? e 50 e 55 e 60 e 65 e 70 e 75 e 80 e 85 e 90 e 95 e 100 e 105 e 110 What is the maximum number of consecutive hours that a surgical resident is permitted to be ‘on call’? e 10 e 12 e 14 e 16 e 18 e 20 e 22 e 24 e 26 e 28 e 30 e 32 e 34 e 36 e 38 e 40 When a surgical resident starts being “on call,” what time do they arrive at the hospital? e 3.00 a.m. e 4.00 a.m. e 5.00 a.m. e 6.00 a.m. e 7.00 a.m. e 8.00 a.m. e 9.00 a.m. e 10.00 a.m. e 11.00 a.m. e 12.00 p.m. e 1.00 p.m. e 2.00 p.m. e 3.00 p.m. e 4.00 p.m. e 5.00 p.m. e 6.00 p.m. e 7.00 p.m. e 8.00 p.m. When a surgical resident leaves the hospital after being “on call” during the night, what time does he or she leave the next day? e 3.00 a.m. e 4.00 a.m. e 5.00 a.m. e 6.00 a.m. e 7.00 a.m. e 8.00 a.m. e 9.00 a.m. e 10.00 a.m. e 11.00 a.m. e 12.00 p.m. e 1.00 p.m. e 2.00 p.m. e 3.00 p.m. e 4.00 p.m. e 5.00 p.m. e 6.00 p.m. e 7.00 p.m. e 8.00 p.m. When “on call” in the hospital, are residents allowed to sleep? e yes e no If a resident does sleep while “on call,” on average, how many hours of sleep does a surgical resident get? e 1 e 2 e 3 e 4 e 5 e 6 e 7 e 8 e 9 e 10 e 11 e 12 During an “on call” period, what is the average number of new patients one surgical resident will evaluate? e 0 e 1 e 2 e 3 e 4 e 5 e 6 e 7 e 8 e 9 e 10 e 11 e 12 How many patients is a surgical resident responsible for while “on call” during the night? e 1–10 e 11–20 e 21–30 e 31– 40 e 41–50 e 51– 60 e 61–70 e 71– 80 e More than 80 How many surgical residents are “on call” and in the hospital during the night? e 0 e 1 e 2 e 3 e 4 e 5 e 6 e 7 e 8 e 9 e 10 How many patients is a surgical resident responsible for during the day when not “on call”? e 1–10 e 11–20 e 21–30 e 31– 40 e 41–50 e 51– 60 e 61–70 e 71– 80 e More than 80 On average, how many patients are on a surgical service at a time? e 1–10 e 11–20 e 21–30 e 31– 40 e 41–50 e 51– 60 e 61–70 e 71– 80 e More than 80 What is the junior surgical resident’s primary role at a cardiac arrest or other emergency? Check only one answer. e No Role e Calling Rapid Response Team e Perform procedures e Running the Code e Call the Attending What is the senior surgical resident’s primary role at a cardiac arrest or other emergency? Check only one answer. e No Role e Calling Rapid Response Team 390
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e Perform procedures e Running the Code e Call the Attending What is the surgical resident’s role in updating families? Check only one answer. e No Role e Only during rounds with an attending e Only patients they know/on their team e Available at any time for any patient What is the surgical resident’s role in patient’s care? Check only one answer. e No independent decision making role e Transcribing what Attendings order e Making suggestions to Attendings e Responsible for all aspects of patient care Are surgical residents allowed to perform bedside procedures (central lines, chest tubes, etc.) without an Attending being present? e yes e no Are surgical residents allowed to perform some parts of operative procedures without an Attending in the room? e yes e no In an emergency, can a chief surgical resident start an operative procedure without an Attending present? e yes e no Can a surgical resident perform the “time out” before starting a procedure? e yes e no How many pagers does a surgical resident usually carry when on call? e1 e2 e3 e4 e5 e6 e7 e8 When on call, on average, how many pages does a surgical resident get in one night? e 1–10 e 11–20 e 21–30 e 31– 40 e 41–50 e 51– 60 e 61–70 e 71– 80 e More than 80 What is the primary role of the nurse when working with a surgical resident on patient care? Check only one answer. e Protect the patient from resident errors e Work in collaboration with the resident e Educate the resident e Follow only the instructions of the attending surgeon e Follow whatever orders a resident gives Does a resident have to pay tuition to the hospital for his/her training during residency? e yes e no What is the average yearly salary of a surgical resident? e none e less than $15,000 e $15–US$30,000 e $31–US$45,000 e $46 –US$60,000 e $66 –US$85,000 e $86 –US$100,000 e greater than $100,000 What is the average debt a surgical resident has at the beginning of residency? e none e less than $25,000 e $26 –US$50,000 e $51–US$75,000 e $76 –US$100,000 e $101–US$125,000 e $126 –US$150,000 e $151–US$175,000 e $176 –US$200,000 e greater than $200,000 How many days does a surgical resident take off in one month? e 0 e 1 e 2 e 3 e 4 e 5 e 6 e 7 e 8 e 9 e 10 How many sick days does a surgical resident take in one year? e 0 e 1 e 2 e 3 e 4 e 5 e 6 e 7 e 8 e 9 e 10 e 11 e 12 What questions do you have about surgical residents? What would improve the effective working relationship between residents and nurses?
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