- Email: [email protected]
Working Together to Build a Respectful Workplace: Transforming OR Culture
Working Together to Build a Respectful Workplace: Transforming OR Culture JUDY COSTELLO, MScN, RN, CCN(C); CATHY CLARKE, MA; GILLIAN GRAVELY, BScN, RN, CPN(C); DINA D’AGOSTINO-ROSE, MA, RN; ROSE PUOPOLO, MN, RN, CPN(C)
ABSTRACT Respect is important in the creation of a positive perioperative work environment and effective OR teams. Low scores for respect in the OR on an employee opinion survey and responses on a more customized survey that examined issues associated with respect prompted leaders at the University Health Network to undertake a multiyear organizational strategy to address respect and quality of worklife initiatives. An interprofessional quality of worklife task force convened to create an action plan to address the outcomes of the surveys. The work of the task force included developing and implementing a code of conduct team charter for the OR, empowering leaders to better manage conflict through education and coaching, creating a collaborative, consistent approach to conflict resolution, and designing an education strategy for staff members to enhance communication and conflict resolution. Results of recent employee opinion surveys have reflected positive outcomes. Efforts to sustain the effects of the project include quarterly recognition awards and ongoing education focused on wellness and communication skills. AORN J 93 (January 2011) 115-126. © AORN, Inc, 2011. doi: 10.1016/j.aorn.2010.05.030 Key words: workplace respect, perioperative work environments, quality of worklife, OR culture.
O
perating rooms are high-intensity, often high-stress environments where team members must work together to provide patient-centered care. Managing the demands of the daily schedule; integrating emergency surgeries; balancing budgets and ensuring revenue streams; and dealing with staffing shortages and the varied personalities of physicians, nurses, and support staff can be daunting tasks. The influence of hierarchical and unbalanced power relationships also can add stress to an already challenging
work environment. As a result, a variety of behaviors are exhibited in the OR, including interpersonal conflict, bullying, verbal abuse, horizontal violence, and harassment.1-4 Professional organizations have called on hospitals to establish code of conduct policies and educational interventions to enable staff members to manage and report disruptive behaviors.5 Employers have been challenged to create healthy work environments that focus on improving staff members’ well-being, patient outcomes, and
doi: 10.1016/j.aorn.2010.05.030
© AORN, Inc, 2011
January 2011
Vol 93
No 1 ● AORN Journal
115
January 2011
Vol 93
COSTELLO ET AL
No 1
performance at the organizational and health care system level.6 Organizations often use employee opinion surveys to measure staff member satisfaction and perceptions about key work environment issues, including the quality of patient care, respect, communication, teamwork, and the learning environment. In 2003, the results of employee opinion surveys in a multisite academic health science center indicated the need for members of the organization to take a more systematic approach to exploring the concept of respect in the OR. OUR HOSPITALS The University Health Network (UHN) is a tertiary-quaternary health science center located in Toronto, Ontario, Canada, and affiliated with the University of Toronto. The UHN has 767 beds at three sites: Toronto General Hospital (TGH), Toronto Western Hospital (TWH), and Princess Margaret Hospital (PMH). Together, these three sites have 31 ORs with 15 different surgical divisions and departments where staff members perform approximately 23,000 surgical procedures annually. At TGH, areas of service include surgical oncology, cardiovascular surgery, vascular surgery, and multiorgan transplant. The focus at TWH is on neurosurgery and musculoskeletal health and arthritis, whereas PMH has two ORs focused on low-complexity surgical oncology procedures. The number of OR staff for the three hospitals totals 200 nurses, 120 surgeons, 57 an-
esthesiologists, 95 central processing department staff members, 50 support staff members, and 40 allied health staff members (eg, perfusion, anesthesia assistants, respiratory therapists). Statistics for each site (ie, hours of operation, percentage of inpatient and outpatient procedures, total procedures performed, average procedure times) are described in Table 1. THE SURVEYS The UHN conducts employee opinion surveys every two to three years using an online survey web site. In the 2003 employee opinion survey results, the percentage of positive scores regarding the issue of respect for the UHN overall was 72%; however, for the TGH and TWH ORs, the scores were 51% (n ⫽ 37 respondents) and 49% (n ⫽ 48 respondents), respectively. Because of the small number of staff members in the PMH ORs, an employee opinion survey report was not available for this site (ie, a minimum of 10 respondents is required to produce a report). The organizational follow-up strategy required managers to take action related to their department’s or unit’s results. The OR managers presented and discussed results with staff members. Some examples of actions taken included revisions of the OR booking policy and staffing schedules and updates to staff member orientation. Given the low scores for respect in the OR in comparison with the overall organization scores, the OR managers, directors, and human resources organizational
TABLE 1. University Health Network OR Statistics
Site
Hours of operation
Toronto General Hospital Toronto Western Hospital Princess Margaret Hospital
24 hours 7 days per week 24 hours 7 days per week 10-hour days, 4 days per week
116
AORN Journal
Inpatient procedures
Day surgery procedures
Total procedures per year
Average procedure time
89.0%
11.0%
8,647
4.0 hours
40.8%
59.2%
11,815
2.1 hours
54.7%
45.3%
1,660
1.8 hours
TRANSFORMING OPERATING ROOM CULTURE development staff members teamed up to develop a short, eight-item tool that would provide a deeper understanding of the problem. Respondents were asked to select the position title that applied to them in the OR (ie, physician, nurse, allied health professional, support staff member). Five questions focused on how often a particular situation was experienced (ie, never, sometimes, often):
Have you been treated with disrespect by a member of the OR surgical team? Have you witnessed a colleague treating a member of the surgical team with disrespect? Have you treated a member of the OR surgical team with disrespect? Do you think there are situations in which disrespectful behavior is warranted to provide appropriate patient care? Do you think that disrespectful behavior needs to be addressed and actions taken to rectify it?
In addition, participants were asked: Which choice best characterizes your position in the OR? I am a member of a team that supports each other. Members of the OR team are there to support me. What would help you to be consistently respectful with everyone working in the OR?
In 2005, all OR staff members received the eight-item respect survey. There were 248 respondents: 101 nurses (41%), 87 surgeons/anesthesiologists (35%), 44 support staff members (18%), and 16 allied health staff members (6%). Despite the differences in site structures and cultures, results were similar across all three sites and disciplines. More than 60% of respondents at each site indicated they had been treated with disrespect at times and indicated that they had periodically witnessed disrespect among other staff members. Ten percent of respondents indicated that they often witnessed disrespect, and 7% indicated that they were often treated with disrespect. Respondents
www.aornjournal.org
also admitted having treated others with disrespect at times (30%). Of interest, was that 20% to 35% of staff members believed that disrespect was warranted in a crisis or emergency and at times when practices to facilitate equitable use of OR resources were not followed according to policy (eg, when scheduled cases were “bumped” for nonelective procedures that did not meet the definition for emergency cases). Many of the comments expressed by staff members indicated that disrespectful behavior is never warranted, however, because it only aggravates an already stressful situation. Respondents provided a number of examples of disrespect, including rude behaviors and language, unprofessional conduct (eg, gossip), and inappropriate use of OR resources (eg, time overruns, not following policies and procedures, misuse of equipment). Disrespectful interactions and rudeness occurred at times among members of the same professional group as well as from senior staff members toward less experienced staff members and trainees. Staff members all agreed that disrespectful behavior needed to be addressed and that managers needed to take action both formally and informally to improve the situation. Operating room managers, directors, and human resources organizational development team members analyzed the results of the surveys and developed presentations to ensure that all staff members heard the results, were aware of the commitments that managers were making to respond to the results, and had an opportunity to give feedback before the next steps were taken. This work happened at different paces for the ORs surveyed because of organizational issues, with the manager at TWH moving more quickly with improvement strategies. As the results of the respect survey were being circulated to staff members, the 2006 employee opinion survey results became available. The percentage of positive scores in regard to respect at the UHN overall had increased to 75% from 72%. For the TGH and TWH ORs, the positive AORN Journal
117
January 2011
Vol 93
COSTELLO ET AL
No 1
scores were 47% (n ⫽ 35 respondents) and 86% (n ⫽ 82 respondents), respectively. The response rate and scores for TWH had increased significantly since 2003, whereas the TGH scores and response rates had decreased slightly. Of note was that at both the TWH and TGH sites, the time frame between 2003 and 2006 was marked by the reorganization of the OR management structures; hiring of new leaders; and a focus on the roles, responsibilities, and accountabilities for work culture and behavior. At TGH, staff members also moved into new ORs in 2003. While concurrently reviewing the 2005 respect and 2006 employee opinion survey results, leadership personnel launched a major quality improvement transformational initiative in surgical services. It was important that respect initiatives align with the transformation project. As Table 2 illustrates, the journey toward changing the OR culture occurred over a number of years and included several initiatives that focused on people and processes.
TABLE 2. Time Frame and Scope of the OR Transformation Project Time frame 2003-2004
OR day redesign, workflow, human resources analysis, supply and technology, and quality of worklife.
Each area had a working group associated with it. Essentially, we focused on processes of care (items 1, 2, and 4) and people (items 3 and 5). We identified the quality of worklife focus as a foundational element in the project. We did not initially include a focus on respect in the OR Transformation Project, but UHN leaders advocated to have the subject of respect included in this major OR initiative. 118
AORN Journal
2005-2006
2006-2008
2007-2008
OR TRANSFORMATION PROJECT The purpose of the OR Transformation Project was to transform the ORs at the UHN into higher performing clinical areas by implementing sustainable process redesign strategies in a focused and outcome driven framework. The project included five key areas: 1. 2. 3. 4. 5.
Initiatives
2008-present
Review of employee opinion survey results Response to critical events (eg, a behavioral incident that affected communication and patient safety in the OR; retirement of the entire OR leadership team at one site) Dissemination of focused survey on respect Analysis of survey results Recommendations from survey results Staff member presentations Start of the OR Transformation Project Evaluation of processes and people LEAN initiatives, including value stream mapping and rapid improvement events (ie, multiple projects to enhance patient flow and improve efficiency) Educational strategy development and implementation Celebration and launch of the team charter Evaluation of the sustainability of the project Evolution of the project Launch of the recognition strategy
Our focus on processes of care was important to determine how the perioperative team’s use of resources affects culture and behaviors. The respect survey highlighted a number of process issues that required attention. The key outcomes for the processes of care redesign included the following changes for OR day design and workflow: an update of the OR booking policy, creation of procedure booking and finish time reports categorized by service and surgeon, implementation of an average procedure duration report by service and surgeon, development of a cancellation policy, and
TRANSFORMING OPERATING ROOM CULTURE development of a cancellation queue to track when patients whose procedures were cancelled finally underwent surgery.
Introducing standard operating procedures for these potentially conflict-generating situations provided structure, transparency, clarity, and accountability. A human resources management group and a quality of worklife task force were created for the people component of the OR Transformation Project. Members of the human resources management group were responsible for reviewing roles and responsibilities across sites, updating role descriptions, reviewing staffing allocation, and standardizing leadership structures across the sites. The quality of worklife task force members were responsible for using the employee opinion survey and respect survey results and any other information they found to create a plan for addressing the issues identified. Committee membership was interprofessional and included direct care staff members, managers, directors, physicians, and human resources staff members. We conducted a detailed literature review with a focus on patientcentered care, MagnetTM environment elements, teamwork, leadership, education, and ethics. In addition, direct care staff members conducted a short “pulse” survey that focused on key satisfying or dissatisfying components in the current
www.aornjournal.org
OR environment. In reviewing all survey results (ie, employee opinion survey, respect survey, pulse survey), task force members identified hierarchies and differential power relationships, particularly with surgeons, as important components to address to ensure that staff members were confident about speaking up regarding patient-centered care and safety. The literature review emphasized that environments that promote a culture of respect are linked to high levels of staff member satisfaction, employee engagement and retention, improved effectiveness and productivity of interprofessional teams, and improved patient safety. In addition, we noted that members of today’s workforce expect an environment in which all team members are respected, are enabled to contribute and develop fully, and are recognized for their contributions.7-10 The task force members then developed recommendations and presented them to senior leaders to gain support for the plan. The key recommendations from the quality of worklife task force and its organizational commitments for changing culture are outlined in Table 3. Senior leaders supported the recommendations and requested that task force members develop an action plan. We developed a framework to guide the next steps (Figure 1). The task force’s framework focused on four key commitments:
TABLE 3. OR Transformation: Quality of Worklife Committee Recommendations and Organizational Commitment Key recommendations
Define respectful OR behavior based on the University Health Network code of conduct. Empower and hold members of the OR leadership team accountable for managing conflicts effectively and creating a culture of respect. Create and follow clear guidelines for resolving conflicts and ensure consequences for repeat offenders. Provide education in advanced communication, conflict resolution, and diffusing hostility.
Commitments
Create a code of conduct team charter for the OR. Provide a coaching course for managers to teach a collaborative resolution process for conflict and define roles and responsibilities. Commit to a collaborative resolution process. Educate staff members about building a respectful workplace.
AORN Journal
119
January 2011
Vol 93
COSTELLO ET AL
No 1
Figure 1. Respect survey and quality of worklife task force commitments.
developing and implementing an OR team charter that aligned with the UHN code of conduct, empowering managers and leaders to better manage conflict through education and coaching, creating a collaborative resolution process to ensure a consistent approach to conflict resolution, and designing an educational strategy for staff members to enhance their communication and conflict resolution competencies.
The quality of worklife task force developed the perioperative services team charter (Figure 2) that defines respectful behavior in the OR and sets standards for all team members in the areas of communication, teamwork, treating others with respect, and being part of a supportive and inclusive workplace. The team charter is the embodiment of how OR team members are expected to live out the UHN code of conduct. The leadership development component of this strategy included a full-day educational program on conflict coaching for perioperative service man120
AORN Journal
agers and leaders. The program was designed to address the leaders’ accountabilities in managing conflict, an analysis of individual approaches to resolving conflict, interest-based conflict resolution approaches, and ways to coach others to resolve conflicts. The course included a self-assessment, role play, and conflict coaching simulation. We then developed the collaborative resolution process. This process supports the UHN code of conduct and team charter by establishing a stepby-step process for resolving interpersonal conflicts respectfully (Figure 3). The collaborative resolution process also defines team member and leader responsibilities for resolving disputes. For the final component of the strategy, direct care staff member education, all interprofessional staff members (excluding physicians) attended an allday course titled “Making a Workplace Full of Respect.” The overall focus of the course was about communicating effectively while under pressure. Staff members learned self-management in the moment and three conversation tools and approaches for constructively resolving conflict
TRANSFORMING OPERATING ROOM CULTURE
www.aornjournal.org
University Health Network Perioperative Services Team Charter As members of the perioperative services department we aspire to be: • supportive, • reliable, • hard working, • cooperative, and • patient-centered in our care. Communication: We will • communicate in an open, honest, positive, respectful, and professional manner. • be active listeners. • clarify what we see and hear. • take responsibility for how we communicate, both verbally and nonverbally. • discuss concerns directly in a constructive and private manner with other persons as soon as possible. • use the collaborative resolution process or other resources if a conflict or issue cannot be resolved. • use respectful humor in our daily interactions. Teamwork: We will • understand our own and others’ roles in the department to maximize teamwork and enhance patient care. • offer and accept help to promote and foster teamwork and our own professional development. • solve problems in new and active ways to improve our effectiveness. Respect for others: We will • avoid gossip and making hurtful comments about others. • embrace diversity and respect each team member’s culture, values, beliefs, and uniqueness. • recognize and value our team members by using courteous terms to address each other (eg, please, thank you), by introducing ourselves, and by addressing people by name. Supportive and inclusive workplace: We will • follow standards, policies, processes, and protocols to support all aspects of patient care. • trust that each other’s intent is to make decisions that are inclusive and patient-centered. • support a safe work environment. • discuss observations of potentially unsafe practices with our team members. • share what we know to promote a positive teaching and learning environment. • hold ourselves and others accountable for following the team charter.
Figure 2. University Health Network perioperative services team charter.
(ie, speaking up respectfully, listening actively, gaining perspective). For example, staff members were taught to use key phrases, such as, “I am sorry you are upset by this, let’s try to figure out what to do” and “It’s hard for me to understand when you are shouting at me.” Last but not least, the quality of worklife task force members developed a communication strategy to ensure that their work was communicated to all staff members in the ORs and to members of the organization’s senior management. The communication strategy, titled “Building a Workplace Full of Respect Starts With You,” was meant to be a personal message to all staff members to engage them in the required change pro-
cess. The strategy for communication with physicians included a presentation of the survey results and organizational commitments to the surgical executive committee. The chief of surgery, the site OR administrative director, and a staff member from the human resources organizational development group attended each division or department physician meeting to review the issues, survey results, next steps, and accountabilities for all staff members and physicians. In the fall of 2008, we held a formal celebration to highlight the results of the many initiatives that had emanated from the OR Transformation Project. The efforts of the quality of worklife task force were highlighted. Team members, including AORN Journal
121
January 2011
Vol 93
No 1
COSTELLO ET AL
Figure 3. Collaborative resolution process.
RNs, central processing staff members, an anesthesia assistant, and a surgeon, gave examples that illustrated the effect of the team charter implementation on their work. All staff members who attended the celebration received a booklet that outlined the respect initiative, an introductory letter from the chief of surgery, the UHN code of conduct, the UHN perioperative services team charter, team member and leader accountabilities, a definition of inappropriate behavior, the collaborative resolution process, the constructive conflict resolution approach, tips and communication tools to manage stress in the moment (eg, 122
AORN Journal
reframe the situation, take a deep breath, change the scene), and a list of other helpful resources available to them in the organization. OUTCOMES MONITORING AND SUSTAINABILITY One of the key steps in any change process is ensuring that metrics are identified for monitoring outcomes. The OR managers, directors, and human resources staff members identified key metrics for monitoring the effect and sustainability of the “Building a Workplace Full of Respect” strategy. Turnover rates and results from the
TRANSFORMING OPERATING ROOM CULTURE employee opinion surveys were the areas identified for monitoring outcomes of the changes. During the course of the initiative (ie, from 2005 to 2009), staff turnover rates were unchanged for TWH at 6% and reduced at TGH by 50% (ie, from 8% to 4%). We evaluate the effectiveness and sustainability of the project by conducting ongoing organizational employee opinion surveys, which are embedded in organizational improvement strategies. Sharing the results of the employee opinion survey makes the results transparent within the organization. The 2009 employee opinion survey results for TGH and TWH
www.aornjournal.org
can be found in Figures 4 and 5, respectively. At the TGH site, scores on all elements of the employee opinion surveys, work practices, recognition/ compensation, communication, commitment, physical/environmental safety, teamwork, and respect, increased more than 40% (n ⫽ 87 respondents). We believe that this shift in scores is a result of the respect strategy, the commitment of the new OR leadership team to changing the culture, and implementation of the process changes in the OR Transformation Project, as well as improved response rates. For the TWH site, the high employee opinion survey scores from the 2006
76%
Work practice
74% 42%
71% 69%
Recognition/ compensation
41% 80% 79%
Communication 55% 66% 59%
Commitment 30%
Physical/ environmental safety
77% 80% 53% 79%
Teamwork
74% 53%
81%
Respect
76% 55%
0%
10%
20%
30%
40%
50%
60%
70%
80%
90%
100%
Subscale Score (%)
TGH OR 2006
TGH OR 2009
UHN 2009
Data source: employee opinion surveys conducted in 2006 and 2009 Respondents: n = 35 in 2006; n = 87 in 2009 Positive score based on response of good/very good/excellent or moderately agree/strongly agree
Figure 4. Toronto General Hospital (TGH)/University Health Network (UHN) 2009 OR employee opinion survey results.
AORN Journal
123
January 2011
Vol 93
COSTELLO ET AL
No 1
76%
Work practice
88% 85% 71%
Recognition/ compensation
78% 86% 80% 89% 92%
Communication
66%
Commitment
82% 78%
Physical/ environmental safety
77% 86% 89% 79% 84%
Teamwork
85% 81%
Respect
87% 88%
0%
10%
20%
30%
40%
50%
60%
70%
80%
90%
100%
Subscale Score (%)
TWH OR 2006
TWH OR 2009
UHN 2009
Data source: employee opinion surveys conducted in 2006 and 2009 Respondents: n = 82 in 2006; n = 106 in 2009 Positive score based on response of good/very good/excellent or moderately agree/strongly agree
Figure 5. Toronto Western Hospital (TWH)/University Health Network (UHN) 2009 OR employee opinion survey results.
survey were sustained. After the most recent results were made available, we held celebrations that acknowledged the collaboration and outcomes achieved. Celebrating such milestones is an important component of sustaining the momentum of change in the ORs. The sustainability plan for the respect strategy included posting of the team charter in all clinical areas, distribution of the respect booklet to all perioperative staff members at orientation, and an all-day “respect” course for new staff members. Another key component of the project’s sustainability was the creation of a recognition 124
AORN Journal
strategy, the Team Charter Recognition Awards. We designed the recognition award to honor an individual or team that demonstrates the six crucial qualities outlined in the team charter by being
supportive, reliable, respectful, hard working, cooperative, and patient centered.
We held a contest during which staff members were asked to submit slogans or catchy phrases
Working Together to Build a Respectful Workplace: Transforming OR Culture JUDY COSTELLO, MScN, RN, CCN(C); CATHY CLARKE, MA; GILLIAN GRAVELY, BScN, RN, CPN(C); DINA D’AGOSTINO-ROSE, MA, RN; ROSE PUOPOLO, MN, RN, CPN(C)
ABSTRACT Respect is important in the creation of a positive perioperative work environment and effective OR teams. Low scores for respect in the OR on an employee opinion survey and responses on a more customized survey that examined issues associated with respect prompted leaders at the University Health Network to undertake a multiyear organizational strategy to address respect and quality of worklife initiatives. An interprofessional quality of worklife task force convened to create an action plan to address the outcomes of the surveys. The work of the task force included developing and implementing a code of conduct team charter for the OR, empowering leaders to better manage conflict through education and coaching, creating a collaborative, consistent approach to conflict resolution, and designing an education strategy for staff members to enhance communication and conflict resolution. Results of recent employee opinion surveys have reflected positive outcomes. Efforts to sustain the effects of the project include quarterly recognition awards and ongoing education focused on wellness and communication skills. AORN J 93 (January 2011) 115-126. © AORN, Inc, 2011. doi: 10.1016/j.aorn.2010.05.030 Key words: workplace respect, perioperative work environments, quality of worklife, OR culture.
O
perating rooms are high-intensity, often high-stress environments where team members must work together to provide patient-centered care. Managing the demands of the daily schedule; integrating emergency surgeries; balancing budgets and ensuring revenue streams; and dealing with staffing shortages and the varied personalities of physicians, nurses, and support staff can be daunting tasks. The influence of hierarchical and unbalanced power relationships also can add stress to an already challenging
work environment. As a result, a variety of behaviors are exhibited in the OR, including interpersonal conflict, bullying, verbal abuse, horizontal violence, and harassment.1-4 Professional organizations have called on hospitals to establish code of conduct policies and educational interventions to enable staff members to manage and report disruptive behaviors.5 Employers have been challenged to create healthy work environments that focus on improving staff members’ well-being, patient outcomes, and
doi: 10.1016/j.aorn.2010.05.030
© AORN, Inc, 2011
January 2011
Vol 93
No 1 ● AORN Journal
115
January 2011
Vol 93
No 1
Surgical Programs and Critical Care Services at the University Health Network, Toronto, Ontario, Canada, and Scott McIntaggart, vice president of Integrated Surgical Services, Critical Care, and Transplantation at the University Health Network, Toronto, Ontario, Canada, and thank the members of the quality of worklife task force. References 1. 2. 3.
4.
5.
6.
7.
8. 9. 10. 11.
Gilmour D, Hamlin L. Bullying and harassment in perioperative settings. Br J Perioper Nurs. 2004;13(2):79-85. Buback D. Assertiveness training to prevent verbal abuse in the OR. AORN J. 2004;79(1):148-150. Bartholomew K. What is horizontal hostility? In: Ending Nurse-to-Nurse Hostility: Why Nurses Eat Their Young and Each Other. Marblehead, MA: HPro, Inc; 2006:3-22. Bigony L, Lipke TG, Lundberg A, McGraw C, Pagac G, Rogers A. Lateral violence in the perioperative setting. AORN J. 2009;9(4):688-696. AORN supports the Center for American Nurses call for an end to lateral violence and bullying in nursing work environments. AORN, Inc. http://www.aorn.org/ News/March2008News/CENTERForAmericanNurses CallsForAnEndToLateralViole/. Accessed August 24, 2010. Healthy work environments best practice guidelines: professionalism in nursing. Registered Nurses Association of Ontario. http://www.rnao.org/Storage/28/ 2303_BPG_Professionalism.pdf. Accessed August 24, 2010. Shewchuck M. Pearls of wisdom for leadership skills. Looking in the mirror and asking, “How do I like me now?” Can Oper Room J. 2004;22(4):20-22. Sutton R. Building the civilized workplace. McKinsey Q. 2007;2(May):47-55. Parsons ML, Newcomb M. Developing a healthy OR workplace. AORN J. 2007;85(6):1222-1223. Hamlin L. The OR and a “just culture.” AORN J. 2009; 90(4):495-498. Mahatma Gandhi quotes. Thinkexist.com. http:// thinkexist.com/quotation/be_the_change_you_want_to_ see_in_the_world/148490.html. Accessed August 27, 2010.
Resources Forsythe L. Using an organizational culture analysis to design interventions for change. AORN J. 2005;81(6):12901302. Girard N. Dealing with perioperative prima donnas in your ORs. AORN J. 2005;82(2):187-189. O’Brien-Pallas L, Hiroz J, Cook A, Mildon B. NursePhysician Relationships: Solutions and Recommendations for Change. Comprehensive Report for Nursing Secretariat and Ministry of Health and Long-Term Care Research Unit. Toronto, Canada: Nursing Health Services Research
126
AORN Journal
COSTELLO ET AL Unit; 2005. http://www.nhsru.com/documents/Revised% 20FINAL%20Nurse-physician%20Report%20-%20Dec% 2013%2005.pdf. Accessed August 24, 2010. Reynolds A, Timmons S. The doctor-nurse relationship in the operating theatre. Br J Perioper Nurs. 2005;15(3): 110-115. Shermont H, Krepcio D. The impact of culture change on nurse retention. J Nurs Admin. 2006;36(9):407-415.
Judy Costello, MScN, RN, CCN(C), is the director surgical services, Toronto General Hospital, University Health Network, Toronto, Ontario, Canada. Ms Costello has no declared affiliation that could be perceived as posing a potential conflict of interest in the publication of this article. Cathy Clarke, MA, is the manager of organization and employee development, University Health Network, Toronto, Ontario, Canada. Ms Clarke has no declared affiliation that could be perceived as posing a potential conflict of interest in the publication of this article. Gillian Gravely, BScN, RN, CPN(C), is a nurse manager at Toronto General Hospital OR and Princess Margaret Hospital OR, University Health Network, Toronto, Ontario, Canada. Ms Gravely has no declared affiliation that could be perceived as posing a potential conflict of interest in the publication of this article. Dina D’Agostino-Rose, MA, RN, is the clinical director, Surgical Services and Arthritis Program, Toronto Western Hospital, University Health Network, Toronto, Ontario, Canada. Ms D’AgostinoRose has no declared affiliation that could be perceived as posing a potential conflict of interest in the publication of this article. Rose Puopolo, MN, RN, CPN(C), is a patient care manager, Toronto Western Hospital, University Health Network, Toronto, Ontario, Canada. Ms Puopolo has no declared affiliation that could be perceived as posing a potential conflict of interest in the publication of this article.
ABSTRACT Respect is important in the creation of a positive perioperative work environment and effective OR teams. Low scores for respect in the OR on an employee opinion survey and responses on a more customized survey that examined issues associated with respect prompted leaders at the University Health Network to undertake a multiyear organizational strategy to address respect and quality of worklife initiatives. An interprofessional quality of worklife task force convened to create an action plan to address the outcomes of the surveys. The work of the task force included developing and implementing a code of conduct team charter for the OR, empowering leaders to better manage conflict through education and coaching, creating a collaborative, consistent approach to conflict resolution, and designing an education strategy for staff members to enhance communication and conflict resolution. Results of recent employee opinion surveys have reflected positive outcomes. Efforts to sustain the effects of the project include quarterly recognition awards and ongoing education focused on wellness and communication skills. AORN J 93 (January 2011) 115-126. © AORN, Inc, 2011. doi: 10.1016/j.aorn.2010.05.030 Key words: workplace respect, perioperative work environments, quality of worklife, OR culture.
O
perating rooms are high-intensity, often high-stress environments where team members must work together to provide patient-centered care. Managing the demands of the daily schedule; integrating emergency surgeries; balancing budgets and ensuring revenue streams; and dealing with staffing shortages and the varied personalities of physicians, nurses, and support staff can be daunting tasks. The influence of hierarchical and unbalanced power relationships also can add stress to an already challenging
work environment. As a result, a variety of behaviors are exhibited in the OR, including interpersonal conflict, bullying, verbal abuse, horizontal violence, and harassment.1-4 Professional organizations have called on hospitals to establish code of conduct policies and educational interventions to enable staff members to manage and report disruptive behaviors.5 Employers have been challenged to create healthy work environments that focus on improving staff members’ well-being, patient outcomes, and
doi: 10.1016/j.aorn.2010.05.030
© AORN, Inc, 2011
January 2011
Vol 93
No 1 ● AORN Journal
115
January 2011
Vol 93
COSTELLO ET AL
No 1
performance at the organizational and health care system level.6 Organizations often use employee opinion surveys to measure staff member satisfaction and perceptions about key work environment issues, including the quality of patient care, respect, communication, teamwork, and the learning environment. In 2003, the results of employee opinion surveys in a multisite academic health science center indicated the need for members of the organization to take a more systematic approach to exploring the concept of respect in the OR. OUR HOSPITALS The University Health Network (UHN) is a tertiary-quaternary health science center located in Toronto, Ontario, Canada, and affiliated with the University of Toronto. The UHN has 767 beds at three sites: Toronto General Hospital (TGH), Toronto Western Hospital (TWH), and Princess Margaret Hospital (PMH). Together, these three sites have 31 ORs with 15 different surgical divisions and departments where staff members perform approximately 23,000 surgical procedures annually. At TGH, areas of service include surgical oncology, cardiovascular surgery, vascular surgery, and multiorgan transplant. The focus at TWH is on neurosurgery and musculoskeletal health and arthritis, whereas PMH has two ORs focused on low-complexity surgical oncology procedures. The number of OR staff for the three hospitals totals 200 nurses, 120 surgeons, 57 an-
esthesiologists, 95 central processing department staff members, 50 support staff members, and 40 allied health staff members (eg, perfusion, anesthesia assistants, respiratory therapists). Statistics for each site (ie, hours of operation, percentage of inpatient and outpatient procedures, total procedures performed, average procedure times) are described in Table 1. THE SURVEYS The UHN conducts employee opinion surveys every two to three years using an online survey web site. In the 2003 employee opinion survey results, the percentage of positive scores regarding the issue of respect for the UHN overall was 72%; however, for the TGH and TWH ORs, the scores were 51% (n ⫽ 37 respondents) and 49% (n ⫽ 48 respondents), respectively. Because of the small number of staff members in the PMH ORs, an employee opinion survey report was not available for this site (ie, a minimum of 10 respondents is required to produce a report). The organizational follow-up strategy required managers to take action related to their department’s or unit’s results. The OR managers presented and discussed results with staff members. Some examples of actions taken included revisions of the OR booking policy and staffing schedules and updates to staff member orientation. Given the low scores for respect in the OR in comparison with the overall organization scores, the OR managers, directors, and human resources organizational
TABLE 1. University Health Network OR Statistics
Site
Hours of operation
Toronto General Hospital Toronto Western Hospital Princess Margaret Hospital
24 hours 7 days per week 24 hours 7 days per week 10-hour days, 4 days per week
116
AORN Journal
Inpatient procedures
Day surgery procedures
Total procedures per year
Average procedure time
89.0%
11.0%
8,647
4.0 hours
40.8%
59.2%
11,815
2.1 hours
54.7%
45.3%
1,660
1.8 hours
TRANSFORMING OPERATING ROOM CULTURE development staff members teamed up to develop a short, eight-item tool that would provide a deeper understanding of the problem. Respondents were asked to select the position title that applied to them in the OR (ie, physician, nurse, allied health professional, support staff member). Five questions focused on how often a particular situation was experienced (ie, never, sometimes, often):
Have you been treated with disrespect by a member of the OR surgical team? Have you witnessed a colleague treating a member of the surgical team with disrespect? Have you treated a member of the OR surgical team with disrespect? Do you think there are situations in which disrespectful behavior is warranted to provide appropriate patient care? Do you think that disrespectful behavior needs to be addressed and actions taken to rectify it?
In addition, participants were asked: Which choice best characterizes your position in the OR? I am a member of a team that supports each other. Members of the OR team are there to support me. What would help you to be consistently respectful with everyone working in the OR?
In 2005, all OR staff members received the eight-item respect survey. There were 248 respondents: 101 nurses (41%), 87 surgeons/anesthesiologists (35%), 44 support staff members (18%), and 16 allied health staff members (6%). Despite the differences in site structures and cultures, results were similar across all three sites and disciplines. More than 60% of respondents at each site indicated they had been treated with disrespect at times and indicated that they had periodically witnessed disrespect among other staff members. Ten percent of respondents indicated that they often witnessed disrespect, and 7% indicated that they were often treated with disrespect. Respondents
www.aornjournal.org
also admitted having treated others with disrespect at times (30%). Of interest, was that 20% to 35% of staff members believed that disrespect was warranted in a crisis or emergency and at times when practices to facilitate equitable use of OR resources were not followed according to policy (eg, when scheduled cases were “bumped” for nonelective procedures that did not meet the definition for emergency cases). Many of the comments expressed by staff members indicated that disrespectful behavior is never warranted, however, because it only aggravates an already stressful situation. Respondents provided a number of examples of disrespect, including rude behaviors and language, unprofessional conduct (eg, gossip), and inappropriate use of OR resources (eg, time overruns, not following policies and procedures, misuse of equipment). Disrespectful interactions and rudeness occurred at times among members of the same professional group as well as from senior staff members toward less experienced staff members and trainees. Staff members all agreed that disrespectful behavior needed to be addressed and that managers needed to take action both formally and informally to improve the situation. Operating room managers, directors, and human resources organizational development team members analyzed the results of the surveys and developed presentations to ensure that all staff members heard the results, were aware of the commitments that managers were making to respond to the results, and had an opportunity to give feedback before the next steps were taken. This work happened at different paces for the ORs surveyed because of organizational issues, with the manager at TWH moving more quickly with improvement strategies. As the results of the respect survey were being circulated to staff members, the 2006 employee opinion survey results became available. The percentage of positive scores in regard to respect at the UHN overall had increased to 75% from 72%. For the TGH and TWH ORs, the positive AORN Journal
117
January 2011
Vol 93
COSTELLO ET AL
No 1
scores were 47% (n ⫽ 35 respondents) and 86% (n ⫽ 82 respondents), respectively. The response rate and scores for TWH had increased significantly since 2003, whereas the TGH scores and response rates had decreased slightly. Of note was that at both the TWH and TGH sites, the time frame between 2003 and 2006 was marked by the reorganization of the OR management structures; hiring of new leaders; and a focus on the roles, responsibilities, and accountabilities for work culture and behavior. At TGH, staff members also moved into new ORs in 2003. While concurrently reviewing the 2005 respect and 2006 employee opinion survey results, leadership personnel launched a major quality improvement transformational initiative in surgical services. It was important that respect initiatives align with the transformation project. As Table 2 illustrates, the journey toward changing the OR culture occurred over a number of years and included several initiatives that focused on people and processes.
TABLE 2. Time Frame and Scope of the OR Transformation Project Time frame 2003-2004
OR day redesign, workflow, human resources analysis, supply and technology, and quality of worklife.
Each area had a working group associated with it. Essentially, we focused on processes of care (items 1, 2, and 4) and people (items 3 and 5). We identified the quality of worklife focus as a foundational element in the project. We did not initially include a focus on respect in the OR Transformation Project, but UHN leaders advocated to have the subject of respect included in this major OR initiative. 118
AORN Journal
2005-2006
2006-2008
2007-2008
OR TRANSFORMATION PROJECT The purpose of the OR Transformation Project was to transform the ORs at the UHN into higher performing clinical areas by implementing sustainable process redesign strategies in a focused and outcome driven framework. The project included five key areas: 1. 2. 3. 4. 5.
Initiatives
2008-present
Review of employee opinion survey results Response to critical events (eg, a behavioral incident that affected communication and patient safety in the OR; retirement of the entire OR leadership team at one site) Dissemination of focused survey on respect Analysis of survey results Recommendations from survey results Staff member presentations Start of the OR Transformation Project Evaluation of processes and people LEAN initiatives, including value stream mapping and rapid improvement events (ie, multiple projects to enhance patient flow and improve efficiency) Educational strategy development and implementation Celebration and launch of the team charter Evaluation of the sustainability of the project Evolution of the project Launch of the recognition strategy
Our focus on processes of care was important to determine how the perioperative team’s use of resources affects culture and behaviors. The respect survey highlighted a number of process issues that required attention. The key outcomes for the processes of care redesign included the following changes for OR day design and workflow: an update of the OR booking policy, creation of procedure booking and finish time reports categorized by service and surgeon, implementation of an average procedure duration report by service and surgeon, development of a cancellation policy, and
TRANSFORMING OPERATING ROOM CULTURE development of a cancellation queue to track when patients whose procedures were cancelled finally underwent surgery.
Introducing standard operating procedures for these potentially conflict-generating situations provided structure, transparency, clarity, and accountability. A human resources management group and a quality of worklife task force were created for the people component of the OR Transformation Project. Members of the human resources management group were responsible for reviewing roles and responsibilities across sites, updating role descriptions, reviewing staffing allocation, and standardizing leadership structures across the sites. The quality of worklife task force members were responsible for using the employee opinion survey and respect survey results and any other information they found to create a plan for addressing the issues identified. Committee membership was interprofessional and included direct care staff members, managers, directors, physicians, and human resources staff members. We conducted a detailed literature review with a focus on patientcentered care, MagnetTM environment elements, teamwork, leadership, education, and ethics. In addition, direct care staff members conducted a short “pulse” survey that focused on key satisfying or dissatisfying components in the current
www.aornjournal.org
OR environment. In reviewing all survey results (ie, employee opinion survey, respect survey, pulse survey), task force members identified hierarchies and differential power relationships, particularly with surgeons, as important components to address to ensure that staff members were confident about speaking up regarding patient-centered care and safety. The literature review emphasized that environments that promote a culture of respect are linked to high levels of staff member satisfaction, employee engagement and retention, improved effectiveness and productivity of interprofessional teams, and improved patient safety. In addition, we noted that members of today’s workforce expect an environment in which all team members are respected, are enabled to contribute and develop fully, and are recognized for their contributions.7-10 The task force members then developed recommendations and presented them to senior leaders to gain support for the plan. The key recommendations from the quality of worklife task force and its organizational commitments for changing culture are outlined in Table 3. Senior leaders supported the recommendations and requested that task force members develop an action plan. We developed a framework to guide the next steps (Figure 1). The task force’s framework focused on four key commitments:
TABLE 3. OR Transformation: Quality of Worklife Committee Recommendations and Organizational Commitment Key recommendations
Define respectful OR behavior based on the University Health Network code of conduct. Empower and hold members of the OR leadership team accountable for managing conflicts effectively and creating a culture of respect. Create and follow clear guidelines for resolving conflicts and ensure consequences for repeat offenders. Provide education in advanced communication, conflict resolution, and diffusing hostility.
Commitments
Create a code of conduct team charter for the OR. Provide a coaching course for managers to teach a collaborative resolution process for conflict and define roles and responsibilities. Commit to a collaborative resolution process. Educate staff members about building a respectful workplace.
AORN Journal
119
January 2011
Vol 93
COSTELLO ET AL
No 1
Figure 1. Respect survey and quality of worklife task force commitments.
developing and implementing an OR team charter that aligned with the UHN code of conduct, empowering managers and leaders to better manage conflict through education and coaching, creating a collaborative resolution process to ensure a consistent approach to conflict resolution, and designing an educational strategy for staff members to enhance their communication and conflict resolution competencies.
The quality of worklife task force developed the perioperative services team charter (Figure 2) that defines respectful behavior in the OR and sets standards for all team members in the areas of communication, teamwork, treating others with respect, and being part of a supportive and inclusive workplace. The team charter is the embodiment of how OR team members are expected to live out the UHN code of conduct. The leadership development component of this strategy included a full-day educational program on conflict coaching for perioperative service man120
AORN Journal
agers and leaders. The program was designed to address the leaders’ accountabilities in managing conflict, an analysis of individual approaches to resolving conflict, interest-based conflict resolution approaches, and ways to coach others to resolve conflicts. The course included a self-assessment, role play, and conflict coaching simulation. We then developed the collaborative resolution process. This process supports the UHN code of conduct and team charter by establishing a stepby-step process for resolving interpersonal conflicts respectfully (Figure 3). The collaborative resolution process also defines team member and leader responsibilities for resolving disputes. For the final component of the strategy, direct care staff member education, all interprofessional staff members (excluding physicians) attended an allday course titled “Making a Workplace Full of Respect.” The overall focus of the course was about communicating effectively while under pressure. Staff members learned self-management in the moment and three conversation tools and approaches for constructively resolving conflict
TRANSFORMING OPERATING ROOM CULTURE
www.aornjournal.org
University Health Network Perioperative Services Team Charter As members of the perioperative services department we aspire to be: • supportive, • reliable, • hard working, • cooperative, and • patient-centered in our care. Communication: We will • communicate in an open, honest, positive, respectful, and professional manner. • be active listeners. • clarify what we see and hear. • take responsibility for how we communicate, both verbally and nonverbally. • discuss concerns directly in a constructive and private manner with other persons as soon as possible. • use the collaborative resolution process or other resources if a conflict or issue cannot be resolved. • use respectful humor in our daily interactions. Teamwork: We will • understand our own and others’ roles in the department to maximize teamwork and enhance patient care. • offer and accept help to promote and foster teamwork and our own professional development. • solve problems in new and active ways to improve our effectiveness. Respect for others: We will • avoid gossip and making hurtful comments about others. • embrace diversity and respect each team member’s culture, values, beliefs, and uniqueness. • recognize and value our team members by using courteous terms to address each other (eg, please, thank you), by introducing ourselves, and by addressing people by name. Supportive and inclusive workplace: We will • follow standards, policies, processes, and protocols to support all aspects of patient care. • trust that each other’s intent is to make decisions that are inclusive and patient-centered. • support a safe work environment. • discuss observations of potentially unsafe practices with our team members. • share what we know to promote a positive teaching and learning environment. • hold ourselves and others accountable for following the team charter.
Figure 2. University Health Network perioperative services team charter.
(ie, speaking up respectfully, listening actively, gaining perspective). For example, staff members were taught to use key phrases, such as, “I am sorry you are upset by this, let’s try to figure out what to do” and “It’s hard for me to understand when you are shouting at me.” Last but not least, the quality of worklife task force members developed a communication strategy to ensure that their work was communicated to all staff members in the ORs and to members of the organization’s senior management. The communication strategy, titled “Building a Workplace Full of Respect Starts With You,” was meant to be a personal message to all staff members to engage them in the required change pro-
cess. The strategy for communication with physicians included a presentation of the survey results and organizational commitments to the surgical executive committee. The chief of surgery, the site OR administrative director, and a staff member from the human resources organizational development group attended each division or department physician meeting to review the issues, survey results, next steps, and accountabilities for all staff members and physicians. In the fall of 2008, we held a formal celebration to highlight the results of the many initiatives that had emanated from the OR Transformation Project. The efforts of the quality of worklife task force were highlighted. Team members, including AORN Journal
121
January 2011
Vol 93
No 1
COSTELLO ET AL
Figure 3. Collaborative resolution process.
RNs, central processing staff members, an anesthesia assistant, and a surgeon, gave examples that illustrated the effect of the team charter implementation on their work. All staff members who attended the celebration received a booklet that outlined the respect initiative, an introductory letter from the chief of surgery, the UHN code of conduct, the UHN perioperative services team charter, team member and leader accountabilities, a definition of inappropriate behavior, the collaborative resolution process, the constructive conflict resolution approach, tips and communication tools to manage stress in the moment (eg, 122
AORN Journal
reframe the situation, take a deep breath, change the scene), and a list of other helpful resources available to them in the organization. OUTCOMES MONITORING AND SUSTAINABILITY One of the key steps in any change process is ensuring that metrics are identified for monitoring outcomes. The OR managers, directors, and human resources staff members identified key metrics for monitoring the effect and sustainability of the “Building a Workplace Full of Respect” strategy. Turnover rates and results from the
TRANSFORMING OPERATING ROOM CULTURE employee opinion surveys were the areas identified for monitoring outcomes of the changes. During the course of the initiative (ie, from 2005 to 2009), staff turnover rates were unchanged for TWH at 6% and reduced at TGH by 50% (ie, from 8% to 4%). We evaluate the effectiveness and sustainability of the project by conducting ongoing organizational employee opinion surveys, which are embedded in organizational improvement strategies. Sharing the results of the employee opinion survey makes the results transparent within the organization. The 2009 employee opinion survey results for TGH and TWH
www.aornjournal.org
can be found in Figures 4 and 5, respectively. At the TGH site, scores on all elements of the employee opinion surveys, work practices, recognition/ compensation, communication, commitment, physical/environmental safety, teamwork, and respect, increased more than 40% (n ⫽ 87 respondents). We believe that this shift in scores is a result of the respect strategy, the commitment of the new OR leadership team to changing the culture, and implementation of the process changes in the OR Transformation Project, as well as improved response rates. For the TWH site, the high employee opinion survey scores from the 2006
76%
Work practice
74% 42%
71% 69%
Recognition/ compensation
41% 80% 79%
Communication 55% 66% 59%
Commitment 30%
Physical/ environmental safety
77% 80% 53% 79%
Teamwork
74% 53%
81%
Respect
76% 55%
0%
10%
20%
30%
40%
50%
60%
70%
80%
90%
100%
Subscale Score (%)
TGH OR 2006
TGH OR 2009
UHN 2009
Data source: employee opinion surveys conducted in 2006 and 2009 Respondents: n = 35 in 2006; n = 87 in 2009 Positive score based on response of good/very good/excellent or moderately agree/strongly agree
Figure 4. Toronto General Hospital (TGH)/University Health Network (UHN) 2009 OR employee opinion survey results.
AORN Journal
123
January 2011
Vol 93
COSTELLO ET AL
No 1
76%
Work practice
88% 85% 71%
Recognition/ compensation
78% 86% 80% 89% 92%
Communication
66%
Commitment
82% 78%
Physical/ environmental safety
77% 86% 89% 79% 84%
Teamwork
85% 81%
Respect
87% 88%
0%
10%
20%
30%
40%
50%
60%
70%
80%
90%
100%
Subscale Score (%)
TWH OR 2006
TWH OR 2009
UHN 2009
Data source: employee opinion surveys conducted in 2006 and 2009 Respondents: n = 82 in 2006; n = 106 in 2009 Positive score based on response of good/very good/excellent or moderately agree/strongly agree
Figure 5. Toronto Western Hospital (TWH)/University Health Network (UHN) 2009 OR employee opinion survey results.
survey were sustained. After the most recent results were made available, we held celebrations that acknowledged the collaboration and outcomes achieved. Celebrating such milestones is an important component of sustaining the momentum of change in the ORs. The sustainability plan for the respect strategy included posting of the team charter in all clinical areas, distribution of the respect booklet to all perioperative staff members at orientation, and an all-day “respect” course for new staff members. Another key component of the project’s sustainability was the creation of a recognition 124
AORN Journal
strategy, the Team Charter Recognition Awards. We designed the recognition award to honor an individual or team that demonstrates the six crucial qualities outlined in the team charter by being
supportive, reliable, respectful, hard working, cooperative, and patient centered.
We held a contest during which staff members were asked to submit slogans or catchy phrases
Working Together to Build a Respectful Workplace: Transforming OR Culture JUDY COSTELLO, MScN, RN, CCN(C); CATHY CLARKE, MA; GILLIAN GRAVELY, BScN, RN, CPN(C); DINA D’AGOSTINO-ROSE, MA, RN; ROSE PUOPOLO, MN, RN, CPN(C)
ABSTRACT Respect is important in the creation of a positive perioperative work environment and effective OR teams. Low scores for respect in the OR on an employee opinion survey and responses on a more customized survey that examined issues associated with respect prompted leaders at the University Health Network to undertake a multiyear organizational strategy to address respect and quality of worklife initiatives. An interprofessional quality of worklife task force convened to create an action plan to address the outcomes of the surveys. The work of the task force included developing and implementing a code of conduct team charter for the OR, empowering leaders to better manage conflict through education and coaching, creating a collaborative, consistent approach to conflict resolution, and designing an education strategy for staff members to enhance communication and conflict resolution. Results of recent employee opinion surveys have reflected positive outcomes. Efforts to sustain the effects of the project include quarterly recognition awards and ongoing education focused on wellness and communication skills. AORN J 93 (January 2011) 115-126. © AORN, Inc, 2011. doi: 10.1016/j.aorn.2010.05.030 Key words: workplace respect, perioperative work environments, quality of worklife, OR culture.
O
perating rooms are high-intensity, often high-stress environments where team members must work together to provide patient-centered care. Managing the demands of the daily schedule; integrating emergency surgeries; balancing budgets and ensuring revenue streams; and dealing with staffing shortages and the varied personalities of physicians, nurses, and support staff can be daunting tasks. The influence of hierarchical and unbalanced power relationships also can add stress to an already challenging
work environment. As a result, a variety of behaviors are exhibited in the OR, including interpersonal conflict, bullying, verbal abuse, horizontal violence, and harassment.1-4 Professional organizations have called on hospitals to establish code of conduct policies and educational interventions to enable staff members to manage and report disruptive behaviors.5 Employers have been challenged to create healthy work environments that focus on improving staff members’ well-being, patient outcomes, and
doi: 10.1016/j.aorn.2010.05.030
© AORN, Inc, 2011
January 2011
Vol 93
No 1 ● AORN Journal
115
January 2011
Vol 93
No 1
Surgical Programs and Critical Care Services at the University Health Network, Toronto, Ontario, Canada, and Scott McIntaggart, vice president of Integrated Surgical Services, Critical Care, and Transplantation at the University Health Network, Toronto, Ontario, Canada, and thank the members of the quality of worklife task force. References 1. 2. 3.
4.
5.
6.
7.
8. 9. 10. 11.
Gilmour D, Hamlin L. Bullying and harassment in perioperative settings. Br J Perioper Nurs. 2004;13(2):79-85. Buback D. Assertiveness training to prevent verbal abuse in the OR. AORN J. 2004;79(1):148-150. Bartholomew K. What is horizontal hostility? In: Ending Nurse-to-Nurse Hostility: Why Nurses Eat Their Young and Each Other. Marblehead, MA: HPro, Inc; 2006:3-22. Bigony L, Lipke TG, Lundberg A, McGraw C, Pagac G, Rogers A. Lateral violence in the perioperative setting. AORN J. 2009;9(4):688-696. AORN supports the Center for American Nurses call for an end to lateral violence and bullying in nursing work environments. AORN, Inc. http://www.aorn.org/ News/March2008News/CENTERForAmericanNurses CallsForAnEndToLateralViole/. Accessed August 24, 2010. Healthy work environments best practice guidelines: professionalism in nursing. Registered Nurses Association of Ontario. http://www.rnao.org/Storage/28/ 2303_BPG_Professionalism.pdf. Accessed August 24, 2010. Shewchuck M. Pearls of wisdom for leadership skills. Looking in the mirror and asking, “How do I like me now?” Can Oper Room J. 2004;22(4):20-22. Sutton R. Building the civilized workplace. McKinsey Q. 2007;2(May):47-55. Parsons ML, Newcomb M. Developing a healthy OR workplace. AORN J. 2007;85(6):1222-1223. Hamlin L. The OR and a “just culture.” AORN J. 2009; 90(4):495-498. Mahatma Gandhi quotes. Thinkexist.com. http:// thinkexist.com/quotation/be_the_change_you_want_to_ see_in_the_world/148490.html. Accessed August 27, 2010.
Resources Forsythe L. Using an organizational culture analysis to design interventions for change. AORN J. 2005;81(6):12901302. Girard N. Dealing with perioperative prima donnas in your ORs. AORN J. 2005;82(2):187-189. O’Brien-Pallas L, Hiroz J, Cook A, Mildon B. NursePhysician Relationships: Solutions and Recommendations for Change. Comprehensive Report for Nursing Secretariat and Ministry of Health and Long-Term Care Research Unit. Toronto, Canada: Nursing Health Services Research
126
AORN Journal
COSTELLO ET AL Unit; 2005. http://www.nhsru.com/documents/Revised% 20FINAL%20Nurse-physician%20Report%20-%20Dec% 2013%2005.pdf. Accessed August 24, 2010. Reynolds A, Timmons S. The doctor-nurse relationship in the operating theatre. Br J Perioper Nurs. 2005;15(3): 110-115. Shermont H, Krepcio D. The impact of culture change on nurse retention. J Nurs Admin. 2006;36(9):407-415.
Judy Costello, MScN, RN, CCN(C), is the director surgical services, Toronto General Hospital, University Health Network, Toronto, Ontario, Canada. Ms Costello has no declared affiliation that could be perceived as posing a potential conflict of interest in the publication of this article. Cathy Clarke, MA, is the manager of organization and employee development, University Health Network, Toronto, Ontario, Canada. Ms Clarke has no declared affiliation that could be perceived as posing a potential conflict of interest in the publication of this article. Gillian Gravely, BScN, RN, CPN(C), is a nurse manager at Toronto General Hospital OR and Princess Margaret Hospital OR, University Health Network, Toronto, Ontario, Canada. Ms Gravely has no declared affiliation that could be perceived as posing a potential conflict of interest in the publication of this article. Dina D’Agostino-Rose, MA, RN, is the clinical director, Surgical Services and Arthritis Program, Toronto Western Hospital, University Health Network, Toronto, Ontario, Canada. Ms D’AgostinoRose has no declared affiliation that could be perceived as posing a potential conflict of interest in the publication of this article. Rose Puopolo, MN, RN, CPN(C), is a patient care manager, Toronto Western Hospital, University Health Network, Toronto, Ontario, Canada. Ms Puopolo has no declared affiliation that could be perceived as posing a potential conflict of interest in the publication of this article.