Staff Retention in the OR A Job Satisfaction Study

MAY 1988. VOL. 47. NO 5

AORN JOURNAL

Staff Retention in the OR A JOB SATISFACTION STUDY

Claire C. Olsen, RN

R

ecruitment and retention have become the new buzzwords for hospital administrators. One cannot pick up a newspaper or professional nursing journal without finding some reference to the nursing shortage. Vacancy rates vary for different regions of the countryranging from 3% to 30%’ A study done in December 1986 found that vacancies were twice that of a 1985 survey, 13.6% overall? In general, the larger the hospital, the higher the percentage of vacancies. Many hospitals are paying finder’s fees or a bonus to those who recruit new nurses. Critical care nurses are the most difficult to recruit, and OR nurses are second? Of the 1,000 hospitals responding to the 1986 survey, 47% reported recruiting of OR nurses as “difficult” to “very difticult.”4 A survey of 228 hospitals in California the same year found 60%had difficulty recruiting OR Hospitals in the Long Island (NY) area also are experiencing problems attracting OR nurses, licensed practical nurses (LPNs), and surgical technologists (STs). In addition, frequent staff

turnover is a concern in many hospitals. Although recruitment was the first focus of attention, hospitals are now starting to look at retention (ie, how to keep their staff, once hired). Recruitment costs are high, but orienting new personnel to a hospital also costs thousands of dollars a year. I conducted a study on job satisfaction in the OR to try and identify the most important factors that attract and will help retain OR staff members. The target population included RNs, STs, and LPNs in hospitals in the Queens and Nassau County area of New York, which are the boundaries of the Long Island Chapter.

Literature Review

M

any studies have been done on the registered nurse and his or her job satisfaction. One study found that nurses are dissatisfied and less fulfilled with their opportunities for professional growth and their opportunities for participation in setting goak6 The study also showed that nurses lacked

Claire C.Olsen, W,MS, CNOR, is a professor of surgical technology at Nassau Community

College, Garden City, NY. She earned her nursing diploma from St Luke’s Hospital School of Nursing, New York City, her bachelor of science degree in nursing from C. W Post Center, Long Island University, Greenvale, NK and her master of science degree in health science educationfrom the State University of New York at Stony Brook. 1271

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AORN J O U R N A L

Nurses leave their jobs for lack of internal rewards rather than external or monetary rewards. opportunities for independent action and had low levels of self-esteem. The nurses derived their greatest satisfaction from intrinsic areas of their work-the ability to help people, job security, friendly atmosphere, and self-fulfillment. Another study found that nurses were most satisfied with teamwork, staff rapport, a variety of experiences, learning opportunities, in-service education, and adequate orientation aspects of their jobs.’ The nurses in the same study found inadequate staffing, emotional exhaustion, and scheduling to be the most dissatisfying aspects. One researcher found that although salary was important, it was not, by itself, a motivating factor for retention of nurses.* He found that, more often, both experienced nurses and new graduates left their jobs for lack of internal rewards. He also found that new graduates who left theirjobs within one year did so because of unrealistic job expectations. Nurses cited staffing deficiencies more than any other problem in one study.9These conditions then precipitated other problems such as overwork, floating, and demands for nurses to take on nonnursing tasks. Representation or input into policy-making committees were the most frequent satisfying job aspects for these nurses. A 1986 RN Muguzine reader survey cited staff shortages, lack of administrativesupport, increased paperwork, and poor pay as the most dissatisfying aspects of one’s job as a nurse.1° Nurses in the study also were frustrated with administrators who expected the quality of care to be maintained, but did not provide adequate back-up. A study of RNs who had been in practice three to five years found more than 80%happy in their choice of nursing, and 90%interested in furthering their education.” Tuition reimbursement was an important factor to 51% of the nurses. In their work environment, they were most satisfied with their opportunities to use past training and experience, job security, and opportunities to 1212

develop new skills. They were least satistied with working conditions, pay, opportunities for advancement, and their supervisors. A summary of a 1983 study on “magnet hospitals” indicates that these hospitals attract and hold highly qualified nurses because of several factors: a visible director of nurses, participatory management, primary nursing, continuing education programs in and out of the institution,flexible working hours, tuition reimbursement, career ladders, good nurse-physician relations, excellent orientation programs and preceptors, and specially hired float pools.12Salary was not a primary factor. Overall, the research indicates that nurses remain at their jobs because of multiple conditions that produce satisfactory attitudes toward their jobs, which in turn decreases turnover. Dissatisfaction appears to result from the work setting rather than nursing practice itself. I hypothesized that this would be true for OR personnel as well.

Instrumerit/Methodologv

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y survey questionnaire solicited demographic data, information relating to years on the job, OR experience, call schedules, length of orientation to the OR and satisfaction with the orientation, and reasons for applying to the present institution. Then I adapted for my use among OR personnel a survey tool developed by Billings and Quick to determine job ~ornpatibi1ity.l~Based on Maslow’s hierarchy of needs, the tool measures professional actualization, which is defined as the relationship between the professional and his or her practice setting. This portion of the survey examined characteristics of the employment setting as they related to individual needs, provision of nursing care, and administrative structure. Thirty-six separate characteristics were rated (Table 1). For each characteristic, respondents were asked to check

MAY 1988, VOL. 47. NO 5

AORN JOURNAL

Table 1

Characteristics of the Employment Setting Column 1 (Important)

Column 2 (Present)

Related to provision of patient care in the OR 13. Adequate staffing to meet case loads 14. Case assignments related to one’s level of experience 15. Opportunities for preoperative and postoperative visits 16. Recognition of contributions to patient care 17. Professional role models for clinical care 18. Collaboration and respect between nursing staff and physicians 19. Collaboration and respect between RNs and STs 20. Availability of support services for nonnursing functions 2 1. Other (fill in) 22. Other (fill in)

(Important)

(Present)

Related to administrative structure 23. Established personnel policies related to sick time, leave 24. Competitive salary 25. Flexible time scheduling 26. Opportunities for advancement (career ladders) 27. Adequate training and supervision for new procedures 28. Structured orientation program for new RNs/STs 29. Permanent shifts 30. Adequate space including locker, conference, and lounge 3 I . Supervisors and managers with background in nursing management 32. A quality assurance program for all disciplines, including nursing 33. Input into management decisions (participative management) 34. Communication between nursing service and RN/ST schools 35. Other (fill in) 36. Other (fill in)

(Important)

(Present)

Related to individual needs 1. Opportunity to use past training and education 2. Opportunity to develop new skills 3. Opportunity for promotion and advancement 4. Compensated time for professional activities 5. Educational benefits, such as leave time and tuition reimbursement 6. Opportunities for professional growth (in-service, research) 7. Peer support for stress management 8. Time to eat full meals, coffee breaks 9. Ready access to child care facilities 10. RecreationaVphysical fitness areas nearby 11. Close to home 12. Other (fill in)

Of the choices listed 1-36, the three most important reasons I remain at this institution are: What advice would you give an OR administrator who wants to decrease RN/ST turnover? 1273

MAY 1988. VOL. 47, NO 5

whether the characteristic was important to them in the work setting, and whether the characteristic they had checked was actually present in their work setting. By dividing the number of items listed as important by the items actually present in their work setting, I was able to calculate a percentage satisfaction score. To identify key issues, a fill-in question asked respondents to choose three characteristics from the 36 items that caused them to remain in their institution. A final open-ended question solicited a single suggestion for the OR supervisor who wished to do something about staff turnover. In addition to the validity established by Billings and Quick, I had the survey instrument reviewed by members of our chapter board of directors, and I tested a group of RNs and STs with it to determine clarity, ease of use, and content validity. After obtaining permission from each chapter, surveys were sent to all members of the AORN of Long Island chapter and all members of the Association of Surgical Technologists (AST) of Long Island. To ensure responses from nonmembers, 20 hospitals in our chapter area, ranging from two to 16 ORs in size, also were selected to participate in the survey. Surveys were distributed to all RNs, STs, and LPNs on all three shifts who worked in the OR. The AORN and AST members were asked to complete only one survey if they were employed by a participating hospital. Thirty-three hospitals were involved overall. Three had less than four ORs, 18 had five to eight ORs, eight had nine to 12 ORs, and four had 13 to 16 ORs. There were four governmentrun, 18 community, and 1 1 proprietary hospitals involved. Six had medical center status. Six hundred surveys were distributed, and 219 were returned for a 36.5%response rate.

Data A nalysidConclusions Personal data. Of the 219 responses, there were 167 RNs, five LPNs, and 47 STs. For purposes of analysis, the LPNs and STs were combined. Not every respondent answered each item in the demographic section.

A O R N JOURNAL

By job title, there were 116 staff nurses, 48 staff technicians, 26 head nurses, nine supervisor/ nursing care coordinators, five O R director/ administrators, five in-service educators, five others, and five did not answer the question. By education, 74 of the RNs were diploma graduates, 40 had associate degrees, and 53 had baccalaureates (19 BSN degrees and 34 other BS degrees). Seven of the STs had on-the-job training, 16 had six months to one year of education in certificate programs, and 29 had associate degrees (26 had associate degrees in surgical technology and three had other associate degrees). Seventeen percent of the nurses and 80%of the technologists were certified by their professional organization. A majority of the RNs and STs belonged to their professional associations60% of the RNs belonged to AORN, and 54% of the STs belonged to AST. A good mix of OR personnel responded; 78% were from general staff positions. The RN to ST ratio in hospitals in our chapter area is 3.2:l. Although 25% of the RNs hold baccalaureates, less than half are in nursing. Employment data. Although retention is reported to be a problem, 73%of the respondents (78%of RNs and 60%of STs) have been at their present institutions for more than three years, and 26% (25% of RNs and 32% of STs) for more than 11 years. Eighty-two percent of all the respondents had more than three years of OR experience, and 38% had more than 1 1 years. But, I found that many of the RNs with less than five years experience were recruited from within the institution, which may not be practical or cost-effective in the future, in light of today’s overall nursing shortage. As expected, a majority (78%) of the 219 respondents worked the 7 AM to 3 PM shift, 9%worked 3 PM to 1 1 PM, 1% worked 1 1 PM to 7 AM, and 12%worked other overlapping shifts. Of the respondents, 123 (56%)took call for emergencies, 48 (22%) took call once or twice a week, and 21 (10%) took call three to five times per week. Orientation. Length of orientation to the OR in which the respondents worked varied widely. Of 207 responses, 44 (28%)RNs and 19 (40%) 1215

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Table 2

Reasons for Applying Reason

Close to home Shifts available Type of hospital Salary Fringe benefits Professional advancement Only job available Tuition reimbursement Other (mixed)

First

Second

Third

Total

98 27 127 23 13 11 13 1 14

41 55 42 26 6 11 6 5 10

22 42 31 29 16 10 12 6 13

161 124 100 78 35 32 31 12 37

STs had less than two weeks, 41 (26%) RNs and 12 (25%) STs had three to six weeks, 43 (27%) RNs and 13 (27%) STs had seven weeks to 15 weeks, and 31 (19%) RNs and 4 (8%) STs had more than four months. Fifty-five percent of the respondents thought the orientation was sufficient, 4%thought it was too long, and 41% found it too short. Overall, 56% of the respondents had less than six weeks of orientation, and 41% of them thought it was too short. Considering today’s diversity of procedures and technology in the OR, this amount of dissatisfaction with orientation is not surprising. This dissatisfaction is supported again in this article under “Employment Setting Characteristics.” Reasons for job application. When asked to indicate the three most important reasons for applying to the institution in which they worked from a list of eight items, the respondents chose: “close to home,” “shifts available,” and “type of hospital” (Table 2). When seeking employment,being close to home was by far the most important reason for applying to an institution. And yet, only 52% were so employed. Time in scrub/circulator/t assistant roles. Respondents were asked to indicate their usual percentage of time in scrub, circulator, and first assistant roles. Responses were separated

according to RNs and STs. Of the 190 who said they were involved in these roles, STs did most of the scrubbing (91% of the time), and RNs did most of the circulating (87% of the time). Both groups indicated that first assisting was rare, and most participated less than 10% of the time. Twenty-seven of the respondents indicated that their role was in the area of in-service or supervision/administration. When respondents were asked if they were satisfied with their roles, 44% replied no. Those who answered no were asked how they would change it. The answers ranged from more help to more money, but the most common responses were from RNs who wanted to scrub more and STs who wanted to circulate more. Overall, both RNs and STs would like more diversity in their assignments.

Employment Setting Characteristics

T

his section used an adapted version of the job compatibility tool as seen in Table 1 and rated 36 characteristics of the work setting. Of the 36 items listed, there were no significant differences between RN and ST responses; therefore, only total group responses were reported. The top five were adequate staffing to meet case loads at 92%;opportunity to develop new skills at 90%;case assignments related to one’s experience at 8996, collaboration between RNs 1277

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A 0 R N J 0I 1 R N A L

Table 3

Most Important Characteristics of Work Setting Characteristic

Adequate staffing Develop new skills Cases related to experience Collaboration RN/MD Collaboration RN/ST Adequate supervision of new procedure Competitive salary Recognition of contribution to patient care Use of past training, education Established personnel policies and MDs at 89% and collaboration between RNs and STs at 89%. (The top 10 of the 36 items are shown in Table 3.) What really stood out was how few of the respondents found these characteristics present in their practice settings. Adequate staffing to meet case loads was found by 38%, opportunity to develop new skills by 52%, m e assignments related to one’s experience by 4576, collaboration between RNs and MDs by 38%,and collaboration between RNs and STs by 58%of the respondents. When the respondents were asked to choose the three most important reasons they remain in their jobs from the 36 items, the two items with the greatest response were the opportunity to use previous training and education (99%) and the opportunity to develop new skills (60%).The third item was close to home (26%), which also was their primary reason for choosing the institution. When the items each respondent rated as important were related to those items that were actually present, only 56 (26%) out of 219 respondents had a satisfaction index more than 50%, and 18 (8%) respondents had a 0 rating. That is, none of the items they checked off as important to them in the work environments were actually present (Table 4). Considering that 74% of the respondents were seriously dissatisfied with their practice setting, one would question why they stay. One answer might

Important

Present

Tolal

%

Total

%

202 198 195 196 195 193 193 192 192 186

92 90 89 89 89 88 88 88 88 85

77 103 87 75 113 59 64 38 122 142

38 52 45 38 58 31 33 20 64 76

be seniority because most of them have been employed at their institutions for more than three years. Another might be because most hospitals do not pay much more than entry level salaries for years of experience, and therefore, it may not be cost-effective for experienced RNs and STs to leave, no matter how unhappy they are. Finally, when asked an open-ended question about what single piece of advice they would give an OR supervisor who wished to do something about RN/ST turnover, the comments were grouped by key words into ten areas. Thirty percent made comments that related to communication. Typical responses include the following. “Listen to your staff.” “We want more input into policy-making.’’ “Our opinions are asked, but never used.” “The OR director stays in her office; we see her about once a month.” “The supervisor does not know what is going on in the rooms.” Twelve percent of the respondents wanted to be treated with more respect, 6% wanted more recognition, and 4%wanted fairer treatment. These comments imply that 22% of the respondents perceive that their contributions and needs are not given due attention. Fourteen percent commented about salaries-making them more competitive or increasing them. I279

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Table 4

Job Satisfaction Score

t-16 to 100

51 to 75 26 to 50 1 to 25 0 (no matches)

RN

ST

Tord

18 29

6 5 23 14 4

24 34 100 45 18

77 31 14

Eleven percent believed they should have had better orientation-that they were not adequately prepared for the types of procedures to which they were &\signed.

Summary/Recomrnendations

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glance at the help-wanted advertisements will show that hospitals are desperately seeking nurses. In our area, hospitals have been forced to reduce OR schedules, and surgeons complain that they cannot get OR time. In some cases. elective admissions are being curtailed. Staff members are being assigned to mandatory overtime or mandatory call time which, according to the respondents, has built up great resentment. This study has revealed some shocking data about OR staff members. Although most have been employed at their hospital for more than three years, 74%are seriously dissatisfied with their work environment. Fifty-six percent had less than six weeks orientation. and 41% found that insufficient. They are frustrated when they are assigned to procedures beyond their level, and then have to deal with intolerant surgeons. More than 50% of the RNs and STs would like to exchange scrub and circulating roles periodically. And there is a large gap between what RNs and STs consider important in their practice and what is actually present. Adequate staffing to meet case loads, opportunity to develop new skills, case assignments related to one’s experience. and collaboration between RNs and I280

3’% Satisfied on job

Number

76 Satisfaction score

RN

ST

Total

11

11 10 27 27 8

11 15 44 21 8

17 18 18 8

MDs and between RNs and STs exists less than half the time in most cases. Salary, though important, is not a priority item. When working conditions deteriorate, however, the lack of appropriate compensation is more frequently voiced. The nursing profession relies on experience, but does not reward it. Advanced level salaries do not always rise as entry level salaries do. A staff member with several years of experience often is earning only a few thousand dollars more than the new practitioner. The range between entry level and top level is small, and after five years, the more experienced staff members frequently get only cost of living increases. Although higher pay is part of the solution, it must be accompanied by greater recognition and respect for staff members’ contributions to patient care. Recognition once a year, on O R Nurse Day, is not enough. It is clear that there is a large number of dissatisfied O R nurses and technologists. With the nursing shortage increasing, and the ability to attract nurses getting more difficult, we need to institute change quickly. The respondents have made their priorities clear. They want more and better two-way communication on all levels. They want adequate staffing. They want better and longer orientations to prepare them for the jobs they are asked to do. And they want to be better compensated for what they do. There is no mistaking their message. Is anyone out there listening? 0

MAY 1988. VOL. 47. NO s

Notes I . C Curran, A Minnick, J Moss, “Who needs nurses?“ American Journalof Nursing 87 (April 1987) 444-447. 2. Ibid. 3. /bid. 4. Ibid. 5. S Flores, “OR technical and professional staff:

A study of California acute care hospitals,” AORN Journal 45 (January 1987) 97-108. 6. R Blalack, “How satisfied are hospital staff nurses with their jobs?“ Hospital Topics 64 (May/June 1986) 14-18. 7. E Bayley, “Breaking a turnover cycle: A successful approach,” Supervisor Nurse 12 (March 1981) 19-21.

AORN JOURNAL

8. A Brief, “Turnover among hospital nurses: A suggested model,” Journal of Nursing Administration 6 (October 1976) 55-58. 9. A Lee, “Where hospitals fall short,” RNMagmine 47 (April 1984) 34-37. 10. “What really makes nurse angry,” RN Mugmine 49 (January 1986) 55-60. 1 I . B Munro, “Young graduate nurses: Who are they and what do they want,” The Journal of Nursing Administrution 13 (June 1983) 21-26. 12. P Schull ed, “Magnet hospitals: Why they attract nurses,’’Nursing ’84 14 (October 1984) 50-53. 13. C Billings, M Quick, “Does your job work for you?“ American Journal of Nursing 85 (April 1985) 407-409.

Improvements Cited in Total Hip Replacements Researchers at the Mayo Clinic, Rochester, Minn, found significant improvements in total hip replacements using contemporary surgical and cement-fixation techniques when compared to earlier techniques. Between five and seven years postoperatively, patients rated 246 of 251 hip replacements as excellent, according to a presentation by Gary Russotti, MD, at the annual meeting of the American Academy of Orthopaedic Surgeons. The researchers studied 1 15 male and 1 I9 female patients who had a total of 25 1 hip replacements. Patients ranged in age from 22 to 90 years, with a mean age of 63.5 years. Surgeons used a chrome cobalt alloy femoral component with a rounded head to replace the upper part of the femur. The head fit into a replacement for the hip socket; replacement components were cemented in place. Before and after surgery, patients rated pain, function, use of walking aids, limp, walking distance, sitting, and stair climbing. Before surgery the mean score was 46.8 points and after surgery it was 97.4 points. Only five patients gave scores of less than 90 points postoperatively. None of the patients need reoperation or revision, or suffered fractures of the femoral shaft, perforations of the femoral cortex, or serious

infections or blood clots. Researchers attribute the improvements to better surgical techniques and cement fixation, improved femoral component design, modified bone preparation, and more experienced orthopedic surgeons. The information was presented in a Feb 7, 1988 news release from the American Academy of Orthopaedic Surgeons.

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Toxic Shock Syndrome from Infusion Sites Two cases of toxic shock syndrome have been reported in patients with insulin pump infusions at Eastern Idaho Medical Center, Idaho Falls, according to the Jan 15. 1988, issue of the Journal of rhr) American Medical Associarion. In both cases, the patients had symptoms of toxic shock syndrome, and in addition, had positive cultures for Smph.vlococcus aureus from abscesses at the infusion sites. Case I involved a 13-year-old girl with type I diabetes for four years. She had been using insulin pump therapy approximately one year. but neglected to clean the site or change the pump frequently. Instead of changing the site every three days. she sometimes neglected to do this for as long as 10 days. according to the article. Case 2 involved a 25-year-old woman with

type I diabetes for 20 years. She had cleaned the site by washing with soap and water and disinfecting it with alcohol, and changed the site at least every three days. Both patients had similar physicial findings: lethargy, facial puffiness, infection of their conjunctiva. minimal abdominal tenderness, a 2 cm area of induration at the pump infusion site, and a blanching rash, which is particularly indicative of toxic shock syndrome. Both patients improved after receiving surgical intervention to drain the abscess and being treated with parenteral antistaphylococcal agents. While originally noted in connection with tampon use, toxic shock syndrome has been associated with other S aureus infections. Researchers have reported that infection is the most common complication of pump therapy.

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