Introduction
Provider burnout in the OR has been a problem for years, but the COVID-19 pandemic has brought staff morale to a low point in hospitals across the US. Many OR leaders are facing staffing shortages just as demand for elective surgery is increasing. This is a significant problem for hospitals that are counting on a strong rebound in procedural revenue to drive their financial recovery.
The pandemic has forced many OR professionals to spend much of the past year coping with unfamiliar problems in unfamiliar settings. The 2021 OR Manager Salary/Career Survey found that nearly half (46%) of respondents lost staff in the past year because of the pandemic, and half reported increased turnover rates for RNs, up from 34% in 20191. The percentage of OR leaders reporting increased surgical technologist turnover doubled from 24% in 2020 to 48% this year1.
Aside from the strain of the pandemic, several ongoing issues are fueling OR staff burnout. Longstanding problems include the inherent stress of delivering care in a high-acuity setting, the frustration of working in a complex healthcare system, and a loss of professional autonomy.
Not all these issues can be addressed head on, but there is a common theme — uncertainty. In many ORs today, surgeons, anesthesia providers, nurses, and support staff do not know what to expect from their work environment, have little control over it, and feel unprepared to meet its challenges.
No single strategy will solve the problem of provider burnout. However, OR leaders can make significant progress by realizing that the antidote to uncertainty is predictability. They can decrease some of the uncertainty by creating an environment where physicians, nurses, and other staff members know what is expected of them, which will help make them feel secure in their roles and better equipped to deliver excellent care.
Eliminate Erratic Schedules
In many ORs, nurses are routinely asked to stay late to cover add-on cases. Conversely, the same nurses are frequently sent home early on slow days. In addition, nearly two-thirds of perioperative nurses work on call, according to the most recent survey from AORN. For the vast majority of these nurses (nearly 9 out of 10), on-call hours are mandatory.
This lack of predictability in work hours is unsustainable for a growing number of OR nurses. For many staff members, arranging flexible childcare is a major issue.
Anesthesiologists and certified registered nurse anesthetists (CRNAs) face similar issues, with an unpredictable case schedule and even greater expectations for coverage. Even surgeons struggle with schedule predictability, even though in many ways the OR schedule revolves around surgeon needs. Schedule access is often driven by a complex pecking order, and many surgeons find themselves unable to book cases conveniently for themselves and their patients.
The root cause that underlies all these problems is not complicated: Most OR leaders have never developed effective systems for managing add-on and emergent cases. This gap leads to wide fluctuations in daily and hourly case volumes, resulting in an erratic schedule for everyone who works in the OR.
To begin creating a more staff-centered schedule, OR managers should concentrate on two general strategies:
Rework the block schedule to consolidate volume.
Surgical Directions, a Chicago-based healthcare consulting firm, recently described how predictive analytics can help OR leaders control costs and increase revenue (“Using advanced analytics to maximize OR utilization,” OR Manager, December 2020, pp 22-23, 25). Just as important, an analytic strategy can help optimize the staff schedule and improve schedule access for surgeons.
The OR schedule may appear to be unpredictable, but analyzing volume data over a long period will typically identify predictable patterns. These patterns can be used to design a block schedule that consolidates volume as much as possible to prime time hours. This will minimize the need to extend (or cut short) the workday for OR staff and will reduce the disruption of on-call hours.
Rework the staffing model to match volume and work hours.
Even if the bulk of elective cases are consolidated to be performed during prime time, most ORs will still have non-prime time case volume that does not conform to the standard 7 am to 3 pm staffing model. Adjusting the model for staffers willing to working other shifts will help make the entire schedule more predictable for the entire team.
One option is to add an afternoon shift to accommodate add-on and emergent cases. This shift could start at 3 pm and run until 9 pm or 11 pm, depending on predicted need. Another option is to open one add-on/emergent room at noon to absorb fluctuations. Again, it all depends on the predicted need per hour of day and day of week.
Higher-volume hospitals should consider staffing the OR around the clock. From a workforce point of view, doing so will immediately alleviate most of the schedule fluctuation that leads to staff burnout. From a financial point of view, 24-hour staffing will in most cases be more economical than a model that relies on call pay plus time-and-a-half for after-hours coverage. Depending on demand, OR leaders could also consider extending around-the-clock staffing to weekend rooms.
Around-the-clock staffing offers an additional benefit in OR efficiency. In most instances, the third-shift team will be able to help ensure that rooms are ready for morning cases. This will alleviate the morning workload for prime time staff and help ensure a strong first-case on-time start rate.
Staffing model redesign can be used in tandem with predictive analytics and block system redesign. These three tools form a suite of strategies for matching the demands of case volume to the personal needs of staff, thus reducing the unpredictability that leads to burnout.
Build Staff Confidence
Expectations are rising steadily for OR staff. In just the last few years, perioperative nurses and surgical technologists have had to take on many new tasks, meet several new documentation requirements, and master many new devices and technologies.
Acquiring new skills is part of professionalism, but the pace and scale of change have left many OR staff feeling unprepared and overwhelmed. To combat these problems, OR leaders should consider committing resources to two key areas:
Invest in staff education.
Most hospital ORs have reduced staff education budgets significantly in the last several years. These cuts save money, but they leave staff feeling unprepared and can undercut professional pride. From a cost/benefit perspective, greater investment in staff education can yield several hard- and soft-dollar benefits.
For many ORs, a good first step is to reestablish weekly in-service time to provide education on new equipment, new procedures, and new regulatory requirements. In addition, OR managers with robust budgets should consider investing in simulation training, which can improve OR team dynamics and increase staff confidence.
Invest in support roles.
Most ORs have adopted leaner staffing models in recent years. Lower labor costs have helped healthcare organizations, but running lean can add to staff stress. OR leaders should reevaluate the balance between additional labor costs and costs associated with low staff morale, including burnout and high turnover rates.
The standard OR today is staffed by one registered nurse in the circulator position and one surgical technologist in the scrub position. This generally meets minimum staffing requirements, but with just two staff, patients are sometimes left unattended while these individuals perform other tasks. To alleviate this problem, OR managers could consider hiring an additional technologist to support every two rooms. This team member could minimize distractions for other staff by assisting with tasks such as room setup, positioning patients, retrieving supplies, and facilitating room turnover.
Similarly, hospitals should consider hiring anesthesia technologists/technicians to support anesthesia providers. The extra support would help decrease interruptions for anesthesiologists and CRNAs and increase patient safety.
Offer Personal Support
Schedule redesign and workforce investments will go a long way toward increasing work hour predictability and professional confidence for OR staff. However, these benefits can easily be undermined by a negative culture or an abusive working environment.
Although structural changes are important, “soft” leadership skills are also key to preventing and mitigating burnout among OR professionals. Following are three recommendations:
Create an environment of appreciation.
The first priority is to address any physician behavior issues. Surgeons drive OR revenue, but margins are no longer strong enough to offset the effects of negative physician behavior. Staff turnover is not the only expense. A negative environment can also contribute to high direct costs, as nurses open more supplies than needed to avoid being yelled at by surgeons.
There is no easy solution to a negative culture. Ultimately, confronting poor behavior requires principle and courage. However, OR leaders can also take positive steps to elevate the role of OR nursing in their organizations. One strategy is to work with physician leaders to establish a robust time-out process that explicitly validates the role of nurses in patient safety and care quality.
Another strategy is to create dedicated nursing teams to support specialties like orthopedics and urologic surgery. In this model, surgeons and nurses get to know each other better and see each other as colleagues. This increased collegiality can help prevent abusive behavior. It can also create opportunities for nurses to feel greater pride in their practice, thus reducing the risk of burnout.
Be a leader, not just a manager.
The need for leadership cuts across the entire perioperative team and applies to both OR nursing leaders and anesthesia directors. Leaders should know their staffs well enough to understand the professional challenges and personal struggles they are experiencing, and be ready to provide support when either threatens to overwhelm a team member’s ability to function.
In some cases, this is as simple as listening to staff and providing encouragement and guidance. In other cases, perioperative leaders should be ready to put individuals in a position where they can succeed. For example, an RN may be burning out on the circulator role and would benefit from opportunities to scrub in on more cases. Or an anesthesiologist who is struggling with the demands of clinical care could thrive as director of the preanesthesia testing clinic or in an administrative leadership role.
Not every solution needs to be a major job change. For instance, say a nurse is frustrated with constantly walking to the corner of the OR to document at the nursing desk. Investing in workstations on wheels that can be positioned for convenient documentation, no matter how the room is set up, could alleviate such frustration.
Be present.
The simplest way for OR administrators to escalate their leadership skills is simply to be more visible. In our experience, perioperative nurses are happiest when they regularly see the OR director in the department. Even a 15-minute stop in the OR—to help position a patient or turn over a room—can have a tangible effect on nursing staff morale.
OR leaders can also develop a powerful presence by modeling work-life balance. This can be difficult for many more tenured nursing leaders and physician providers, but it is key to setting the tone for staff and creating space for positive change in the department.
Strategic Investments
Most of the above recommendations require some level of investment. Some of these investments will pay off quickly. Others will take time to show a return. Either way, it is important to focus on long-term success and a multiyear bottom line.
In the next few years, workforce issues will become a huge stress on the hospital OR business model. Organizations that are “penny wise and pound foolish” will continue to see an unmanageable decline in OR volume and margin.
Strategic investments in staffing, education, analytics, and leadership will help create a predictable and positive work environment for physicians, nurses, and other staff members. This stable foundation is key to creating a high-performing team that drives an efficient and profitable OR.
Resources
1. Bacon D R, Stewart K A. Results of the 2019 AORN salary and compensation survey. AORN J.2019;110(6):578-595. https:// aornjournal.onlinelibrary.wiley.com/doi/10.1002/aorn.12862.
