Filling the void created by reductions in nurse staffing - Educational Innovations

AORN Journal,  April, 2002  by Caroline Van Cleave,  Jo Ann Scherffius

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During this time of competition and reduced fees for services, it is imperative for health care organizations to be cognizant of the need to change direction, plan for future survival, and recognize the aging workforce. An exodus out of the nursing profession of nurses age 40 and older is becoming apparent. The number of people entering nursing programs is declining steadily and does not offset the void that this exodus creates. The resulting vacuum in specialty areas, such as the OR, is likely to grow significantly before the nursing profession successfully realigns. This vacuum affects the ability of many health care organizations to provide quality, experienced care.

The problems associated with today's nursing shortage became evident to the division of OR services management team at Santa Clara Valley Medical Center, San Jose, Calif, in 1998. It was apparent that anticipated reductions in staffing at the facility would intensify these problems. Based on these circumstances and the number of nurses approaching retirement age, OR services team members needed to identify ways to reduce costs while maintaining an efficient and productive OR.

Recognizing that many nurses would be patients in the future and wanting to ensure that all patients would receive high-quality, competent care, we--the nurse manager and staff developer--wanted to create a surgical staff member position that was an adjunct and support for nurses. This paradigm has required and continues to require changes in perceptions of our patients, administrators, and staff members.

BACKGROUND

Santa Clara Valley Medical Center is a designated level one trauma center and a division of the Santa Clara Valley Health and Hospital System. It is owned and operated by Santa Clara County. The division of OR services included nine ORs, the postanesthesia care unit (PACU), and the ambulatory surgery unit (preoperative and postoperative). In 1996, the facility underwent what many in health care anticipated and dreaded--reengineering. Phase one reengineering involved reducing costs by downsizing the number of inpatient RNs and support staff members (eg, respiratory therapy technicians, dietary technicians), which increased RNs' duties.

In phase two, the time-consuming downsizing process was initiated in OR services. Hospital administrators had established the path--to eliminate $750,000 from the OR services budget. We knew we could not alter the outcome, only the course. Recognizing this forced us to approach this situation as an opportunity to find alternatives and to become creative in our vision of how OR services would look and survive in the future.

Operating room services staff members included RNs, surgical technologists (STs), hospital service assistants, central service technicians, medical unit clerks and receptionists, and stocking clerks. Many of these staff members served on several reengineering teams. One reengineering team was charged with reviewing practice changes, including staffing realignment and skill mix. This team was composed of RNs, STs, hospital service assistants, OR managers, and the OR administrator.

To reduce labor costs, team members determined that a shift from an almost all-RN staff mix to a 60:40 RN to ST staff mix was necessary. Team members also reviewed the cost of lost OR time when delays occurred in room turnover or transport of patients. An additional factor considered was the facility's anticipated move to a new building in early 1999, which would add three ORs for a total of 12, 12 monitored PACU beds for a total of 22, and 10 secondary recovery beds for a total of 20. The move meant a change for OR services not only in size but also in flow, logistics, and process.

We spent significant time contemplating ideas and assumptions about the reengineering process. One major problem was channeling team members into a creative mode that allowed them to function apart from set patterns, routines, and expectations.

IDENTIFYING RESPONSIBILITIES

We began by having team members identify routine tasks performed during a 24-hour period in OR services. Next, team members identified exceptions and changes (eg, trauma patients, patients suffering cardiac arrests) that interrupted or interfered with these routine tasks. They began identifying and isolating each activity performed during the surgical process. Team members made copious lists on large charts, which were impressive, modernistic art forms in vibrant script and colors. The charts illustrated the exceptional amount of work involved in preoperative, intraoperative, and postoperative patient care.

Team members deliberately and systematically identified who currently was responsible for each task and why. Guided by the California Board of Registered Nursing: Nursing Practice Act, (1) we identified which tasks must be performed by RNs. In an environment in which RNs performed all tasks, it was eye-opening to realize that many tasks could be delegated to assistive personnel.