Social Stressors in the Operating Room
Louis J Auguste, MD

Of all the different sections of a hospital, the Operating Room Suite probably receives the most attention. Indeed, it is the highest revenue producer. It is also the most regimented service of all. First, many different specialists, from gynecologists to neurosurgeons, have the opportunity to perform their skills for the benefit of the patients. In order to do so, an elaborate, multi-layered staff is indispensable, including anesthesiologists and nurse anesthetists, circulating nurses, scrub technicians, porters and turnover technicians and they all must work in a synchronized manner, in order to maximize the effectiveness of this endeavor. To keep that machine going, multiple levels of nurse managers work around the clock, to provide support wherever and whenever it is needed.  In a tertiary care hospital, one sees a concentration of more difficult cases, thus, with a greater possibility of tense moments and serious complications.  These stressful moments are experienced by the entire team.  Blood needs to be available immediately. This instrument is not working properly and needs to be replaced right away. The patient is unstable. Tempers flare up. This one is too slow. That other one does not know what she or he is doing. The surgeon is frustrated. Harsh words are exchanged. Such a situation can make anyone’s blood boil and raise one’s blood pressure. Fortunately, this is not a daily occurrence, but everyday a staff member sets foot in the OR, it is a distinct possibility.  These situations provide however, an opportunity for self-selection, as the weak hearted staff will leave at the first opportunity they find and the hardy ones will as they say, “stick it out.”

However, this is probably the least of the stresses faced by the staff in the operating room.  Perhaps a throwback of the olden days or perhaps a reflection of one’s true personality, some surgeons have taken the deplorable habit of yelling and cursing to get the staff to do their job.  This abusive attitude has been shown to be associated with an increased risk for adverse events in the OR and over the past few years, the Joint Commission on Accreditation of Healthcare Organizations (JCAHO) has zeroed in on any such complaints by the staff.  Thus, this attitude has led to reprimand for certain surgeons while others simply had their privileges terminated.  Conversely, playing a background music to the liking of the surgeon and or the staff, has been shown to be associated with less complications.

From a managerial standpoint, although different models are use to predict the variation in the workflow in the OR, the unexpected and the uncontrollable can never be fully anticipated. Members of the staff can call in sick. Most of the staff, looking for affordable housing, tend to live away from the hospital and may have a long commute. Traffic accidents lead to late arrival. Unexpected number of emergencies during the night may result in delay in the morning schedule.  Life-threatening emergencies may arrive during the day, forcing the delay of a scheduled case. Surgery planned for two hours may last six hours. Elective procedures may continue into the night. In the midst of this entire ordeal, the managers have to satisfy the requirements of the unions, 15-minute break in the morning and in the afternoon and one hour lunch or dinner break.  This ritual is sacrosanct for the staff and they do not hesitate to voice their displeasure if it is not observed.

More importantly though is the time of dismissal.  Indeed, although the average age of an RN in the United States is 44.6 years, 15 % of the nurses are 31 years old or less. Thus, a significant percentage of the nurses is likely to consist of young mothers, who have rigid schedules regarding baby sitting or child care in general. One can see the anxiety in the eyes of these nurses when the time to leave is getting near and there is no relief in sight.

An additional stressor is sleep deprivation. Indeed, although there is a team of nurses assigned to work the night shift, if a given number of emergencies is exceeded, a roster of on-call nurses can be mandated to report to the Operating room to handle the emergencies.  Then, they may have to come back the following day for their regular daily assignment.

Finally, one of the most serious sources of tension and aggravation in the operating room is the manager/staff relationship, particularly when it comes to holiday celebration and vacation time.  The repartition is supposed to be based strictly on seniority and the timing of one’s request. Nevertheless, there is always a sense of victimization or a suspicion of favoritism among the staff that often may be real. This sentiment is further exacerbated by the fact that between 20 and 50 % of the staff consist of ethnic minorities, while the majority of the managers are Caucasian.

In this context, the staff evolves into three categories:

-        the passive ones who will endure all the vexations because they cannot afford to be unemployed

-        the aggressive ones who complain the loudest and do not hesitate to call out unfairness. Those usually are also good workers and the usually end up gaining respect and what they want.

-        The third group rebel against what they perceive as an intolerable stressful situation and they move on.

Indeed, overall 13 % of the nurses quit their department after one year, while 37 % state that they would like to do so. However, it does not have to be that way. Proper staffing and fair management practices may reduce these social stressors and improve the employees’ morale.



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