THE OPERATING ROOM AS A MICROSYSTEM

A work system is essentially any environment in which work is performed. In the OR, for example, the work system can be described as a microsystem in which small, interdependent groups of people work as a team to provide patient care. The microsystem typically consists of 5 to 15 people, including the surgeon, assistants, anesthesia providers, scrub person, circulating nurse, unlicensed assistive personnel (e.g., nursing assistants, equipment technicians, housekeeping personnel), perfusionists, monitoring technicians, and possibly others. The large number of participants gets further complicated by hierarchical issues within the system and the multiple handoffs that take place during a typical case. Although each member of the microsystem has a specific role, one member cannot function effectively without the support of others. Finally, this group needs to perform in routine situations and highly specialized or crisis situations. These factors describe some issues that occur daily in the OR that are not generally considered in their entirety in attempts to create a safe environment.

Viewing the OR as a microsystem provides a basis for understanding the complexity of systems, and this shifting of approach may allow for a significant decrease in errors (Weigmann et al, 2007). From the systems perspective, errors are viewed as a consequence of a system breakdown rather than being caused by an individual working in the system. This thinking is fundamental to the field of human factors, which has been used in other complex industries to balance the components of work (Yourstone and Smith, 2002).

HUMAN FACTORS

Human factors is an umbrella term that refers to the interaction of humans on and by the system in which humans work. Historically the term human factors has been used in the United States, and the term ergonomics has been used in Europe. Much of the current literature uses the terms interchangeably. The Human Factors and Ergonomics Society (n.d.) defies the terms as “concerned with the understanding of interactions among humans and other elements of a system, and the profession that applies theory, principles, data, and other methods to design to optimize human well-being and overall system performance.” Human factors science offers a way to understand the interactions among the elements of the work system, as opposed to addressing the elements individually. It takes into account human strengths and limitations with the goal of offering solutions that limit the dependence of the work system on less-reliable human characteristics (i.e., memory) and places greater emphasis on systems processes (e.g., standardization).

In their study of work systems, Smith and Sainfort (1989) developed the Balance Theory to conceptualize the interaction of five human factors components within the system: the individual, tasks, tools and technologies, the environment, and organizational factors (Figure 27-1). These components work together to create a “stress load” that challenges an individual’s biological, psychologic, and behavioral resources (Carayon and Smith, 2000). These five components should be considered equally when designing a product, process, or system to achieve effective, efficient, and safe results. This chapter presents those human factor components as they relate to the OR and discusses how balancing all five factors within a work system can improve patient safety.

Figure 27-1 Smith and Sainfort work system model.

(From Smith MJ, Sainfort PC: A balance theory of job design for stress reduction, Int J Ind Ergon 4:67–79, 1989.)

BALANCE THEORY

Individual

The characteristics of an individual in the work system include everything the perioperative nurse “brings” to work, including individual characteristics such as past experience, abilities, physical and emotional health, motivation, and professional aspirations. Many of these characteristics are not static. Fatigue, for example, has been implicated in errors in disasters such as the Exxon Valdez oil spill, Chernobyl nuclear disaster, and Three Mile Island situation (Mitler et al, 1988). Adverse surgical outcomes have been linked to fatigue (Gaba and Howard, 2002), and, although little is known specifically about the impact of fatigue on the practice of OR nursing, it presents some unique challenges.

Fatigue

In addition to working a full-time schedule, perioperative nurses often need to take call. Balancing work and personal obligations becomes more difficult, which can force nurses to work without adequate sleep. Lack of sleep impairs one’s ability to deliver safe care. Research has shown that after 17 hours without sleep, performance is equivalent to having a blood alcohol level of 0.05% (Page et al, 2009); it further degrades to 0.10% after 24 hours without sleep (Rosekind et al, 1997). Recognizing fatigue as an important factor in the OR, the Association of periOperative Registered Nurses (AORN) has issued a position statement based on an extensive review of the literature outlining recommendations for safe on-call practices (AOR, 2008).

Experience Level

Another individual characteristic that demands consideration in the designing of a safe OR is the experience level. Like other specialty nurses, perioperative nurses bring varying degrees of knowledge, skills, and experience to the OR. The gap between available experienced perioperative nurses and the needs of operating rooms around the country has required creative hiring and training practices by perioperative leaders. New graduate nurses and experienced nurses from other specialties are choosing perioperative nursing for their career paths. Compounded by the aging surgical patient population and the complexity of modern surgical interventions, orientation and ongoing skill development are crucial to balance the work environment. Addressing this issue, AORN published a position statement “Orientation of the Registered Professional Nurse to the Perioperative Setting,” which provides suggested timelines for orientation of novice and experienced perioperative nurses. These guidelines provide justification for perioperative leaders as they request resources of time, staff, and money. The fallout of this phenomenon is complex; the need for ongoing preceptorship programs can burden the experienced staff who are adding this additional responsibility to their full workload. Training and development only go so far to facilitate transition to perioperative nursing. Novice perioperative nurses who have expertise in other clinical areas of practice also may require special support as they move from being “expert” nurses in one specialty to “novice” perioperative nurses.

Although this section focuses on individual human factors, including fatigue and experience, several other characteristics can be managed by targeting elements within the work system. Human factor limitations and error reduction strategies can be implemented to compensate for them. Some of those factors include the following:

• Humans have a limited short-term memory capacity, so use checklists to reduce reliance on memory.

• Sensory overload in the OR requires staff to be constantly alert to everything around them. Limiting the availability of choices, such as by using unit dose medication whenever possible, can decrease the likelihood of a medication error.

• Cognitive tunnel vision can occur related to stress in high-intensity situations. Using forcing functions whenever possible, such as automatic shut-off valves on warming devices, can mitigate this risk.

Task

According to the Balance Theory, the tasks of the work system affect and are impacted by the individual, technology, and the environment (Carayon and Smith, 2000). The tasks required in the OR must be considered to achieve a balanced work system, necessitating attention to concepts such as the appropriate use of skills, workload, and work pressures.

The ability to identify and prioritize the enormous number of individual tasks required of a perioperative nurse is a skill that evolves along the novice-to-expert continuum. Time pressures, combined with high-level multitasking, are routine. Nurses face significant competition for attention during routine and critical points in a surgical procedure (Christian et al, 2006). The workload in the OR varies and is affected by the need to retrieve additional resources, such as supplies and equipment, and the need to perform safety-related activities, such as “count” and handoff. The requirements of these tasks are physical and cognitive. Standardization and simplification should be the mantra for developing error reduction strategies for the task component of a balanced work system. As part of the “Safe Surgery Saves Lives” campaign, the World Health Organization (WHO) (2008) developed the WHO Surgical Safety Checklist, which can be used to remind the surgical team of key tasks to be performed in the preoperative, intraoperative, and immediate postoperative phases of care (World Alliance for Patient Safety, 2008).

Situational awareness, a concept borrowed from high-reliability organizations (Weick and Sutcliffe, 2001), allows members of the team to have an accurate understanding of “what’s going on” and “what is likely to happen next.” It allows the entire team to be on the same page. Institutions across the country are identifying ways to increase situational awareness in their ORs. Memorial Health System in Colorado Springs, Colorado, identified briefings as the first step in creating situational awareness. The elements of briefing were determined by the Unit Practice Council and were designed into the current “count board,” which offers the appropriate visual cue when in the OR scrubbed and standing at the table (Figure 27-2). Electronic documentation of a physician-led briefing was later added to facilitate the collection of metrics for this process improvement (Figure 27-3). Likewise, during the design and construction of their OR platform, Memorial Sloan Kettering Cancer Center in New York developed the concept of the “wall of knowledge” (Figure 27-4). One component of the wall of knowledge is the “OR dashboard,” which displays continuous real-time data to all members of the surgical team regarding patient information, the progress of the case, and team members.