Using a systems approach to evaluate a circulating nurse's work patterns and workflow disruptions

Highlights

• An operating room layout can influence work patterns of circulating nurses.

• Smaller zones may predispose circulating nurses to more flow disruptions.

• Layout can influence travel distance and number of zones travelled through.

• Physical environment is an influential element of the work system.

Abstract

The physical environment affects how work is done in operating rooms (OR). The circulating nurse (CN), in particular, requires access to and interacts with materials, equipment, and technology more than other OR team members. Naturalistic study of CN behavior is therefore valuable in assessing how OR space and physical configuration influences work patterns and disruptions. This study evaluated the CNs' work patterns and flow disruptions (FD) by analyzing 25 surgeries across three different ORs. The OR layouts were divided into transitional and functional zones, and the work of CNs was categorized into patient, equipment, material, and information tasks. The results reveal that information tasks involve less movement than other types of work, while across all ORs, CNs were more likely to be involved in layout and environmental hazard FDs when involved in patient, material, or equipment-related tasks compared to information tasks. Different CN work patterns and flow disruptions between ORs suggest a link between OR layout and a CN's work. Future studies should examine how specific layout elements influence outcomes.

Introduction

Operating rooms (OR) are dynamic work systems whose functioning involves complex interactions between surgical team members, patient characteristics, surgery type, tasks that need to be performed, equipment and technology used as well as the physical environment in which the work is performed. This is also a high-risk patient care environment. In industrialized countries, 3%–16% of inpatients experience major surgical complications, with mortality between 0.4% and 0.8% (Anderson et al., 2013). Problems with teamwork, communication, equipment design, or tasks have often been associated with these adverse outcomes (Gawande et al., 2003; Greenberg et al., 2007).

The study by Karsh et al. (2006) on a human factors engineering paradigm for improving patient safety suggests that in order to improve patient and staff safety in healthcare settings, there needs to be a better understanding of how the work system impacts the healthcare professional. They argue that healthcare systems which support healthcare providers’ performance and reduce hazards will result in improvements in patient safety outcomes (Karsh et al., 2006).

The surgical process is complex, dynamic, and requires coordination between surgical team members throughout the surgery. The circulating nurse (CN) plays a key role in anticipating and supporting the needs of other team members (Simmons et al., 2009), such as the scrub nurse, the surgeon, and the anesthesiologist (Ritchie, 2009). Also, the CN plays a key role in protecting and maintaining patient safety (Alfredsdottir and Bjornsdottir, 2007) throughout different phases of the surgery by ensuring that the surgical protocols are in place when staff is handling the surgical tools in the preparation phase and providing the necessary care in the intra-operative phase (Spry, 2009; Yang et al., 2012). Thus, the CN's work is deeply impacted by all the components that make up the work system. The CN works outside the sterile field, acting as the link between sterile and non-sterile, supplying equipment, materials, and information to the surgeons and scrub nurse at the operating table, and accessing other resources in the surgical suite beyond the OR (Kang et al., 2015). They require access to appropriate storage and information systems; must have space to prepare or hold information and items; must maintain sterility; and must avoid knocking or bumping into other people or equipment in the often crowded OR. Thus, the locations of equipment, materials, the OR team, and communication devices can impact the performance of the CN, especially once the operation is underway. Configuration of zones designated to perform such activities can influence the CN's ease of access to areas they constantly travel to as well as travel distances and time spent on performing their activities.

Distraction, interruptions, and layout issues are frequent occurrences during most surgical procedures (Palmer et al., 2013). One study of cardiac operations found an average of 100 flow disruptions (FD) during a cardiac procedure (Palmer et al., 2013). In another study, Wheelock et al. (2015) found that intense equipment distractions were correlated with higher stress levels for scrub nurses. Additionally, an analysis of 731 reported medication errors in ORs showed that distractions and interruptions were associated with 48% of surgical errors (Beyea et al., 2003). These FDs can be attributed to various factors including communication breakdowns, environmental hazards, equipment malfunctions, and the layout of the OR (Palmer et al., 2013). The CN is the most ambulatory surgical team member and potentially impacted by and involved in a range of flow disruptions. However, no studies have explored how flow disruptions may impact the work of the CN.

The purpose of this study was to examine the difference in movement patterns of the CN and disruptions to the CN's workflow while performing different types of tasks in three OR environments. This study sought to explore the locations in which work was done, the transitions required, and distances travelled between different locations, as a function of the tasks, surgery, and OR layout. This study uses the interrelationship between the factors within the work systems as the basis for the approach. This analysis was done within a systems-framework by analyzing tasks and the environment while controlling for the person-role. The tools and technology as well as the organizational factors were relatively consistent across the surgeries as they were all within the same organization with similar equipment in each OR. The research team also examined the flow disruptions experienced during these tasks; their classification; how they signified deeper systems problems; and how they related to surgeries, tasks, and OR layout. This is one of the first studies to use an evidence-based approach to explore the interaction between OR layout and task requirements.