October Journal Club

[katevaughn]

This month's journal club is presented by Mary Scott-Herring. She chose an article that takes a deeper look into CRNA working conditions and outcomes. This is a topic that is very important to everyone and the longevity of their careers. She composed two great questions too that should elicit some great discussion! Enjoy! 

Here is a link to the article.

The questions to encompass within your response:

1. What do you think about the four common themes identified in the literature?



2. Do you see similarities to our work environment? What do you think we do well and how can we improve in others?

[Ben Waldbaum]

What do you think about the four common themes identified in the literature?
4 themes:
1.) Communication and collaboration: Undoubtedly a source of stress for many as roles, ego, communication style all play a role in creating stress.
2.) Professional role and autonomy: professional overlap and long standing conflict between provider types. Providers want to reach consensus through collaborative discussion as well as be respected and trusted, not out-ranked and over ruled regardless of the validity of their concerns.
3.) Work relations: Partially redundant with number 1 and number 2, but clearly a pervasive challenge
4.) Outcomes: incivility & aggression, combined with theme 1, 2, and 3 can lead to burnout. Both incivility and aggression are ingrained in healthcare and commonly tolerated by both those being victimized and by the enablers. Whether we want to admit it or not, nurses (OR and Floor), technologists, secretaries, call center employees, billing staff, all OR staff, etc depend on a revenue generator such a surgeon to bring a patient to the hospital, which then creates downstream jobs and its associated revenue. With this power, it is quite difficult for administration to address incivility or aggression from a high level revenue generator because those downstream employees are dependent on the revenue generator. Money can cloud judgment.

Combined the 4 themes are a recipe for workplace stress.

Do you see similarities to our work environment? What do you think we do well and how can we improve in others?

Any place that utilizes the ACT will have the challenges described above. Improvement to me goes back to the basics of interpersonal relationships, treat everybody, everyday with respect, no exceptions. If everyone did this, many of these problems would melt away.

[Dahlia Rouchon]

1. My thoughts on 4 themes as identified: a) effective communication is important for idea exchange/collaboration. I agree better communication typically occurs among same providers vs. in between providers of different specialties. Many times there's miscommunication between nursing/anesthesia or surgery and nursing staff. I agree sometimes there's decreased communication between CRNAs as related to unintentional and less stellar handoffs. It was mentioned there is a percentage of ACT practice of > 50% CRNAs' attitudes on collaboration being decreased, and role conflict being increased. I wonder if this is due to conflicting expectations not being fulfilled?
b). On personal identity/autonomy I wondered why there was this threat of personal identity? Is 1 provider encouraging another provider to be unsafe? As a result, the other's ability to protect the patient is compromised? If the team knows each other's practice/knowledge base/vigilance then trust is established and no sense of "threat of the identity exists". Problems arise when providers do not know each other's practice, or disregard of the CRNA occurs for illegitimate reasons. Communication is key as mentioned to de-escalate and collaborate in plan of care.
c). In regards to work relations of CRNAs, I agree there's increased level of stress of CRNAs vs other professional groups when personal objectives may be different than the requirement of patient safety needs. Effective communication in respect of the role of the CRNA
alleviates this issue.
d). CRNA outcomes- I agree burnout can increase aggression and incivility can affect job satisfaction when coupled with increased job demands and stress related effects of our profession occurs on the CRNA.
Similarities to work environment, what we do well? As related to discussion mentioned, each individual's perspective will differ due to their own interpersonal relationships with providers. Frequency of collaboration due to cohort/posting helps build relationships and understanding between providers/trust. Areas to improve can be on establishing effective communication when working with different providers no worked with regularly.
Related to CRNA outcomes, we do well in that we are offered a variety of cases loads to try to decrease stress on the provider, i.e. if a person had a heavy clinical day, the next day typically is a bit "lighter". Overall as a whole we do well on offering breaks to each other.
What can be improved upon is for the individual provider to be more vocal on when help is needed, or support is necessary. Great article!!

[Jessica Switzman]

1. Effective Communication is essential for effective outcomes. In order to collaborate, we must listen effectively to one another. Professional identity and autonomy are not compromised when we respectively communicate and collaborate with each other. Work relations in a ACT require both parties to commit to the case at hand and work together, rather than one person taking on more of the work. Positive outcomes, decreased stress and burnout, come when we respect and communicate effectively with one another.

2. As with any ACT these stressors do exist in our workplace but I don't feel they are excessive. I try to treat my colleagues with respect and in turn expect the same.

[vania]

1.)I think communication and collaboration are the keys to solving many of these other issues. I have always thought that 75% of anesthesia is learning to work well with others, especially those with more "difficult" personalities This becomes even more of a challenge in a huge institution like Hopkins, where it is nearly impossible to get to know everyone well and establish a good, trusting work relationship.

2.)Hopkins also has many different providers that allow extreme variances in CRNA autonomy and independence. We all know how good it feels to be with someone that openly supports us, allows plenty of say in the plan for the cases and refuses to micromanage. Unfortunately, providers vary greatly and even go to the other extremes of behaviors, like blatantly ignoring you for the entire day (including breaks!) and/or basically doing the case themselves while you just stand there feeling useless. These days are awful and are extremely detrimental to feelings of satisfaction and personal identity. I'm all about compromise, but I am not happy when the compromise is one sided...

3.)Let's face it, we have stressful jobs. When we can't rely on our colleagues to support us, or if there is open animosity, or we feel pressured to provide care we don't agree with, or we have no relief in sight when we're supposed to be heading home to our families, work relations and our levels of tolerance are severely diminished.

4.)Incivility, burnout and workplace aggression are real in many institutions. Thankfully I've had minimal exposure, but the few occasions have made me want to run out of here and never come back I really think that more focus on communication and mutual respect are critical. If an ACT is truly intended to be a true mix of autonomy and collaborative practice, then we have some work to do to get there.

Overall, my experience is that most CRNA's and anesthesiologists work well together. There are obviously those that are more challenging to deal with and require a more than fair level of compromise and/or workload on our part and those days I am less satisfied. On a regular basis though, I work with the same core group of people, so this allows a much greater level of trust, respect and mutual collaboration that everyone wants.

[jhadley]

1. Collaboration/communication: This is a central component of our job and one that is almost as nuanced as anesthesia. With such a large department I think it is challenging to effectively communicate/collaborate 100% of the time. Most providers collaborate well but there are a few who direct rather than collaborate.

Professional identity and autonomy: I agree with Vania's statement that there can be a great degree of variance in autonomy depending on who you are working with on a given day. For the most part I feel a good degree of autonomy in my day to day practice, however I do agree when I am being micromanaged and underappreciated it definitely makes me feel dissatisfied.

Work relations: It is critically important to have a good working relationship and feel supported by colleagues. I think having the CRNA coordinator role has really helped improve working relations between the CRNA group. It is helpful to know that there is someone who is helping ensure breaks happen and that we get relief in a timely manner as well as a resource of information if need be.

CRNA outcomes: The reality of this professional is that it can be quite stressful which can lead to incivility, burnout, and workplace aggression. We also face balancing keeping patients safe, production pressure, and managing challenging personalities which also can effect job satisfaction and lead to burnout.

2. I can definitely identify with some of the challenges that have been expressed in this article. I think for the most part our department functions well with ACT model, unfortunately a few chronic outliers exist. As others have mentioned, the formation of cohorts has enabled us to form closer working relationships with providers helping enable trust and respect between providers.

[Moishe Mayer]

I feel that communication and collaboration are often the key too many problems. Whether it be within ACCM itself, or amongst the other disciplines. The literature has addressed failure in communication in many professions. We have all seen comparisons between aviation and healthcare, and the need to improve communication. The key behind all communication is true respect for each individual. Effective and consistent communication will not be sustained without mutual respect.
Regarding the second factor of professional identity and autonomy, I believe this problem is present for CRNAs more than any other specialty “non-physician” field (barring primary care NPs). The reason being that CRNA is the only specialty field where the non-physician practitioner has an identical scope of practice to their MD counterparts. Hence, it is no wonder we often find CRNAs that feel their professional identity and autonomy are compromised. The only resolution for this is to grant CRNAs autonomy and the ability to practice to their full SOP. To push for federal and state recognition of our SOP. Did you know that in Pennsylvania and New York, CRNAs are still not considered APRNs?! In Maryland, CRNAs do not have prescribing abilities. It is difficult to maintain a professional identity with so many variations between states. It is easy to lose our identity if we do not have a strong professional identity on a federal or state level.
I also believe that these four issues will be found in every ACT setting.

[nanci]

1)Collaboration/communication: effective communication and collaboration to exchange ideas and work together in the best interest of patients. This is really at the core of our ACT practice. Learning to work with others, being flexible and dynamic, having the ability to self-assess and work with so many different ideas/attitudes/personalities with patient care as primary focus. Can get difficult when the amount of new people one works with increases (agree with article on this).

Professional identity/ Autonomy: Interesting that over 60% of conflict resolved through compromise and avoidance- thought it would have been much higher as in ACT and so many different providers my thoughts would be that compromise would account for a much higher percentage. 24% not accounted for so assume that was escalated communication (seems about right to me). Agree that threats to identity are deemed intractable- very difficult for anyone to respond positively to professional and personal threats (in aspect of clinical and professional attributes and decision making). As compromise is greater than 50% of conflict resolution makes sense that providers experience moral distress and think of leaving the field. Should be promoting each other and reinforcement of knowledge/ideas/ process as CRNA's to maintain professional identity.

Work relations of CRNA's: When scope of practice is restricted it can definitely lead to occupational and personal stress when one is then required to perform something that has been restricted from them for a long time. Avoidance of these situations is reasonable but definitely a stressor. Greater work loads/requirements, doing more with less clinically, feeling production pressure, being rushed can all create concern for not only patient safety but also puts a lot of personal stress on that provider. I'd say self-reported stress among CRNA's is definitely underreported.

CRNA Outcomes: Workplace stress and aggression definitely happens. Some disrespectful behavior may happen unintentionally or providers do not realize that their manner of speaking or their actions to others are as hurtful as intended. Couple someone being aggressive with your own workplace stressors and incivility and even more disrespectful behavior will occur. Being held over late often and micromanagement of time/performance can quickly lead to burnout and dissatisfaction.


2)Similarities/improvement: I think everything covered in this article are directly relatable to our positions here in an ACT practice- great article bringing it to the forefront and putting a name on the themes. I would like to believe that everyone who reads it and works here can relate to all aspects of the described CRNA working conditions, workforce outcomes and the complex nature of our careers. Our institution can definitely do a lot better with workplace civility, increasing autonomy, evening out workloads, better distribution of stressful cases, etc. I think that formation of the CUSPs and allowing providers to start working more regularly within groups has been helpful in decreasing some workplace stress and improvement of interpersonal relations which help with communication and formation of mutual professional respect. We can definitely improve by helping to decrease stress, looking out for one another more, standing with each other instead of against each other, being more helpful, etc... More frequent CRNA group meetings to help identify, discuss, improve workplace stressors and more open communication can be something that would help this environment. Too often things are left unsaid or people go home upset/stressed because they avoid discussion, do not want to introduce stress on others by having discussion or bringing up things that they are unhappy about. We really have a lot of room for improvement to help decrease stress. I think a Wellness committee was instituted which may be a way to focus and give support.

[Fara Lekhnych]

I think the four themes presented can be applied in any career field to assess for job satisfaction. In our field in particular, we collaborate with so many other disciplines, all of which come together to plan and execute patient care. Communication is a vital key in any relationship, particularly with colleagues; both of these can have a profound impact on job satisfaction as it relates to the process as well as the final outcome. Professional identity and autonomy are closely tied in with a sense of self. Many people in our field find a great sense of pride and accomplishment from being a CRNA, which increases self esteem therefore increases production and the quality of care provided (although not exclusively). Being in such a specialized and high-stress field, it is important to have other colleagues who are able to provide avenues for stress relief, and to support and be supported by professionally and personally. Each of these factors are ranked in importance differently for each person. Normally, it is always likely that there will be some sort of negative disruption to any one of these factors, but a significant negative imbalance in any combination that cannot be resolved can lead to job dissatisfaction to the point of leaving a job or the profession all together. The results of this study on outcomes is interesting and thought-provoking.


In our institution I think the CRNA's have a pretty good collaborative relationship amongst ourselves in terms of civility, professionalism, and overall efforts to take care of and support one-another professionally and personally. I personally have experienced many people going out of their way for me and going above and beyond, which makes me feel appreciated and grateful to be apart of such a great team. I think the CRNA/MD relations is good, although can be improved relatively speaking. We do have room to decrease stress and improve relations, as previously stated, but I believe discussions such as these can be the impetus to improvements in the system.

[Kristen Praesel Lang]

1. What do you think about the four common themes identified in the literature?

Collaboration and Communication – Collaboration and communication are most important in the work place to all parties involved. This practice can both avoid and solve most problems that arise in any work environment; however, it is especially significant in an environment like the operating room in which multiple departments are working together to service one patient. Collaboration and communication are key in demonstrating mutual respect between providers and in maintaining professional satisfaction.

Professional Identity and Autonomy – This can vary from each individual provider to another. Overlapping skills/duties, level of provider experience (on both sides), level of autonomy, level of trust, and general expectations of each provider’s duties for the day are all factors affecting this theme on a day to day and provider to provider basis.

Work Relations of Certified Registered Nurse Anesthetists – Working relations between providers can undoubtedly ease stress and promote satisfaction in the work environment. This ties into communicating well with your colleagues on all sides of the aisle and will also vary day to day depending on who you are working alongside. Even when the job is stressful, simply interacting with another CRNA colleague (on a break or in passing during case turnover) can help mitigate a provider’s level of stress.

Workplace Aggression – Behaviors including verbal abuse, bullying, conflict, or threatening behaviors will all lead to professional dissatisfaction. These behaviors are compromising to all participating and witnessing parties and will increase provider turnover in addition to increasing stress.


2. Do you see similarities to our work environment? What do you think we do well and how can we improve in others?

I think overall our group functions well in the ACT module. As with any work environment and any work profession, there will always be a few outliers that create discord. I aim to treat my fellow staff (regardless of position and title) with the same respect that I appreciate. As I mentioned previously, the issues can change day to day depending on who you are working with each day and the working relationship you have developed with that provider. Indisputably, solid communication can avoid and solve problems that arise in the OR and mutual respect between providers is paramount.

[Soo-Ok Kim]

1. What do you think about the four common themes identified in the literature?

Collaboration and Communication-This is the most important factor for safe practice in multidisciplinary care setting.
Professional Identity and Autonomy- I believe self professional identity is more important than the one defined by other source. Conflict between different job can happen when there is confusion about the role of each professional.

Work Relations of CRNA-This can be good or bad; if providers have similar goal in their mind, it can be positive relationship between groups. if not, that can create unforeseen conflict.

Workplace Aggression-Lack of respect of individual or group, overwork, misunderstanding/ignorance of one's role can encourage workplace aggression. There should be some mechanism in place to address such behaviors.

2. Do you see similarities to our work environment? What do you think we do well and how can we improve in others?
Overall, collaborative practice works well. However, there is role confusion or ignorance of role exist (who should do what, what is the expectation of each providers..). Sometimes, there are two many people involved in simple decision making process and this can lead to communication failure and some contention between providers. This is more frequent if each providers are new to each other. The goal, plan and expectation has to be discussed at the beginning of the day, so there is clear understanding for what needs to be done.

[emedina1]

I agree that effective communication exchange and collaboration are very important ingredients in any discipline.
As we practice our specialty we develop our strength and also realize our weakness. Then we have identity and therefore autonomy.
This will bring about our response to all situations and therefore our ability to develop our relationship to others .