January 2, 2008

The Impact of Multi-Skilled Staff Availability on Day Surgery Cancellations

By Lloyd, Helen

KEYWORDS Day surgery / Multi-skilled / Theatre utilisation This paper outlines a study undertaken by Helen Lloyd to assess the impact of multi-skilled theatre practitioners on reducing cancellations in stand alone day surgery units in England and Wales. The author provides the background to the study together with an overview of the results. The literature review undertaken before the study is published in full. It identifies what factors influence the efficiency of day surgery and operating theatre facilities, traditional staffing of operating theatres and day surgery facilities, together with other influencing factors for theatre utilisation. The author recieved partial funding from ERFF to complete her MBA in Health Service Management at Greenwich School of Management (accredited to University of Hull) in 2007.

Introduction and overview

The Norfolk and Norwich University Hospital NHS Trust (NNUH) is committed to rebuilding Cromer Hospital on its existing site by 2010. There is now a clear opportunity to ensure that the services identified in the full business case will be focused on the needs of the local population. The drive towards providing comprehensive services for patients 'closer to home' is based on ensuring that staff employed at Cromer will have the appropriate skills and competencies required to support and treat patients.

The current facilities are not designed to provide a 'seam/ess' patient journey through the perioperative care areas. The theatre and ward areas are both physically and managerially separate and this has led to situations in recent years where there has not been enough trained staff available to assist in other areas when staff have had unexpected absences.

The purpose of the research project was to assess the impact of the availability of qualified and competent multi-skilled nursing and technical staff in the workplace on reducing the number of operating sessions cancelled in 'stand alone' day surgery facilities in England and Wales. This question was selected to examine what is happening nationally and to use any recommendations to influence the development of the workforce plan for the hospital services following the redevelopment.


The postal questionnaire, distributed nationally to 244 day surgery facilities in England and Wales in May 2007, used both qualitative and quantitative research methods to obtain data and commentaries about the opening time, staffing establishments, session usage and skills shortages within the day surgery facilities. Feedback was also obtained about the availability of training for staff, and issues of morale and motivation. Information was also requested about the number of cancelled operating sessions between April 2006 and March 2001 and the reasons why those lists were cancelled.


The overall response rate was 27.4%. However the responses provided a large amount of data, which was analysed and coded. Data analysis focused on four main areas. These were:

* Six day surgery facilities which reported cancelled operating sessions due to lack of appropriately skilled staff.

* Nine day surgery facilities with only one dedicated day surgery operating theatre.

* Analysis of the qualitative data provided in the questionnaire responses to determine the three key emerging themes from the data.

1 The challenges which have faced these units in terms of recruitment and development of multi-skilled staff and consideration of what internal change management is required to develop a multi- skilled force from existing staff groups including the impact of job satisfaction and morale.

2 The proactive measures undertaken by units to improve the situation in terms of recruitment and development of multi-skilled staff.

3 The organisational behaviour of different teams within an organisation who may be required to work more closely together within the preoperative setting.

* Qualitative data analysis to determine the other reasons for operating lists being cancelled. This area provided the most interesting and informative data for discussion and analysis.

The Healthcare Commission report Day Surgery: Acute Portfolio Review (2005) and the Newchurch Review (2005) recommended a system to reallocate planned cancelled sessions to surgeons. However, it was not clarified or explored how this system should be managed. The allocated surgeon not being available, usually a planned event, was identified in this research project as the predominant reason for an operating session not taking place, and was responsible for 63.1% of all cancelled sessions, while an anaesthetist not being available was responsible for 4.7% of cancellations in this research. The number of sessions cancelled due to lack of available nursing and technical staff was 0.06%, which was statistically insignificant.

Recommendations of the study

Recommendations have been made from analysis of the research findings. These include internal and external recommendations. Internal recommendations include a complete review of the skills and competencies of existing perioperative staff at Cromer Hospital to ensure that the right competencies are being developed. Issues of staff morale and motivation were identified in the analysis and staff will need to be involved in this process. Involvement of the service users (i.e. the potential patients who will use the new facility) is recommended in a series of patient focus groups to enable their views to be accommodated in the workforce plan.

External recommendations include the need to reduce the amount of sessions cancelled due to the lack of medical cover because of annual leave, study leave and professional leave. The under- utilisation of day surgery facilities and nursing staff due to lack of surgical cover is unacceptable in the 'business' of healthcare and would not be acceptable in other areas of industry and commerce.

The author recommends this area be examined in consultation with the national day surgery interest groups and the medical profession.

The literature review

(a) Other factors influencing the efficiency of day surgery facilities

The literature review highlighted research projects, which identified factors related to the efficiency of day surgery theatres. These needed to be recognised in order to ensure the other extrinsic factors, which could influence the efficiency of units were noted. Ensuring the availability of multiskilled staff may not solve all the issues surrounding efficiency in the day surgery facility.

Guglielmo et al (2002) and Diers and Pelletier (2001) both demonstrated that the introduction of computerised scheduling systems into theatres improved utilisation and efficiency. This enabled managers to identify areas within the patients' clinical pathway through the operating theatre journey where there were 'bottlenecks' which caused the list to stop or slow down. The research enabled additional resources to be provided in the areas: for example, extra first stage recovery staff. This allowed patients to be recovered in a more timely manner and return to the ward to recover prior to discharge. The ability to improve efficiencies through the use of information technology was a relatively new concept and allows the reviewer to replicate the research in his or her own clinical area.

Bowers and Mould (2005) undertook research, which demonstrated that separating elective and emergency work resulted in ensuring elective surgical sessions ran without delay and theatre utilisation was increased. It was an interesting project which reinforced the current trend within the NHS in clinical surgery where elective surgery cases are undertaken separately from emergency operating theatres. It ensured the elective work continued without interruption and without a loss of available resources such as operating capacity or clinical staff.

Concerned about the inadequate utilisation of operating theatre facilities in their facility, Cole and Hislop (1998) undertook a trial of grading proposed elective surgical cases prior to surgery to indicate case length and this ensured operating sessions were much more efficiently utilised. Utilisation rose from 70% to 98% and had a corresponding impact on reducing the waiting list time for surgery within the trust. This study demonstrated that in elective care, where surgical cases are more likely to be less complex, such a system can increase theatre utilisation. However, this system is already used by surgeons in most clinical specialities including Cromer and although they can influence the overall efficiency of a session it cannot reduce the threat of cancellation due to lack of appropriately trained staff.

(b) International studies on the influences of staffing of operating theatre

The literature review illustrated an international problem with ensuring suitably qualified staff to ensure efficiency and good utilisation in operating theatres. In Northern Ireland, Payne (2001) reported that less than two thirds of available operating sessions were used due to lack of appropriately skilled theatre staff, although there was no discussion about how the situation could be resolved, except for promoting recruitment from abroad. The research also did not include any recommendations on how internal changes could improve the situation. A study in Barbados undertaken by Jonnalagadda et al (2005) highlighted the lack of suitably trained staff as accounting for 11% of all cancellations of elective cases and promoted the multi-skilling of staff in this case. It concentrated on the development of in-house training and also efforts to ensure that once trained the staff remained in post. (c) Traditional staffing of operating theatres

Traditionally, in the United Kingdom, operating theatres have been staffed by operating department assistants (ODAs) who underwent in-house basic training in conjunction with the City and Guild Training Forum to enable them to work alongside anaesthetists in the care of unconscious patients. Trained nurses and support staff have both been employed to staff the operating theatres and recovery areas. It has enabled both groups to develop a high level of dexterity and skill in order to deal with highly complex operative procedures. The first comprehensive report into the use of operating theatres in the United Kingdom took place in the late 1980s. Bevan (1989) was originally requested to undertake research as a response to the lack of suitably trained staff to cope with the increased demand for operating theatre sessions. He made several recommendations in how operating theatres should be managed and he also made recommendations on how they should be staffed. He recommended that the two distinct roles of nurses and ODAs should be merged into a unified grade in order to introduce greater flexibility. Bevan saw the benefits of multi-skilling in this way as reducing costs because it creates a larger pool of staff that can provide cover for each other. This reinforced part of the research question being examined in this research. Bevan concluded that it also reduced session cancellations because staff can cover each other to perform roles as needed.

Purpose-built day surgery units are able to streamline the patient pathway

Interestingly, Bevan also saw it as bringing 'all the benefits of team working' and some trusts quickly adopted this way of working. Shannon (1999) reported that following the recommendations of Bevan, the acute trust he worked for in East Anglia moved to a common pay spine, invested in a formal programme of education and training for its theatre staff, leading to the development of a highly qualified and multi-skilled workforce. He reported that it enabled the trust to have a greater flexibility in the way it staffs theatre sessions and allowed staff to develop a broader range of skills. The trust had also seen positive results from this, the theatre team had a high staff retention rate and low staff sickness rate compared to the rest of the trust.

This can be seen as reflecting the theories of job design discussed by Hackman and Oldman (1980) and influencing job motivation and satisfaction as a determining factor highlighted by Maccoby's social theory (1988).

(d) Staffing of day surgery facilities

Over the past twenty years the recommendations made by Bevan (1989) on the development of roles have been developed by some trusts. Since the early 1990s and the establishment of designated 'stand alone' day surgery this concept has proved the basis of many workforces in day surgery facilities (Audit Commission 2001). As surgical techniques have developed so had the emphasis on reducing inpatient beds and the interest in letting patients recover in the comfort of their own homes. Therefore the move towards day surgery had produced several reports, which have promoted the best methods for utilising sessions and improving efficiency (Healthcare Commission 2005, Newchurch Review 2005).

Surgery in day surgery facilities was usually routine and of minor complexity. Day surgery facilities, which have been developed from existing facilities and also purpose built units have been able to streamline the patient pathway in order to make best use of the facilities. This had also allowed staff to be encouraged to multi- skill both in the operating theatre (as promoted by Bevan) and also into the ward and preassessment areas, promoting the role of the truly 'multiskilled day surgery practitioner'. The results of the Healthcare Commission Report (2005) and Newchurch Review (2005) seemed to demonstrate that the smaller the day surgery unit the more efficient it was. However, as seen in Cromer, the smaller the staffing establishment, the more emphasis existed on ensuring staff were multiskilled and able to cover each other's absences.

Another interesting factor revealed in the literature was one aspect of the results of qualitative interview research into the day surgery patient experience undertaken by Otte (1996). It showed that patients do not like having a continued changing of the staff who cared for them in day surgery facilities. The continual 'handing over' from practitioner to practitioner in each clinical area was not reassuring for them. The author's own experience shows that in her day surgery facility, where staff rotated throughout the department escorting the patient from admission, anaesthetics, theatres, first and second stage recovery and discharge, resulted in both patients and staff feeling more satisfied. As well as increasing efficiency and utilisation it had the potential benefits of increasing patient satisfaction. In the recent emphasis of the healthcare standards and the focus on patient participation, this consideration had become increasingly relevant but the lack of research in this area of patient care is noticeable in the literature review.

(e) Studies of theatre utilisation: other influencing factors

For several years until 2004, the British Association of Day Surgery (BADS), with the support of an audit organisation, Newchurch, undertook an annual and fully comprehensive research into the performance of day surgery units in the United Kingdom. Apart from the Healthcare Commission report, Day Surgery Performance (2005), this was the only recent national report comparing day surgery units' performance. Unlike the Audit Commission report which was compiled following a mandatory retrospective audit of all NHS trusts in England and Wales, the BADS research was undertaken by participating trusts who 'bought' into the audit. The aim of the research was to encourage benchmarking between trusts and to identify elements of good practice for trusts to replicate.

Forty per cent of respondents reported losing over 15% of their theatre sessions

However, due to the 'buy-in' nature of the research it could be argued that only trusts who were interested in improving their performance in day surgery would participate in the research, and therefore they were already more advanced in their proactive management of day surgery utilisation. Therefore the reliability of the sample could be questioned. However, a review of the latest report Day Surgery Performance Review 2003/2004 (Healthcare Commission 2005) provided some interesting discussion on staffing and productivity relevant to the research question posed in this research.

Forty per cent of respondents reported losing over 15% of their theatre sessions for planned (including medical staff leave) and unplanned reasons. Fifty-three per cent of respondents reported losing more than 5% of theatre sessions for unplanned reasons, such as staff sickness and lack of equipment. Interestingly, the results of the review also indicated that trusts that performed poorly, for example had a larger number of cancelled operating sessions, had comparatively large numbers of staff designated to the day surgery unit, whereas the best performing trusts have small staff bases. Furthermore, in contrast to the poorly performing trusts, the best performing trusts have comparatively few beds, trolleys and reclining chairs which, according to the review, suggests that small day surgery units promote streamlined and efficient management. Although the day surgery unit at the NNUH site participated in this research the performance of the Cromer Day Surgery Unit was not considered in isolation or within the trust response so specific data cannot be identified.

Developing teams in perioperative care

The review indicated that if the decision to merge the day surgery theatre and ward staff was made in Cromer hospital then the importance of planning the change was imperative to ensure it was successful. Pickett (1995) described the 'the progression of any enterprise is dependant on relationships among members of the group'. His research concentrated on the process of merging medical teams in the USA and concluded that the smaller the teams to be merged the more likely the merger would be to succeed. Macdonald (1999) described a longitudinal study of 11 members of a day surgery facility nursing team. The research showed that the self-managed team had a higher morale than other clinical areas, were able to expand their roles and also increase efficiency within their facility. The study, undertaken to assess the validity of self management within a small team echoes most of the literature found in the review which indicated the smaller the team the easier it was to lead and develop it into a multi-skilled workforce.

The emphasis of the literature review did not specially look for research on the size of perioperative teams but these two studies had determined that a 'small' team could both merge and develop in a more cohesive manner. However, there seems to be no agreed definition of what is a 'small team' therefore the data cannot be fully corroborated.

One of the unexpected consequences of the work of Potter et al (1994) saw that when using Total Quality Management to improve organisational performance in an operating theatre it actually enabled the theatre staff to feel more confident in developing internal and external links within the organisation. It also provided a more effective communication between staff groups identified as medical staff and the nurses and ODA/ODP group and therefore promoted the development of multi-skilling staff in different clinical areas within the operating theatre. National and international focus

The recent interest in the subject of efficient utilisation was identified. Kmietowski (2003) reported that on average 6% of elective admissions were cancelled before they were due to take place in the United Kingdom due to reasons such as lack of theatre time or suitably trained staff. The impact of the lack of appropriately skilled staff is widely reported. Payne (2001) indicated that the underuse of operating theatres in Ireland resulted in four out of 10 theatres in one hospital been left vacant due to lack of appropriately skilled staff. Their solution was to look to Australia for staff and to send patients abroad for treatment. There was no mention of the steps been undertaken to promote dealing with the situation 'in house' by multi-skilling.

In the USA, where there is a clear financial emphasis in ensuring operating time is fully utilised, it is ensured that the multiskilling of staff for routine cases has been widely discussed and researched. Research undertaken by Dexter and Epstein (2005) reported that in order to reduce the cost of surgical treatment in public facilities, the ability to ensure staff could undertake several key roles during the perioperative patient journey reduced the need for as many staff.

Wurstner et al (1995) redesigned roles in perioperative care in Dallas and the outcome of the redesign process was the creation of a multi-skilled worker whose presence had resulted in increased physician and perioperative nurse collaboration and increased operating theatre efficiency, supported by the provision of improved information technology. Clinicians were seen to take a more active role in preparing equipment and patients for minor cases, relieving the nursing staff who could then concentrate on recovering the patients after the procedure. Van Cleave and Scherffius (2002) in another study in the USA also highlighted the positive influence of teamwork success of developing multiskilling in the operating theatres.

Summary of the literature review

One of Bevan's (1989) main recommendations was that developing multi-skilled staff would bring out all the benefits of team working and the literature review has broadly supported this.

The tools to assist departments to develop a flexible workforce do exist. For example Tackling Cancelled Operations (NHS Modernisation Agency 2002) is a document developed to assist in providing frameworks for trusts to consider. However, the use of documents such as this in a comparatively small workforce would need to be considered carefully before implementation.

This literature review, as well as supporting the research proposal, has indicated that undertaking the research may also result in the determination of other factors which may be incorporated into the perioperative care service redevelopment at Cromer Hospital - for example staff participation in role development. The literature review has produced some interesting discussion about the potential positive developments in multi- skilling staff in small teams and small units.

Summary of the study

Following an extensive review of the available literature and the undertaking of a piece of primary research the author has concluded that the impact of the availability of qualified and competent multi- skilled nursing and technical staff in the workplace on reducing the number of operating sessions cancelled in 'stand alone' day surgery facilities in England and Wales is high. Of all the main reasons explored for determining why operating sessions are cancelled, the lack of available competent staff had the least impact. It has been challenging to determine from the responses whether it is by skilled use of effective skill mix/training and staff allocation that this has been achieved or whether it is simply 'luck'.

The continued drive towards providing patient services in facilities within the community means that the need to plan ahead and ensure staff have the correct skills for service developments is critical.

The research data reinforced the findings of both the Healthcare Commission Report (2005) and the Newchurch Review (2005). The continued under-utilisation and cancellation of planned operating theatre sessions due to the unavailability of clinical staff (mainly surgeons) was extremely disappointing and consideration to both internal and external recommendations to ensure that this issue is openly discussed between clinicians and general healthcare managers and a solution sought is imperative.

The smaller the staffing establishment, the more emphasis existed on ensuring staff were multi-skilled

The impact of the availability of multi-skilled staff in the workplace on reducing the number of operating sessions cancelled is high

Of all the main reasons explored for determining why operating sessions are cancelled, the lack of available competent staff had the least impact


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About the author

Helen Lloyd

MBA, BSc (Nursing), RGN, ENB 998/176, DMS

Service Manager, Cromer Hospital

Copyright Association for Perioperative Practice Jan 2008

(c) 2008 British Journal of Perioperative Nursing. Provided by ProQuest Information and Learning. All rights Reserved.