Factors motivating

nurses to work in the OR

Kathleen A Lamb, RN

Kathleen A Lamb, RN, MS, is an OR staff nurse at Veterans Administration Hospital, Buffalo, N Y . She is a graduate of the E J Meyer Memorial Hospital School of Nursing, Buffalo, and received her BS and MS degrees in nursing from the State University of New York at Buffalo.

What influences nursing students to select the operating room as their area of specialization? Close association with a relative or friend in similar practice, exposure to the operating room within the nursing curricula, and opportunities to reflect personal goals were noted in a study of 200 registered nurses practicing in the operating room.

Research into what motivates people to do what they do, become what they wish, or reach goals is at times kaleidoscopic in nature. Lewin, Young, Adler, Rogers, Maslow, Jung, and Rank provide the basis for the work of Super, who relates the concept of self to motivation and career develop- ment.’

The concept of self has its roots at birth. Subsequent learning experi- ences provide secondary perceptions about oneself and relationships with others. To conceptualize one’s view of oneself requires that the person recog- nize himself as a distinct individual.2 As the individual matures, he tests himself in many ways, most having implications for educational and voca- tional decisions. The process begins with self-differentiation as a part of a person’s search for identity. At the same time, a process of identification occurs with the like-sexed parent or parent substitute. Here, the child de- velops an image of himself and of the behavior appropriate to culturally approved sexual norms. The child pro- gresses from identification with gen- eral models to specific models.

In nursing, the parallel may be that prior to the nursing student experi- ence, the individual was encouraged or even expected to mirror the success or interest of a relative or close friend. Perhaps indecision in the selection of another career was a deciding factor in the selection of nursing as a vocation

1338 AORN Journal, June 1977, Vol25, No 7

and the operating room as an area of specialization. This does not mean that nursing was an afterthought or the career pursuit accidental. It only im- plies that the nursing student may have been influenced by the process of identification with a relative or close friend and seeks to emulate that per- son’s achievements or behavior. This may be the impetus tipping the bal- ance in favor of nursing in the operat- ing room. This role playing may be an important factor in affecting the growth of self-concept and the change in self-image, and it may stimulate a chain of events having vocational im- plications that may not have occurred otherwise.

Super views behavior as a reflection of an individual’s attempt to imple- ment his self-concept by entering the occupation he believes will permit self-expre~sion.~ He further states that satisfaction from work and life in gen- eral depends on the extent to which the individual realizes adequate out- lets for his abilities, interests, person- ality traits, and personal values in his chosen occupation. Based ’ on these premises, this investigator believes that the motivation responsible for a nurse choosing to practice nursing in the OR must reflect his or her personal goals.

In addition to providing oppor- tunities to practice new knowledge and enhance skills, learning experi- ences for nursing students are geared to expose them to the varied settings in which nursing care is delivered. Since the recent trend in nursing edu- cation has been to curtail severely or eliminate learning experiences in the operating room, perhaps this lack of exposure is a factor in the common decision of new graduate nurses to practice in other settings. In 1964, Peers assessed the learning priorities

of nurse educators when she reported: . . . educators (feel) that “speciali- zation” should be left t o post- graduate training. They believe that learning experiences present in the operating room could be dupli- cated in other areas.4 If Peers has accurately assessed the

learning priorities of nursing educa- tion, it might be safe to make the following assumptions. First, nursing students are presented with a biased and perhaps incomplete picture of nursing practice opportunities. OR specialization can seem remote to nursing practice on other patient units. It requires the nurse to extend her student role for another 6 to 12 months to gain added technical skills. This raises a major question in the process of career development. New nurse graduates wish to become socialized into the nursing profession, end their student status, and be recog- nized as peers by practicing registered nurses. Treating the OR experience as a postgraduate program would rele- gate the nurse once again to the status of student, delaying the implementa- tion of his or her self-concept. Is the nurse willing to accept this delay? Most nurses will not and, thus, are not motivated to pursue OR nursing once the undergraduate program ends.

The second assumption might be that in deleting instruction of nurses in OR principles, colleges and univer- sities imply that OR nurses are mere technicians. This could lead to a de- cline in the personal and human touches expected by nursing students in a nurse-patient relationship. Denied this, the nursing student considering OR practice might be inclined to change his or her area of specializa- tion. If the expectations specialization one pursues nurse’s self-concept related

in the and the to these

d+ 1340 AORN Journal, June 1977, Vol25, No 7

Time

301

O h of total

sample

1.0 1.5 0.5

1.5 4.0

11.5

52.5 72.5

Hours 0- 4 5- 9

10-14

1- 4 5- 9

10-14 More than

Days

15

Assc

Re- sponses

17 13 1

3 1 0

2 37 Total

Time merit in the OR as nursing students Table 1

Ha

Re- ponse

2 3 1

3 8 23

105

145

lital sc

O/O of Qroup

~

1.4 2.0 0.7

2.0 5.6

15.9

72.4 100.0

~

~

iate d

Yo of Qroup

46.0 35.1 2.7

8.1 2.7 0

5.4

~

100.0

lree % of total

jamplt

8.5 6.5 0.5

1.5 0.5 0

1 .o 18.5

Bal

Re- ponses

9 3 0

1 0 1

4 18

xlaureate

% of Qroup

50.0 16.6 0

5.6 0 5.6

22.2 100.0

Yo of total

sample

4.5 1.5 0

0.5 0 0.5

2.0 9.0

Total re-

sponses

28 19 2

7 9 24

111

200

Distribution by program of time spent in the operating room as nursing students by 200 registered nurses.

expectations are in conflict with the attitudes of the institutions educating the student for this career, then this area of specialization might well be avoided.

If either of these two assumptions is true, the student’s motivation to reach desired goals is altered. Treating OR practice as an appendage to nursing education could convince the student that as an OR nurse the outlets for her abilities would be limited, her values changed, and her motivation for ser- vice to people colored by the prospect of being a technically skilled mechan- ic.

Even after student status has ended and employment begins, other factors directly affect a nurse’s decision to re- main in or leave OR nursing practice. Orientation or inservice programs for new nurse employees in operating rmms are often delegated to an al- ready overworked staff nurse. Because of her frustration, pressure, or inabil-

ity to teach, she may plan inservice programs ineffective in preparing the nurse. The end result is often failure to stimulate interest or motivate the new employee, which in turn can cause both the new and the experi- enced OR nurse to leave the surgical suite.

Having reviewed theories of motiva- tion and career development, this in- vestigator sought to determine what factors, if any, in the nursing student experience were instrumental in motivating nurses to select the operat- ing room as a practice setting. The study sample included 200 registered nurses practicing in operating rooms in Erie County, New York State. Data relative to educational preparation and employment as an OR nurse were collected from July through September of 1976.

The returned questionnaires showed that the majority of subjects were be- tween 18 and 27 years of age at the

1344 AORN Journal, June 1977, Vol25, No 7

OR learning experiences Table 2-

Type of experience

Observation of surgical technique and procedure Classroom instruction on aseptic surgical techniques Laboratory practice of the principles of surgical aseptic techniques Second scrubbing in surgery with a regis- tered nurse or technician First scrubbing under the direct super- vision of a registered nurse Circulating with a registered nurse Circulating alone while a registered nurse scrubbed for the case Accompanying the OR nurse on pre and postoperative teaching visits Making pre or postoperative visits to patients alone

Responses

181

167

105

129

110 1 34

43

20

46

Yo of Total

90.5

83.5

52.5

64.5

55.0 67.0

21.5

10.0

23.0

OR learning experiences included in basic nursing programs of 200 registered nurses.

time of graduation from their basic nursing programs. Of the remaining seven who were older than 27 years at graduation, five were graduates of as- sociate degree (AD) programs. Four of these five requested to work in the OR after graduation, and each would ac- cept a transfer to another clinical unit if offered them. Surprisingly, 51.5% of the study sample had a relative in nursing; 24% had a relative in medicine. Although some overlapping may be present, one might speculate that some nurses may have been either influenced by relatives to select nursing and/or OR nursing as a career, or they sought to emulate relatives they admired. In either case, subjects might possibly have been seeking to meet expectations of others while de- veloping their self-concepts.

Data indicated that 144 nurses

(72%) were graduates of hospital schools of nursing. Additionally, since only 28% of the nurses studied noted any experiences with a surgical unit or operating room prior to their basic nursing education, it would appear that they entered schools of nursing without a preformed bias from per- sonal experiences to select the OR for a subsequent area of clinical practice.

The investigator sought to discrimi- nate factors within the nursing school curricula that may have motivated nurses in some way to select the OR as a practice setting. Over 95% of the study participants were graduates from nursing programs that included some experiences in the OR. Table 1 delineates the estimated time spent in the OR as nursing students grouped by hospital schools, associate degree, and baccalaureate programs. Of the total

AORN Journal, June 1977, Vol25, No 7 1345

Learning exper- iences

Observinc aseptic technique Class in- struction on aseptic technique Laborator practice of aseptic technique First scrubbing Second scrubbing but not first scrubbing Circulatin! with RN

OR learning experience distribution Table 3

ital school Ho:

Re- ponses

139

137

92

105

31

123

% of YO of total youp sample

95.8 69.5

94.5 68.5

63.4 46.0

72.4 52.5

21.4 15.5

84.8 61.0

Associate dearee 11 Baccalaureate Yo of total

sample

7.5

6.5

4.0

1.5

1 .o

2.5

Total re-

ponses

181

167

105

110

37

134

Distribution by program of learning experiences in the operating room as nursing students by 200 registered nurses.

sample, 72.9% spent more than 15 days in the OR as nursing students. Four of the 18 baccalaureate subjects (22.2% ) also spent more than 15 days in the OR as students. This was true for only 5.6% of the AD graduates.

Table 2 shows that 90.5% of nursing students observed surgical aseptic techniques and procedures, although only 52.2% recalled practicing this technique in a laboratory setting. Fifty-five percent of the total sample experienced first scrubbing under the direct supervision of a registered nurse. These learning experiences are again compared in Table 3 in

categories of hospital school, associate degree, and baccalaureate programs. Once again, it is demonstrated there is a far greater involvement of the hospi- tal school nursing student in the de- livery of direct patient care in the operating room than in the other two programs.

When analyzing data about nursing experiences following graduation from basic nursing programs, we note that 22.5% of the study population attended a formal course in OR nursing, which may have been in their employing in- stitutions. Also, 75.5% of the nurses requested to work in the OR after

1348 AORN Journal, June 1977, Vol25, No 7

Distribution by length of employment

Years of OR employ- ment

0 to 4 5 to 9

10to 14 15to 19 20 to 24 25 or

Total more

Hc

Re- sponse

46 28 30 23 9

9

145

% of Qroup

31.7 19.3 20.7 15.9 6.2

6.2

Re- sponses

15 1 1 0 0

1

18 100.0 ___

% of group

83.2 5.6 5.6 0.0 0.0

5.6

Table 4

,001 11 Associate dearee

75.7 96.8

I

Yo of

100.0

Baccalaureate I

0.0

9.1 I

200

~ ~

Distribution by program of length of employment of 200 registered nurses.

graduation from basic nursing pro- grams. Of this group, 75.5% were graduates of hospital schools, 17.m of AD programs, and 7.3% of bac- calaureate progrhms. It is interesting that approximately the same propor- tion of subjects requested to practice in surgery: 79% from hospital programs, 72% from AD programs, and 61% from baccalaureate programs. This indi- cates that graduates of all three pro- grams have an interest in practicing in the OR. This interest might be fos- tered as students progress through their programs., This finding also ap- pears t~ negate the general belief that graduates of baccalaureate programs are not interested in OR practice.

Of the 200 subjects, 47 said they would transfer to another clinical set- ting if they could retain all the bene- fits of OR nursing. When analyzed according to program types, it can be seen that the smallest proportion of nurses to accept transfers were graduates of hospital programs. One

might speculate that the hospital school subjects derive greater satisfac- tion from this practice setting by vir- tue of previous learning experiences and a security in the associated skills.

Over half of the study populatior had worked on other patient units prior to the operating room, therefore claiming previous exposure to nursing practice as an RN. A large number (44%) of the nurses studied have been employed as OR nurses between 0 and 4 years. Another 45.5% had practiced OR nursing between 5 and 19 years. The remaining 10.5% of the nurses studied had been practicing in the OR for over 20 years. Table 4 shows that over half of the nurses whose length of employment was 4 years or less were graduates of hospital schools of nurs- ing. This represents only 16% of the total number of graduates from thie type of program. Of the nurses wh worked longer than 5 years in the OR only 5% were graduates of AD pro. grams and only 1% were baccalaureatc

1350 AORN Journal, June 1977, Vol25, No 7

graduates. Nursing leaders and pro- posed legislation point to baccalaure- ate preparation in nursing as the min- imal requirement for entry into the profession. Therefore, it behooves nursing educators to prepare future nurses to insure high-quality patient care in all clinical settings, including the OR.

The majority of subjects studied in- dicated they received extra financial compensation for working in the OR in the form of call time, overtime, or bonus pay.

In an attempt to determine specific reasons why nurses elected to practice in the OR setting, the investigator asked the subjects to identify their three most important reasons. The most frequently cited was “hours- Monday through Friday, 7 am to 3 pm.” Other responses frequently oc- curring were: prefer it to bedside nurs- ing, variety in work and people, enjoy the work, ego-satisfying, important member of the team, feelings of accomplishment-work completion, enjoyed the student experience in the OR, responsibility, and short-term pa- tient care. Many nurses felt the OR setting facilitated professional growth as reflected in comments such as: con- tinuous teaching-learning experience, challenging-exciting, direct patient care given, enjoyed making pre and postoperative patient visits, increased understanding of postoperative care, independent decision making, and individualized patient care. Many ethical concerns were also noted: rec- ognition of the need for RNs in the OR, honesty of surgery-no compromise in quality of care, insuring quality care in an area ignored by nursing educators, providing continuity in pa- tient care, and acting as the patient’s advocate.

Data indicated these responses re-

flected the opinions of the majority of the subjects in all three groups. Further analysis of the responses shows a fairly even percentage dis- tribution of responses for each type of nursing program.

Considering these responses, one wonders why nurses do not elect to practice in the OR in preference to other clinical areas. Responses by the study sample included: limited patient contact, inadequate student exposure, many personality conflicts, high- pressure work situation, fear of loss of nursing skills, call time, patients be- come objects, and poor treatment as a nursing student.

The completed study allowed the in- vestigator to draw the following con- clusions. No generalizations can be made to any other study population.

1. Having a relative in nursing or medicine appears to be an influencing factor in selecting the OR as a nursing practice setting.

2. Graduates of associate degree and baccalaureate programs do not generally elect to practice nursing in the operating room.

3. When learning experiences for nursing students include opportunities to give direct care to patients in the OR, it appears more likely that these students will elect to practice nursing in the OR afier graduation.

4. The lack of opportunities for stu- dents to practice aseptic technique makes one question the effect of this pattern on patient care.

5. The convenience and regularity of hours, the most frequent reason given for preference to practice in surgery, may in part be a reflection of the value system of present-day soci- ety.

6. The teaching-learning oppor- tunities available to practitioners in

1352 AORN Journal, June 1977, Vol25, No 7

the OR appear to be motivating factors for selecting this practice setting.

7. Nurses who perceive the OR as a setting with limited nurse-patient con- tact generally do not elect this setting for practice.

8. Nurses who elect the OR setting for practice tend to remain in this set- ting for the duration of their profes- sional careers.

A major concern. It may be con- cluded that while a considerably large portion (90.5%) of the sample had classroom instruction in aseptic tech- nique, half (47.5%) failed to have opportunities to practice these tech- niques in the laboratory setting. The implication may be that for the nurs- ing student there is little opportunity to grasp an understanding and respect for the application of aseptic technique in other clinical settings.

It is possible that some of the cur- rent nosocomial infections may be due to poor aseptic technique. The ramifi- cations of such a problem may necessi- tate the expenditure of thousands of dollars in research and many hours of work for health care professionals in dealing with postoperative complica- tions of infection and the suffering of patients. Perhaps nursing education could contribute to the decline of hospital-acquired infections by provid- ing learning experiences that allow the nursing student to practice the principles of surgical asepsis. Armed with firsthand experience and per- sonal understanding of these prin- ciples, the nurse is then in a better position to correct breaks in technique made by related health care providers who lack familiarity in this area. It is obvious that the nursing profession should assume responsibility and ac- countability for this important aspect of patient care.

Recommendations for further re-

search. While the questionnaire pro- vided much information, the answers given stimulated new and different di- rections to take in revising question- naires that might yield additional data to enhance a better understanding of career selection and specialization. The following are some recommenda- tions for further research:

1. repeat the study with another sample of OR nurses to look for similarities in response 2. conduct a study to ascertain how much time was spent in nursing practice on other units prior to the OR setting and in which clinical settings these experiences occurred 3. conduct a study (using a similar questionnaire) of randomly selected graduate nurses who practice nurs- ing in other clinical settings to de- termine factors in their nursing student experience that motivated them to elect a practice setting other than the OR 4. conduct a study to determine the long-range effects of the practice of nursing by individuals lacking op- portunities as nursing students to practice the principles of surgical asepsis prior to graduation. 0

Notes 1. Samuel Ostipow, Theories of Career De-

velopment (New York: Appleton-Century-Crofts, 1973) 131-132; 135.

2. /bid, 135. 3. /bid, 131-132. 4. Jerry Peers, “Today’s challenge to the pro-

fessional operating room nurse,” AORN Journal (January-February 1964) 70.

1354 AORN Journnl, June 1977, Vol25, No 7