**4. How can work environment be improved by simple means?**

To increase work attractiveness, according to Bjorn and Josephson [41], special attention should be paid to salary, organisation and physical work environment. Logde, Rudolfsson [4] and Arakelian, Rudolfsson [45] indicated that simple means, such as creating a non-violent atmosphere between colleagues and professionals, the first-line managers being present, stressing everyone's value in the team, giving timely feedback to one's employees, providing healthy work schedules and working with employees' salaries and allowing time to develop in one's profession in the workplace were important steps in working in the right direction.

On a psychosocial level, a friendly and permissive atmosphere can be created by making a workplace a safe place, where one wants to be oneself and develop, namely a homelike place. Simple acts of knowing one's colleagues on a personal level and creating relations, greeting each other every morning when coming to work and thanking each other before going home also played an important role. In such a workplace, where one has a voice, there is joy, a positive learning culture and creativity, all of which impact patient care positively.

Because of the nature of work in perioperative environments, small and smart planned breaks [72], microbreaks (short breaks) and passive- (just for rest) or active breaks (to walk or do small physical exercises) [73], which give an opportunity to change focus between two patients, are very important. In turn, breaks require planning and relevant staffing with relevant competencies to allow the NA or OR nurse to leave the operating room to change focus and be able to drink some water or use the restrooms. Operating settings and aviation settings have been compared in literature. Whereas in aviation, shifts and breaks are strictly regulated, as the staff's focus and full concentration are always required during the flight, there is no consensus about breaks in operating rooms. Even in the transportation sector, there are also rules about taking breaks during a work shift. One has the right to have a meal or lunch 4 hours after starting to work in operating departments, which is not always followed due to hygiene regulations (the rule of not opening doors in, for example, orthopaedic surgery, where prostheses are being operated into patient's body), safety reasons (the risk of missing information when reporting the patient to another nurse, so that one can leave the room) or staff shortage. This directly affects staff's long-term well-being and ability to work.

Healthy work scheduling, with a focus on safety and recovery, is another measure that should be communicated to the staff, teaching them the benefits of correct planning of one's work schedule so that one can feel a work-life balance and recovery, for example, not planning early morning shifts after late evening shifts, which gives less than 11 hours of sleep/recovery or to spread out days off, instead of working more than six or seven days in a row and taking a week off thereafter. According to research results, personal preferences in the workforce should be in balance with the organisational needs of staffing [42, 43]. There have been attempts to shorten the workday from eight to six hours for the workforce in operating departments, by planning the breaks at the end of the work shift, instead of spreading them out during the work shift. This, in the long run, tires the workforce, placing maximal demand on them during the shift. In other words, the idea is to reduce the tips of the iceberg (the peaks of high workload), with smartly placed breaks. It is also important to take into consideration that the staff need breaks more when the workload is the highest. Breaks can be planned during each work shift, but they can also be planned, for example, by mixing multiple tasks so that, for example, OR nurses do not statically stand and assist the surgeon with surgical instruments throughout their entire career every

#### *What Makes It Tip Over and How Can It Be Prevented?: Challenges in Psychosocial and… DOI: http://dx.doi.org/10.5772/intechopen.109244*

week, but to give the person an opportunity during the week to work with other tasks or responsibilities, for example, to work with students, to work with hygiene issues or to contact different firms and order and pack surgical instruments. This way, the person does not have to work statically every day, preserving his/her back, neck and shoulders for more years to come. For NAs, other tasks can include developing nursing care for the patients, taking responsibility for students and organising internal competence development for nurse anaesthetists or nurse assistants. Another way to both offers breaks and allow for competence development is to give time for reflection, where experienced nurses can guide newcomers in their professional development. As almost every minute of perioperative nurses' workday is planned with tasks and the fact that working as a NA or OR nurse is a solitary work (there is just one nurse anaesthetist or operating room nurse per operating room), they need to process and reflect together with other colleagues about nursing care for the patients and how it can be improved, sharing knowledge together. This is a part of one's development process in the profession, needing time and space from one's clinical work.

Perioperative dialogue is a model, a way of working, to guarantee continuity, patient safety and person-centred care in perioperative settings. The model was first described by von Post [74] and developed further [75–78]. According to perioperative dialogue, the same NA or OR nurse should meet the patient before, during and after surgery and anaesthesia. The purpose of this meeting before (pre) is to assess, to have a dialogue, to take in the patient's story and experiences in planning the nursing actions during and after surgery and anaesthesia and give the patient a voice. These are the cornerstones in person-centred care, as described by Ekman [79]. Thereafter, a care plan is formed together with the patient. Meeting the same nurse during surgery and anaesthesia guarantees continuity, a familiar face who welcomes the patient into the operating room, and a nurse who guarantees that she/he is and will be there for the patient, seeing to the patient's best interests [80]. During (perioperatively) surgery and anaesthesia, the nurse guarantees that the plan that was agreed upon with the patient will be carried out. After termination of surgery and anaesthesia (post-operatively), the nurse follows up on the plan with his/her patient. The departments that give the perioperative nurses the opportunity to perform perioperative dialogue will have better-prepared patients and more satisfied nurses, and benefits of perioperative dialogue are known for both patients and nurses who perform it [75, 76, 78, 81–85]. Moreover, perioperative nurses will feel that their unique and specific nursing knowledge will be a force to count on in patient care in perioperative departments. This will lift their pride and increase joy at work, and perioperative nurses will feel less like a secretary for electronic documentation, putting additional demands on their work [86]. The focus has changed in recent years towards digitalisation, and electronic documentation, with systems that do not always interact with each other. Hence, perioperative nurses, especially, must log into different systems, sometimes documenting the same information in several IT journal sights/systems. Furthermore, they have to struggle to find correct information [86, 87] when working with their patients in the operating room. The perioperative nurses describe this shift in focus from the valuable patient care to being forced to act as a secretary for electronic documentation. Working with and increasing the perioperative nurses' pride and joy, lifting their specific competence and specific knowledge in nursing care of the patients should be the number one priority of the operating departments.

Possibilities to continuously develop one's competence at work is another factor to increase job satisfaction. There should be paths of development in one's workplace, both in the academic field and in the clinical field. In the academic field, there should be a plan (three-year or five-year plan) for how many NAs or OR nurses should study on PhD-level, or how many perioperative nurses, who also are associate professors or professors, should be employed and active within each operating department. Furthermore, to be an attractive workplace, nurses with high(er) academic grades should be involved in research and education of the departments, and in management from department levels to the highest level of the organisation at the hospital. There should be a carefully considered competence development plan and tools for assessing everyone's competence and how it can be improved further at the workplace. The competence plan should be connected to and work hand in hand with a salary development plan, and the message should be "development pays off". Salary is costly, but it is an incentive for the workforce to remain in the workplace. While employing new employees is associated with financial challenges, losing staff and being forced to hire temporary staff are even more costly, and training new staff also requires human and financial recourses. Economic means should be invested in the existing staff, as it pays off in the long run when they remain in the workplace. Not everyone is interested in developing an academic career. There should, therefore, be paths to work clinically, and in leadership, and reach the "next level". For example, perioperative nurses or assistant nurses may work in different operating departments, with adult patients or children, and develop their clinical skills, meeting new challenges with new patient groups. Intensive care units and airborne intensive care (used for care of patients, for example, during transportation from one hospital to another and from the scene of injury to hospital) are other clinical work developments, which can be offered to nurse anaesthetists. The third path of development is in leadership and management.

Shortage of time is frequently discussed at the hospitals, and to compensate for that, mandatory education or meetings, which are essential for patient safety are shortened. For example, yearly training in CPR (cardiopulmonary resuscitation), important meetings about changes in surgical routines, instruments or new routines or medications in how to anaesthetise a pregnant woman have a direct impact on the outcome of care and should be prioritised in the organisation. This is not a matter of 'whether we should' but 'how should it be done' systematically! In addition, team training that increases psychosocial well-being, bonds the staff who work together on an everyday basis and gives them a well-deserved break from monotonous work are important means. During team training, time should be allotted for reflection and improvements in care for patients.

Finally, systematic work environment management can improve work environments in perioperative settings for perioperative nurses, nurse assistants [88] and anaesthesiologists [89]. Using a support model for systematic environment management gives the staff (nurses and assistant nurses) in the perioperative context an opportunity to discuss problems with collaboration, work organisation and how to treat each other. Moreover, it gives them the opportunity to be engaged in their work environment issues, helping first-line managers in work environment management [90].

### **5. Conclusion**

Despite the challenges in perioperative work environment, many choose to work in such an environment. As the physical environment is difficult to affect, the psychosocial and organisational environment become more important in the staffs' work life. There are several simple measures that can be used, and actions must be taken today to make perioperative settings healthy and attractive. Actions should be taken

*What Makes It Tip Over and How Can It Be Prevented?: Challenges in Psychosocial and… DOI: http://dx.doi.org/10.5772/intechopen.109244*

against incivility or bullying at work; nurse managers should have proper university education and training to be able to conduct caritative caring for their staff members; salaries for perioperative staff, among the nurses, should be revised and increased; and they should be given the opportunity to use their full competence and advanced nursing knowledge in patient care, and possibilities to develop in their profession in their workplace. This way, newcomers and ordinary staff may choose to stay, develop themselves and their workplace further, as losing perioperative nurses results in cancelled surgeries and suffering for patients.
