S70 MOSS, ET AL.

, The Operating Room Charge Nurse

Article ■

The Operating Room Charge

Nurse: Coordinator and
Communicator

JACQUELINE MOSS, RN, MS, YAN XIAO, PHD, SITI ZUBAIDAH, RN

A b s t r a c t To achieve the potential inherent in the use of computer applications in distrib-

uted environments, we need to understand the information needs of users. The purpose of this
descriptive study was to document the communication of an operating room charge nurse to
inform the design of technological communication applications for operating room coordination. A
data collection tool was developed to record: 1) the purpose of the communication, 2) mode of com-
munication, 3) the target individual, and 4) the length of time taken for each occurrence. The
chosen data collection categories provided a functional structure for data collection and analysis
involving communication. Study findings are discussed within the context of application design.
■ J Am Med Inform Assoc. 2002; 9(Nov-Dec suppl):S70–S74. DOI 10.1197/jamia.M1231.

Introduction the method by which information is transferred and

is essential for all organizational interaction.4
The primary goal of operating room coordination is
In a review of 16,000 hospital deaths due to error,
to insure the prompt, safe, and effective care of surgi-
Wilson et al., found that communication errors were
cal patients. Central to this goal is the operating room
the leading cause and resulted in twice as many
(OR) charge nurse. The charge nurse is integrally
deaths as clinical inadequacy.5 Donchin et al. found
involved in insuring that staff, patients, and equip-
that 37% of errors in a critical care unit were the result
ment come together seamlessly to move patients
of verbal exchanges between nurses and physicians.6
through the surgical process. While in recent years,
On the other hand, facial and vocal cues provide a
operating room patient and staff scheduling systems
significant proportion of a message’s meaning and
have been implemented, little attention has been
the removal of these cues, as with electronic messag-
directed at the totality of coordination needs.1 There-
ing devices, decreases a message’s clarity.7 In addi-
fore, essential to understanding operating room coor-
tion, messaging devices such as paging systems,8-10
dination is an examination of the communication of
and telephones11 can disrupt current activities. Such
the OR charge nurse.
disruptions can cause an individual to forget to carry
The Association of Operating Room Nurses (AORN) out an intended act, even when only ten seconds sep-
lists coordination of care for surgical patients as the arates the intention from the intrusion.12
first item in their outline of the responsibilities of
Communication provides a basis for judgements that
perioperative nursing practice. AORN specifically
are supported by a social network of nurses, sur-
mentions communication skills as a key component
geons, anesthesiologists, technicians, and auxiliary
of coordination.2 Sonneberg advises OR charge
staff.13 The OR charge nurse then becomes a conduit
nurses to “communicate, communicate, communi-
for information flow, receiving, processing, and com-
cate”3 for successful coordination. Communication is
municating this information to others for the coordi-
Affiliations of the authors: University of Maryland, Baltimore, nation of patient care.
School of Nursing (JM), University of Maryland, Baltimore,
School of Medicine (YX), National University Hospital, Singapore Investigations of catastrophic accidents, such as the
(SZ). Challenger disaster, indicate that these incidents are
Journal of the American Medical Informatics Association Volume 9 Number 6 Nov / Dec Suppl 2002 S71

often the result of faulty system design. Computer After receiving the report, she re-evaluates the cases
applications have the capability to change system and begins refining the schedule by either re-
processes to decrease communication that can lead to sequencing or re-scheduling them. On some occa-
error. To achieve the potential inherent in the use of sions, she plans the listing with the attending anes-
computer applications in distributed environments, thesiologist immediately upon receiving her report to
we need to understand the information needs of determine availability of staffing and rooms. By
users.14 The purpose of this descriptive study was to about 7:00am, an ‘informal’ gathering takes place at
document the communication of an operating room the ‘desk’ and staff receive or sometimes discuss
charge nurse to inform the design of a technological room assignments democratically. At this point the
communication application. OR is ready for patients.

The charge nurse coordinates patient flow from other

Setting and Subjects hospital units into the operating room. This includes
ensuring that the patient is ready for surgery, surgeon
This study was conducted in the OR of a hospital spe-
is available to perform the surgery and the operating
cializing in trauma care in the Mid-Atlantic States.
room is cleaned, and prepared with the appropriate
Only patients experiencing traumatic injury are
equipment for the planned surgery, and a competent
admitted to this hospital, and gain access through
operating room staff is assigned.
emergency medical service helicopters or ambu-
lances. The hospital includes six operating suites, one
At each step in this process information is recorded
of which is reserved for patients’ requiring immedi-
on a large display board (12 ft by 4 ft). The board is a
ate surgery. The patients that are admitted to the OR
visual representation of patient, staff, and equipment
may be from the trauma admitting area, hospital
movement throughout the operating room suites and
floor, or as previous patients admitted through the
has evolved into a sophisticated coordination tool for
outpatient department for follow-up care. The oper-
clinicians and supporting personnel. Very rarely does
ating room unit is located within the vicinity of the
anyone, beside the charge nurse, update the display
trauma resuscitation unit, post anesthesia care unit
board. The charge nurse’s role is to gather informa-
and the radiology department.
tion from all sources and represent this information
Operating room staff includes 54 nurses, 4 nurse assis- on the public display board.
tants, and 1 clerk supervised by the operating room
charge nurse. In addition, the charge nurse communi-
cates with surgeons, surgical fellows, anesthesia, nurs- Method
ing and order to facilitate patient movement in a very
Tool Design
robust environment. The charge nurse in the OR was
chosen for this study due to her role as coordinator. Communication behaviors in clinical settings have
been studied through observation,9 self-report
The Charge Nurse logs,8,10 and ethnographic13 methods. The develop-
ment of the data collection tool for this study was an
The charge nurse is responsible for the day-to-day
attempt to consistently capture objective data specific
smooth running of OR activities. She must coordinate
to the organizational context.
activities in conjunction with the trauma resuscitation
unit, general hospital units, and the post anesthesia
Through experience and observation in the operating
care unit. Besides managing the personnel under her
room, the initial categories for the data collection tool
supervision, some of her other activities included staff
were developed. Categories were amended using an
education, competency testing, scheduling, and other iterative process of observation and modification
administrative duties such as budgeting. over three observation periods. Major tool categories
The charge nurse starts her shift at 6:00am and ends could be considered generic to any communication
her shift at 7:30pm. Her day begins with receiving episode, however, determining the extent of coding
report from the night nurse. The report focuses on the under each category must be context specific. Final
number of cases, the scheduling of patients into the categories recorded for each communication episode
specific operating rooms, patient’s readiness, staff were the: purpose, and mode of communication; the
availability, and any other pertinent information target individual; and the length of time taken for
relating to the scheduling of the patients for surgery. each occurrence.
S72 MOSS, ET AL., The Operating Room Charge Nurse

a close second (20%). Figure 1 shows the percentages

associated with each purpose of communication.
The target persons of communication were most fre-
quently OR nurses (37%), surgeons (17%), and floor
nurses (13%). The vast majority (67%) of communica-
tions were face-to-face, then by phone (27%), pager
(3%), and intercom (2%). The duration of the com-
munication episodes ranged from 10 seconds to 10
F i g u r e 1 Frequencies of communication episodes by minutes, with a mean of 1.13 minutes and a mode of
purpose of communication. 1 minute. 76% of the communication episodes were
between 30 and 60 seconds in duration.
There was a relationship between the target person of
Data Collection the communication and the purpose of the commu-
nication (Chi Square, p<.001). For example, 78% of
Two registered nurses experienced in operating room
communication with surgeons was to schedule or re-
procedure in another setting, observed the operating
schedule surgery, while 50% of communications with
room charge nurse and collected data on 381 com-
floor nurses was to coordinate patient preparedness.
munication episodes. Observations occurred during
Table 1. lists the target person of communication by
the operating room’s busiest time, in the morning,
the most frequent purpose of the communication.
over 7 non-consecutive days. Three different charge
nurses were observed and their communications There was a significant relationship between the pur-
recorded. The charge nurse usually remained at the pose of the communication and the mode chosen for
‘desk’, which can be likened to a command center. that communication (Chi Square, p = .002). While the
This is where the majority of coordination activities vast majority of communication was face-to-face
occur. This area consists of a long table situated in (67%), 39% of phone communications were to sched-
front of a 12ft by 4 ft wall-mounted public display ule or re-schedule surgery and 26% to coordinate
board. The board is used to show the patient and staff patient preparedness.
operating room assignments. In addition, the area
has a telephone with intercom and paging capability. Also significant, was the relationship between mode
The Charge Nurse occasionally moved away from of communication chosen and the target person of
her ‘desk’ to assess the progress of a surgery or to dis- that communication (Chi Square, p < .001). 88% of
cuss room assignment face-to-face with the staff. communication with floor nurses, 26% with surgeons,
and 18% with OR nurses, was by phone. Face-to-face
When a communication occurred, a coded response communication was most frequently with OR nurses
was entered on the data collection tool and the dura- (44%), anesthesia staff (15.6%), and surgeons (15%).
tion of the communication was recorded. When the
observer was unclear about the purpose of the com-
munication or the target person, the information was Discussion
clarified with the charge nurse. Occasionally, the
charge nurse voluntarily disclosed the information The purpose of OR charge nurse communication is to
on the communication. This voluntary disclosure of coordinate the activities of the operating room. Infor-
information to the observer oftentimes occurred
when the mode of communication was the telephone Table 1 ■

as it was difficult for the observer to discern the

target person and the nature of the communication. Target Person of Communication by the Most
Frequent Purpose of the Communication
Target Purpose
Results
Surgeon (43%) Schedule Surgery
Surgeon (34%) Re-schedule
381 communication episodes were observed, coded, OR Nurse (31%) Staffing
and recorded on the data collection tool. Scheduling OR Nurse (31%) Room Assignment
surgery was the most frequent purpose of communi- OR Nurse (15%) Equipment
cation (21%), with coordinating patient preparedness, Floor Nurse (50%) Patient Preparedness
Journal of the American Medical Informatics Association Volume 9 Number 6 Nov / Dec Suppl 2002 S73

mation is collected, processed, and finally represented board is that staff are able to view an entire represen-
on the OR board, a public display. The OR board then tation of OR status. A disseminated electronic repre-
becomes a communication device that allows all staff sentation of the OR board would allow staff to view
connected with surgical patients to coordinate their the OR status without disrupting the coordination
activities. However, the fixed location of the board activities of the charge nurse.
limits the staffs’ ability to access and interact with the
device. Therefore, the charge nurse becomes the col- Another strategy for decreasing disruption in charge
lector and author of coordination information on the nurse coordination activities would be the imple-
display board. At times, this interferes with the charge mentation of an asynchronous messaging system.
nurses’ ability to coordinate other activities and they The vast majority of communication episodes (76%)
become ‘tied’ to the public display. The implementa- were from 30 to 60 seconds. These communication
tion of an electronic display of the OR board, via an episodes generally involved short-bursts of informa-
internet or intranet, would increase the ability of the tion exchanged, lending them to a messaging system.
staff to access and update the board and free the OR Nevertheless, due to the unpredictable nature of sur-
charge nurse for other coordination activities. gical workload in a trauma center, the charge nurse
would still need to be constantly aware of the OR
An electronic representation of the OR board dis-
board status. Electronic alerts to changes in scheduling
played on the hospital floors would decrease the
or equipment needs could be communicated to the
need for phone communication with floor nurses.
charge nurses’ and require their confirmation prior to
Coordinating patient preparedness currently repre-
OR board update. This would decrease the need for
sents 88% of the phone communication between
the charge nurse to be in the proximity of the board to
charge nurses and floor nurses and 12% of the total
be aware of and coordinate changes in workload.
communication with surgeons. Generally, this is to
establish if the patient is ready for the OR or if the OR While this discussion has proposed technological
is ready for the patient. Patient readiness could easily solutions for decreasing communication, more infor-
be displayed on an electronic board, at disseminated mation is needed on the character of the communica-
locations, eliminating much of this communication. tion episodes, before these proposals can be imple-
mented. For example, coordinating activities in the
Scheduling and re-scheduling surgery are other cate- OR requires negotiation. OR and hospital staff negoti-
gories of communication that could be decreased ate surgical and staffing schedules with the charge
with the implementation of an electronic board. nurse. In the absence of an existing close relationship,
These categories represent 78% of the communication face-to-face communication provides the greatest rap-
charge nurses have with surgeons. Allowing sur- port and cooperation between participants.7 Remov-
geons to update an electronic display board directly ing this avenue of communication could decrease
through a surgical scheduling system would greatly rather than increase the efficiency of OR coordination.
decrease the need for charge nurse intervention. In
addition, surgeons could also indicate equipment Furthermore, in this interrupt-driven environment,
needs while scheduling surgery. immediate acknowledgement of a message reduces
mental burden by allowing for the quick completion
Coordination of staffing is usually face-to-face (76%) of the task . This is especially true in this environment
and with OR nurses (76%). However, we observed where the consequences of communication errors can
that this communication generally involved the OR be so significant; workers need explicit acknowledge-
nurses’ discussing the status of surgical cases and ment that a communication has been received . Cur-
their next room assignment. Again, disseminated rently, this is accomplished through the use of syn-
electronic displays of the OR board might be utilized chronous communication.
to decrease this communication.
Finally, further investigation is required into the
As previously stated, the majority of communication amount and type of peripheral information gained
was face-to-face (67%), however observation showed during communication episodes initiated for another
that usually this communication was initiated when purpose. We have observed that this information is
staff came to view the OR board. The fixed nature of frequently in the form of a ‘heads up’, or information
the board requires that staff either phone or visit the concerning upcoming events. Knowledge of impend-
board to request any changes in scheduling, staffing, ing events facilitates planning and improves overall
or equipment request. The advantage to visiting the coordination.
S74 MOSS, ET AL., The Operating Room Charge Nurse

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