DECEMBER 1994, VOL 60, NO 6

job satisfaction among nurses: relationships that are friendly and supportive and

II clear, well-defined, well-commu- nicated expectations and rules. The nurse managers scored

lower on the relationship dimen- sion than the nonmanagers. Nurses who worked on maternal/child units were significantly more satis- fied than nurses who worked in medicdsurgical or critical care areas, especially in the areas of tasks and status. The maternal/ child nurses perceived the environ- ment more positively on the rela- tionship dimension. An unexpected finding was that autonomy was not a major contributor to job satisfac- tion. Nurses in perioperative areas (ie, OR, postanesthesia care) were not discussed in the article and may not have been included in the study sample.

Perioperative nursing impllca- tions. These data may not be gen- eralizable to the OR, because peri- operative nurses may not have participated in this study. The study results, however, are rele- vant to perioperative settings. Though there has been a great upheaval in health care delivery systems and workplaces have undergone drastic redesign, job satisfaction among staff nurses remains positive, according to this study, if there are cohesive peer groups and supportive managers. Also important to job satisfaction are environments in which II nurses know what to expect in

their daily routines, change is present but not emphasized, rules are enforced consistently and fairly, and the surroundings are pleasant. Nurse managers may need

assistance in developing manager- ial styles that are viewed as sup-

portive rather than controlling. Supportive managers can provide effective buffers between staff members and unsupportive envi- ronments and can minimize the perceived effects of workplace changes on staff members.

NANCY GIRARD RN, PHD, CS

NURSING RESEARCH COMMIITEE

CHANGING HYSTERECTOMY PAT- TERNS AFTER INTRODUCTION OF LAPAROSCOPICALL Y ASSISTED VAGINAL HYSTERECTOMY M. B. Harris, D. L. Olive American Journal of Obstetrics and Gynecology Vol I71 (August 1994) 340-343

he current focus on health care reform is laden with emphasis on cost containment. New

technological advances have result- ed in less invasive surgical proce- dures, increased patient benefits, fewer risks and complications, and rapid patient recovery rates. This expansion of technology has not occurred without significant impact on the bottom line-price. As health care providers continue with efforts to reform health care, ques- tions regarding new technology must be asked to determine its true impact and overall contribution to patient outcomes, quality of care, and cost.

The purpose of this study was to determine whether the introduction of laparoscopically assisted vaginal hysterectomy (LAVH) would decrease the percentage of women requiring laparotomy for hysterec- tomy. The investigators conducted a retrospective chart review of every patient who underwent a hys- terectomy at the Southeastern Regional Medical Center in Lum- berton, NC, between Jan 1,1990,

and Dec 31,1992. Data collection included type of hysterectomy (ie, abdominal, LAVH, unassisted [tra- ditional] vaginal), length of stay, total hospital charges, and method of payment. The investigators also recorded indications for surgery and complications in the patients who underwent LAVH.

hysterectomies were performed at this hospital. In 1990, abdominal hysterectomy procedures com- prised 5 1.5% of all hysterectomies, whereas in 199 1, this percentage decreased to 45.5%. Following introduction of LAVH in 1992, the percentage of abdominal hysterec- tomies decreased significantly (p = .0012) to 35.6%, while the percent- age of unassisted vaginal hysterec- tomies remained stable.

The mean age for women in all three groups was 42.71 years. The length of stay was greater for patients who underwent abdominal hysterectomy procedures (4.03 f 2.52 days) than those women who underwent unassisted vaginal hys- terectomy procedures (2.65 f 0.89 days) and those who had LAVH (2.32 f 0.69 days). The average cost for patients in the LAVH group was $1 1,93 1 compared to $7,03 1 for patients in the abdomi- nal hysterectomy group and $5,343 for patients in the unassisted vagi- nal hysterectomy group. Ninety-six percent of the patients who under- went LAVH paid by private insur- ance compared to 74% in the unas- sisted vaginal hysterectomy group and 80% in the abdominal hys- terectomy group.

The complication rate for women in the LAVH group was 16% and included complications of postoperative anemia, fever, nau- sea, and vomiting. During the same time, the complication rate for a representative group of women

During the three-year study, 670

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with abdominal and unassisted vaginal hysterectomies was 20% and 12%, respectively.

LAVH can be substituted for abdominal hysterectomy in select- ed cases (eg, myoma, endometrio- sis, previous pelvic surgery, adnex- al mass, vaginal stricture, family history of ovarian cancer, pelvic

The investigators concluded that

only when indicated for certain patients. Proper assessment of new technology is a team effort, and decisions should be made jointly to enhance the quality of patient care outcomes and keep costs within reasonable limits.

DONNA S. WATSON RN, MSN, CNOR

NURSING RESEARCH COMMIITEE adhesions). The average charge for LAVH was more than double that of an unassisted vaginal hysterecto- my. The investigators suggested that this cost difference should decrease as surgeons become more experienced in LAVH technology, thus decreasing operating time. They also commented that the use of reusable rather than disposable instruments could reduce the cost difference between LAVH and abdominal or unassisted vaginal hysterectomies.

Perioperative nursing irnplica- tions. This research indicates the biggest factors in the cost of LAVH are increased operating time and charges for disposable staples and other instruments. As with all new technology, the operating time with LAVH will decrease as surgeons become more experienced using this technology. Perioperative nurs- es should participate in the evalua- tion of disposable versus reusable items and make appropriate recom- mendations, which may include the use of reusable trocars, extracorpo- real ties in place of staples, and bipolar cautery scissors instead of lasers.

Public education is needed to counteract the popular myth that any new technology is better, and therefore more desirable, than stan- dard technology. Laparoscopically assisted vaginal hysterectomy is not a replacement for abdominal hysterectomy or unassisted vaginal hysterectomy and is appropriate

HOW TO LOWER HEALTH CARE COSTS BY IMPROVING

BASED CONTINUOUS QUALITY IMPROVEMENT By M. Daniel Sloan 1 9 9 4 , 2 4 7 ~ ~ $24.95 spiralbound

HEALTH CARE QUALITY: RESULTS-

o ensure quality health ser- vices at lowest total costs is the mission for patients,

providers, and taxpayers. The focus of this mission has been the implementation of the contin- uous quality improvement (CQI) cycle, which currently is prac- ticed in various forms. The CQI cycle with a results orientation was first implemented by Flo- rence Nightingale in 1854. She used statistical methods to pro- mote rapid quality improve- ments. She used counts, mea- surements, and compelling graphs to document results. Her documentation was used to suc- cessfully implement immediate improvement and show that improvement significantly reduced total costs.

Since then, quality improve- ment time cycles and statistical tools have matured. This refer- ence book examines the issue of quality from its history to modem templates of a results orientation with proven cost savings.

This study guide is divided into five units. The information, theory, and ideas are connected in a specific sequence that pro- motes learning of the quality sci- ences. Unit one examines the his- tory of the quality issue and its reference to health care. Unit two is an in-depth analysis of the beliefs of the quality science experts. The key information is the principle of the economic control of quality. Unit three investigates the CQI cycle. It promotes the well-known cycle of plan/do/study/act as a sound theoretical structure in any orga- nization that is results based. Unit four is an in-depth study of charting and measuring the con- trol process. It begins with basic math and continues through sta- tistical analysis. Unit five explains the steps of organiza- tional restructuring to set up a results orientation system.

This book is a complete quality improvement guide for today’s health care team. The information is straightforward and logical. The intensive math content in unit four is challenging, but the charts and examples are helpful.

Continuous quality improve- ment must produce more than good processes and good feel- ings; it must produce results. Economic benefits are natural by- products of quality improvements in patient care services. The steps outlined in this book are essential for lowering costs.

This book is available from ASQC Quality Press, 61 1 E Wis- consin Ave, Milwaukee, WI 53202.

SUSAN PHILLIPS RN, BSN, CNOR

CAROLINAS MEDICAL CENTER CHARLOTIE, NC

DIRECTOR/SUROICAL SERVICES

1014 AORN JOURNAL