Sabrina Rafaeli





Surgery is an anxiety-producing event for most people. Pre-operative anxiety can interfere with pre-operative learning, increase the need for anesthetic medications, and may negatively affect the patient’s physiological and psychological post-operative recovery. As an operating nurse, Sabrina has witnessed first-hand how the strange environment of the operating room, with its unfamiliar sounds, bright lights, noisy machinery, and technical language can be overwhelming for patients and add to their anxiety, which may manifest in physiological responses such as increased blood pressure, heart rate and respiratory rate. These responses can make induction of the patient more difficult, with patients emerging from the anesthesia in the same state of anxiety. Oftentimes, patients require more anesthetic agents, more time to metabolically eliminate agents, which then causes delay in emerging from anesthesia.



Sabrina’s project implemented a ‘silent induction’ strategy in the operating room (OR) to reduce background noises for patients during the time of induction, with the goal to decrease patient anxiety pre- and post-operatively. The silent induction strategy focused on four key areas for noise reduction during this critical time: pause surgical counts, eliminate irrelevant conversation, limit traffic into/out of the OR, and turn off or turn down sound from any unnecessary equipment (e.g. radio).



Sabrina was able to pilot this strategy with 22 patients having a variety of surgical procedures. Implementation of the strategy was most effective when discussion of silent induction was included within the surgical team briefing, which occurs just prior to induction. Staff reported that silent induction was feasible and important for both patient and staff safety; silent induction was most challenging when there were too many people in the room. While patients reported that they did not feel disturbed by the noise in the OR, they did comment on anxiety when seeing so many people in the OR, if it became evident that the team had not worked together previously, listening to the surgical briefing, and the loud conversations in the hallway prior to entering the OR. In particular, anesthetists appreciated the support of nurses to reduce the noise level during the time of induction.



While Sabrina continues to implement and remind others of silent induction in the OR rooms where she works, recruitment of ‘noise champions’ have helped to spread and sustain this work, supporting silent induction in other OR rooms. Education related to silent induction practices will be embedded in professional education days, and Sabrina will continue to find opportunities to share this work within and external to Sunnybrook, with the goal to spread this practice. Additional areas for improvement have also been identified, including how to minimize the traffic and reduce the number of people within the OR, and explorations of the ‘ideal’ briefing strategy in the OR.



Following the fellowship, Sabrina reports being “very satisfied” with her job, and “proud” of her achievements through her project. She is effusive as she credits the fellowship opportunity as one that has changed her, personally and professionally, as she has gained skills in leadership, communication, change management, and quality improvement, skills that she “will take with [her] forever”, and skills that she continues to use regularly. Having seen the results of her own initiative, she sees the value and contribution that point-of-care staff can bring to improving patient care: “The changes need to come from us, as we know what it’s like at the frontlines. Everyone needs to take part of a QI project to bring that lens to their work when you are practicing on a daily basis. You are the one that knows what can be improved and changed.” The opportunity to be a fellow allowed her to “combine those two worlds together”, that is, to make change and influence clinical practice in her area. Now Sabrina sees a myriad of opportunities for improvement, and is constantly thinking about her next project, as she credits the fellowship with “opening up the curtain”, and now she is wearing “improvement glasses” that have helped her to consider what else can be done. Her network has also increased, particularly within her program area, where she feels she has gained credibility, visibility, and respect among managers and peers alike. Her managers are supportive and encouraging her to think about “what next”. She is considering more advanced education in the area of quality improvement, to formalize her credentials, and to build a role in the OR that integrates quality improvement with clinical work. She has also been invited to be a ‘traffic champion’ as part of a project that looks to reduce surgical site infections. Her role would focus on monitoring the number of people in/out of the OR (and potential sources of infection) and subsequent noise levels in the OR.



Sabrina had not anticipated the challenges involved in making change, and that change itself takes time, and thus, the project did not unfold as anticipated. She had broader expectations of what she thought she could accomplish in the six-month timeframe, particularly regarding implementation and evaluation of change. In the end, what Sabrina realized was that her focus was on changing behavior of staff members, and to implement noise reduction strategies. She will continue to consider how she may evaluate the actual reduction of noise within the OR, and the changes in patient outcomes related to anxiety. The skills she gained as a fellow helped her to engage staff in her project, to be both assertive and respectful at the same time.



“I love this feeling, and don’t want it to fade….it is the best feeling in the world, one’s own satisfaction, knowing that I can contribute to my workplace. The fellows, we want to inspire people to