Safeguarding the patient: a grounded theory study of registered nurse anesthetists' main concerns in the process of extubation in the anesthesia setting.

BACKGROUND: The process of extubation is complex as it takes place in the technical and challenging environment of the operating room. The extubation is related to complications of varying severity and a critical moment for the patient, who is in a vulnerable condition when emerging from anesthesia. Registered Nurse Anesthetists (RNAs) in Sweden have specialist training and performs extubations independently or in collaboration with an anesthesiologist. AIM: To obtain a deeper understanding of Registered Nurse Anesthetists' main concerns and how they resolve these in the process of extubation when caring for a patient during general anesthesia. PARTICIPANTS: A total of 17 RNAs, eight male and nine female, were included in the study. Twelve RNAs in the first step of data collection (I); and five RNAs the second step of data collection (II). METHOD: A classic grounded theory approach with a qualitative design was used for this study. FINDINGS: The RNAs' main concern in the process of extubation were Safeguarding the patient in a highly technological environment, which the solved by Maintaining adaptability. Facilitators as well as challenges affected how the RNAs solved their main concern and represented the categories: 'Having a back-up plan', 'Getting into the right frame of mind', 'Evaluating the patient's reactions', 'Using one's own experience', 'Dealing with uncertainty', 'Pressure from others', and 'Being interrupted'. The theory, Safeguarding the patient in the process of extubation, emerged. CONCLUSION: To be able to safeguard the patient in a highly technological environment, the RNAs must oscillate between facilitators and challenges. By maintaining adaptability, the RNAs resolved the difficulties of oscillating, indicating a need for finding a balance between maintaining attentiveness on what is important to keep the patient safe in the process of extubation and all of the disturbances present in the OR.

Beyond the monitors: Anaesthesiologists' experiences of the process of extubation.

BACKGROUND: Although extubation is a high-risk phase associated with risk of severe complications for patients undergoing general anaesthesia, there is a lack of research about this phenomenon from the perspective of anaesthesiologists' experiences of the process of extubation in the anaesthesia setting. AIM: To describe Swedish anaesthesiologists' experiences of the extubation process in the anaesthesia setting. METHODS: A qualitative descriptive design study with individual semi-structured interviews was conducted in three hospitals in Sweden with a total of 17 anaesthesiologists. A qualitative manifest content analysis method was used to analyse the data. RESULTS: The anaesthesiologists' experiences were described in two categories: To assemble sensibilities, where the anaesthesiologists are receptive to inputs, create tailored plans, are guided by emotions and experiences, and sense the atmosphere in the process of extubation; and To stay focused, where they understand the importance of preparation and being prepared, and of being calm and strategic, and of needing to trust the registered nurse anaesthetist in the process of extubation. CONCLUSIONS: Decision-making regarding the process of extubation does not rely solely on monitoring signs; rather, the anaesthesiologists described how, by looking beyond the monitors and by being receptive to inputs from the patient and other professionals, their experience and intuition guides them through the process of extubation.

The Art Is to Extubate, Not to Intubate-Swedish Registered Nurse Anesthetists' Experiences of the Process of Extubation After General Anesthesia.

PURPOSE: To describe Registered Nurse Anesthetists' (RNA's) experiences of the process of extubation of the endotracheal tube in patients undergoing general anesthesia. DESIGN: A descriptive qualitative design. METHODS: This study was conducted in two hospitals with 20 RNAs in total. Data were generated from focus group interviews. Content analysis was used to analyze data. FINDINGS: The RNAs' experiences were described within four categories and eight subcategories. The category To be a step ahead includes assessment and preparation, and To be on my toes, their ability to recognize patterns and build a connection. To use situation awareness relates to their use of experience and feelings, and To be alone in a critical moment, to feeling alone in the team and protecting the patient. CONCLUSIONS: The RNAs make decisions when to extubate by combining theoretical knowledge, clinical experience, and intuition with the uniqueness of each patient.

Clinical intuition in the nursing process and decision-making-A mixed-studies review.

AIMS AND OBJECTIVES: To review what is characteristic of registered nurses' intuition in clinical settings, in relationships and in the nursing process. BACKGROUND: Intuition is a controversial concept and nurses believe that there are difficulties in how they should explain their nursing actions or decisions based on intuition. Much of the evidence from the body of research indicates that nurses value their intuition in a variety of clinical settings. More information on how nurses integrate intuition as a core element in daily clinical work would contribute to an improved understanding on how they go about this. Intuition deserves a place in evidence-based activities, where intuition is an important component associated with the nursing process. DESIGN: An integrative review strengthened with a mixed-studies review. METHODS: Literature searches were conducted in the databases CINAHL, PubMed and PsycINFO, and literature published 1985-2016 were included. The findings in the studies were analysed with content analysis, and the synthesis process entailed a reasoning between the authors. RESULTS: After a quality assessment, 16 studies were included. The analysis and synthesis resulted in three categories. The characteristics of intuition in the nurse's daily clinical activities include application, assertiveness and experiences; in the relationships with patients' intuition include unique connections, mental and bodily responses, and personal qualities; and in the nursing process include support and guidance, component and clues in decision-making, and validating decisions. CONCLUSION: Intuition is more than simply a "gut feeling," and it is a process based on knowledge and care experience and has a place beside research-based evidence. Nurses integrate both analysis and synthesis of intuition alongside objective data when making decisions. They should rely on their intuition and use this knowledge in clinical practice as a support in decision-making, which increases the quality and safety of patient care. RELEVANCE TO CLINICAL PRACTICE: We find that intuition plays a key role in more or less all of the steps in the nursing process as a base for decision-making that supports safe patient care, and is a validated component of nursing clinical care expertise.

Swedish Nurse Anesthetists' Experiences of the WHO Surgical Safety Checklist.

PURPOSE: The World Health Organization (WHO) surgical safety checklist aims to increase communication, build teamwork, and standardize routines in clinical practice in an effort to reduce complications and improve patient safety. The checklist has been implemented in surgical departments both nationally and internationally. The purpose of this study was to describe the registered nurse anesthetists' (RNA) experience with the use of the WHO surgical safety checklist. DESIGN: This was a cross-sectional study with a descriptive mixed methods design, involving nurse anesthetists from two different hospitals in Sweden. METHODS: Data were collected using a study-specific questionnaire. FINDINGS: Forty-seven RNAs answered the questionnaire. There was a statistically significant lower compliance to "Sign-in" compared with the other two parts, "Timeout" and "Sign-out." The RNAs expressed that the checklist was very important for anesthetic and perioperative care. They also expressed that by confirming their own area of expertise, they achieved an increased sense of being a team member. Thirty-four percent believed that the surgeon was responsible for the checklist, yet this was not the reality in clinical practice. Although 23% reported that they initiated use of the checklist, only one RNA believed that it was the responsibility of the RNA. Forty-three percent had received training about the checklist and its use. CONCLUSION: The WHO surgical checklist facilitates the nurse anesthetist's anesthetic and perioperative care. It allows the nurse anesthetist to better identify each patient's specific concerns and have an increased sense of being a team member.