Analysis of Anaesthetic Nursing - Research Paper Example

Analysis of Anaesthetic Nursing Introduction Anaesthesia denotes loss of sensation and ‘anaesthesiology’ connotes the practice in pain management or pain relief. Latest developments of theories have significant influence on the role of the anaesthetic nurses, since anaesthetists are working in close co-ordination with the surgeons, the role of anaesthetists/anaesthetic nurses is very crucial. The benefits of anaesthesia in terms of pain relief need to be balanced against the procedural risks which also to a larger extent depend upon factors such as anaesthetic agent used, pre-existing illness, age and constitution of the person. Physician’s assistants and nurses are usually involved when anaesthetic is underway under the guidance of anaesthetists and the anaesthetists direct intervention is required at the time of administration and at the end. Since nurses have to play a significant role in the patients’ care, tactfulness, knowledge, experience in handling emergency situation, discretion, judgment, alertness and empathy on their part are very important for overall efficiency in treatment to the patients. Evidence based anaesthesia nursing practice calls for placing more emphasis on literature evidence than scientific studies for enhancing the expertise in the field of anaesthesia. For use of current evidence in providing care to the patients, it is essential to analyze the existing evidences in terms of definition of the problem, applications used to overcome the problems, methods adopted, reliability of the evidences used for the study, clinical trials, surveys, expert opinions or case reports and applicability of the evidences to the present case for formulating strategies and implementation by establishing standards. Evolution of Anaesthetic nursing Though Nightingale’s ideology is considered as the starting point for modern nursing, theoretical basis for nursing has evolved later in the history. Frederic Hewitt’s textbook on Anaesthetics and their Administration in 1893 was an important milestone in training in the field of anaesthesia (Scurr, 1971, p. 275). Ether and chloroform had been used as anaesthetic agents for a long time as they were effective and fast. A patient “under ether, sinks into a calm and dreamless sleep” and surgery is performed successfully without suffering pain, but “the danger in breathing ether is chiefly from impeded or failing respiration” (Cheever, 1884, p. 509). However, after the advent of advanced and safer inhalation anaesthetic agents, use of ether and chloroform has been gradually stopped. Chloroform was widely used as an anaesthetic agent. However, it was later found that it caused cardiac problems to the patients and abandoned also due to its toxic properties. Brandy, opium and cocaine were used as anaesthetics throughout the world in various countries. There are number of derivatives such as amylocaine and procaine that are cocaine based. Regulations and standardisation in different countries brought control over their manufacturing and use. Opioid compounds have been used in treatment of pain for a long time in medical history due to its analgesic effects. Opiate based drugs like Codeine and Hydrocodone have been used as pain killers. These drugs have addictive properties which lead to dependence on these drugs. Morphine is a widely used opiate analgesic drug and regarded as standard analgesic. Advent of morphine which could be injected hypodermically changed the course of anaesthesiology completely. Diamorphine called as heroine used to treat severe pain can also be administered intravenously. Nitrous oxide is commonly used in dentistry as an inhalation analgesic. It is considered effective and safe to provide moderate sedation. It is effective as general anaesthesia for suppressing all sensations. It should be cautiously used in some cases like schizophrenia or pregnancy. “Nitrous oxide (N2O) has been used for about 150 years in clinical anaesthesia. Several recent reviews of the effect of nitrous oxide have concluded that there are certain contraindications to the use of this gas for general anaesthesia and its ecological effects, ozone depleting potential, immune depression...” (Gilani and Sofi, 2008, p. 149) Heliox, a mixture of Helium (He) and oxygen (O2) is used for delivery of anaesthesia. Jagannathan et al. (2013, p. 638) stated “administration of an anaesthetic induction agent and neuromuscular blockade before the intubation process minimises the risk of trauma, laryngospasm, bronchospasm and potential dislodgement of the tracheal tube.” In tune with the scientific and technological changes, the system of education has been developed over years with specialization in anaesthesia. In line with the developments in the field of anaesthesiology, the nurses also specialise in anaesthesia to become nurse anaesthetists. Similarly, anaesthesiological assistants specially qualified and trained in this area provide anaesthesia under the supervision of anaesthetist. The refinements in theories over years have increased the responsibilities of the nurses and anaesthetic nursing has become a specialised area. Also, the nursing theories have been evolving to ensure nursing practices to cope up with these developments and the Nursing Diagnosis Classification systems established have enhanced the level of practice of anaesthetic nursing. Therefore, nursing diagnosis is considered an important feature from the view point of responsibility and accountability of independent nursing practice as well. It is important to note that theory based nursing has brought in professionalism and thereby credibility and respectability to the nursing practice in general. Role of anaesthetic nursing The application of nursing models such as Neuman Model or Roy Adaptation Model and nursing theories has culminated into Nursing Diagnosis Movement. Specialisation and diversity in roles that include General Nursing, Paediatric Nursing and Anaesthetic Nursing were necessitated in this juncture. Also personal attributes such as knowledge, interpersonal skills, leadership qualities, previous experiences and communication abilities need to be taken into consideration. Defining the professional role of an Anaesthetic Nurse is very challenging and it is based on their contribution to the care and quality of care apart from theory, practice and professionalism. The role of anaesthetic nurse is very important right from the pre-assessment stage involving clinical tests, applying local anaesthetic cream on the skin before using needle and taking the patient to the anaesthetic room or preparing the patients for emergency ward. The nurses also oversee patient-control analgesia. Nurses are the important part in pain relief team in post-operation phase and watch for side effects of the drugs used for taking remedial measures. They are also concerned with the stability of the patient post-operation. The anaesthetic drugs are used after carefully assessing the risks and side effects in relation to safety in all the cases. However, the probability factor relating to the risks associated with anaesthesia varies from person to person and in some cases side effects cannot be avoided and complications developed due to allergy, breathing difficulties or head ache. The nursing professionals have to ensure that the anaesthetic machines have undergone check-ups before using them to avoid problems that could be encountered during surgeries. For example, blockage in anaesthetic circuit has been reported in some cases, which could have been avoided in check-ups. Anaesthetist’s presence for resuscitation of a person in recovery should always be taken into consideration. The dual responsibility on the part of the anaesthetists has to be overcome by properly synchronising with the anaesthetic nursing professionals. Anaesthetic nurse is mainly responsible for: Verifying medical history, Overseeing the patients’ condition, Determining the method of anaesthesia, Regulating the flow of anaesthetic agent administered, Measuring and monitoring the vital signs of the patients, Co-ordinating with the surgeon for stability of the patient’s condition and Monitoring the recovery process Overseeing patients post operation for pain relief There are several types of incidents that may occur in anaesthetic specialty which are relating to or include inter alia: accidents involving patients, consent, documentation, infrastructure, aggressive behaviour of the patient, infections, refusal to admission, transfer or discharge and medical instruments. It could be observed from the nature of the incidents that the nursing professionals are directly involved in these incidents, and they need to co-ordinate with the staffs of different departments to ensure smooth functioning of the system in providing care to the patients. It is also important to comply with the protocols and operational standards to avoid breach of regulations. Anaesthetic nurses work in different areas of the hospitals which include: Intensive Care Units, Paediatric anaesthesia, Cardiac anaesthesia, Obstetric anaesthesia, Pain relief anaesthesia and Emergency wards. Primarily blocking of the signals in the nervous system to prevent communication with the brain temporarily is the objective involved in anaesthesia. Normal sensation revives when the effects of the drugs used wear off. This means the pain associated with the disease comes back. Anaesthesia need not result in unconsciousness in all the cases and the major types of anaesthesia are: Local Anaesthesia, Regional Anaesthesia and General Anaesthesia. In the case of local anaesthesia, the patient is relieved of the pain but conscious. Spinal and epidural anaesthetics are the examples of regional anaesthesia where the drugs are injected near the appropriate nerve centres. Under General anaesthesia, the patient is in a state of ‘controlled unconsciousness’ which is achieved though injections into the veins or passing anaesthetic gases into the lungs. Therefore, the reactions to the events by the nurses under these types of anaesthesia and the condition of the patients vary. The responsibilities of the anaesthetist as well as the anaesthetic nurse in the process include: Assessment of the suitable anaesthetic agent, using appropriate equipment to monitor the operation for regulating the supply of drug, ensuring safety in dosage while administering drugs and planning for pain relief in recovery phase. “Guidance and standards documents are works in progress in which a balance must be struck between expert opinion and evidence, and satisfactory and excellent standards. They do not replace the need for experienced clinical judgement exercised by individual anaesthetists in the best interests of their patients, but they are very much intended to support this” (The Royal College of Anaesthetists, 2013).  Certified Registered Nurse Anaesthetists practice in hospitals, pain clinics or in other medical centres both in public and private sector and give anaesthesia care to the patients or function in co-ordination with anaesthesiologists in providing care depending upon the organisational setup. British Anaesthetic & Recovery Nurses Association has issued standards for nurses working within the peri-anaesthetic and recovery environment and “expects their members to follow these standards and provide professional care which is delivered in an ethical manner, for the benefit of patients and the reduction of risk” (barna, 2013). Maintaining standards in the delivery of anaesthetic services hinges on organisational structure, management’s commitment and the knowledge, skills and attitude of the practitioners. Growing expectations consequent upon increased awareness among the patients due to advent of internet and other developments such as social media added new dimension to the medical services in terms of enhanced level of services, ethical standards and regulatory compliance in view of litigations considering the risks involved. Audit of practicing in anaesthesia has gained prominence over years in the evolutionary process. Trust and confidence reposed on the anaesthetic nurse by the anxious patients is very crucial for overall success. Pain management process is critical as it involved dealing with the patients and their family who are emotionally charged. It is very important to make the patients comfortable by clearing their doubts without prejudice by being courteous while obtaining their consent through effective interpersonal relationship in the process. The anaesthetic nurse’s ability to work harmoniously with the team consisting of doctors and other health professionals is very important in providing quality anaesthetic service to the patients. Diversity in responsibilities of the anaesthetic nurses in different departments of the hospital anaesthetic interventions needs to be managed efficiently. Co-ordination or delegation/sharing of responsibilities with the other team members should be carried out effectively since accountability does not change. Anaesthetic care starts from pre-operative visit to cessation of the effects of anaesthetic agents and the anaesthetic nurse is involved in every stage. Approaches to enhance evidence based anaesthetic nursing practice Patients look at anaesthetic nurse for reassurance during pre-operation, operation and post-operation stages. Therefore, anaesthetic intervention calls for balance between human care and good understanding of physiology as well as psychology in dealing with the patients in surgical environment. The nature of this role makes an anaesthetic nurse very important in the perioperative team. Evidence based practice enhances reliability of the methods adopted. Meticulous evaluation of literature available is essential for systematic appraisal of evidences. Various experiments or researches conducted in anaesthesia need to be carefully reviewed. Opinions of the industry experts with regard to efficacy of the solutions should be sought for if necessary. Review of the developments or evolution of the process over years will give a broader picture. A systematic approach to the problem in the following lines with modifications depending upon the circumstances, which may vary from case to case, is necessary. Author Single/group Institution University/organization Research question/objective Relevance Variables in the study Independent and dependent variables Method of Data collection Questionnaire/Survey Sampling used in study Adequacy and appropriateness Results Probability Supporting evidences Advantages Benefits Resources needed Shortcomings/drawbacks Grading of the evidences is made based on the data gathered as outlined for adoption, discarding or further analysis. No. Grade Description Remarks 1. 80-100 Very good evidence. Recommended for use. 2. 70-80 Good evidence. Can be considered for adoption. Obtain expert opinion. 3. 50-70 Further evidence needed. Problems are not addressed fully. Drawbacks are not explained satisfactorily. 4. Less than 50 Not recommended Poor quality of research. Lack of good evidence. Risk – reward is negative. According to Brady (2011, p. 53) “Incorporation of EBP education and guided instructions in the EBP process for an anaesthetic and recovery nurses can only serve to sustain its primary goal of combining the best available evidence with skilled professional opinion to achieve safe and sound practice at the bedside.” Patient safety and avoiding untoward incidents in anaesthesia call for adhering to the highest level of standards in practice. Though it is unavoidable untoward incidents completely, taking precautions to avoid recurrence of such incidents is of paramount importance. The nurses play an important role in monitoring the patients during treatment as well as in the recovery phase. Therefore, reporting of such incidents enable further analysis of the attendant risks involved in treatment. Sharing of such information is vital for enhancing the level of care and making improvements. The anaesthetic nurse should have communication skills to effectively communicate the issues to the other team members for solving the problems. Evidence based anaesthetic nursing practice, if properly followed, will form a strong basis in the system for the improvement in practices and procedures. Evidence based practice relates to various aspects in day to day activities of nursing which includes checking general health condition of the patient, administration of drugs, and pain relief after surgery. General health condition of the patient is very important in anaesthesia and the anaesthetic nurse plays a vital role in checking up the general health and fitness of the patients, pre-existing diseases, allergic conditions, health history of the patients and their parents or family members, chest pain, respiratory problems, habits of the patients such as smoking and consumption of alcohol or use of drugs. This information would be very useful in deciding the anaesthetic agent and its dosage. Evidence based practice enhances confidence in approach and ensures sustainable development in practice. Developments in anaesthetic nursing Anaesthesia is given in the emergency ward generally by the nurses. Developments such as application of ultrasound guidance and electrical simulation in paediatric cardiac anaesthesia for surgeries relating to complex heart diseases of children have enhanced the results in the last decade (Ponde, 2012). Continuous learning is very important to keep pace with the developments in science and technology relating to the field. Therefore, publications of the organisations like The Royal College of Anaesthetics and Association of Anaesthetists of Great Britain and Ireland are considered essential for upgrading knowledge. For example Paolo et al. (2013) stated “Protective mechanical ventilation provided during general anaesthesia for open abdominal surgery improved respiratory function and reduced clinical signs of pulmonary infection during the first 5 days after surgery.” There are number of research papers published in this field. Electronic processing and analysis of the data available with the hospitals would be useful in developing strategies to enhance patient care based on the historical data, suitably adjusted for abnormalities. “Risk prediction models can be used not only to aid in a diagnostic or prognostic setting, but also as a risk-adjustment tool in a monitoring and auditing context” (Gary and Yannick, 2013). Multivariable risk prediction models developed and other research papers published on continuous basis by various journals such as Anesthesiology, British Journal of Anaesthesia, Anesthesia and Analgesia and Anesthesia and Intensive Care would be useful in identifying the causes for variations in outcomes between different hospitals, patient groups or other factors through comparison. New anaesthetic agents are developed and marketed by the companies after trials and testing to make anaesthesia safer in administration to the patients. Science News (2012) reported “Researchers are using sophisticated and powerful new tools to develop and evaluate new anesthetic agents with important advantages over current drugs, according to a set of papers in the August issue of Anesthesia & Analgesia, official journal of the International Anesthesia Research Society (IARS).” Intravenous anaesthesia is increasingly preferred by the anaesthetists. The drugs which are presently in use are refined or reformulated to enhance their efficacy or ensure safety in application. In spite of the failures in development of the drugs, the process in search of new forms of drugs continues. Research continues to extend the scope of i.v. anaesthesia and to find novel applications for old drugs. Increasing familiarity with the necessary clinical techniques of i.v. anaesthesia and their theoretical underpinnings will probably increase their use. Future drug development in anaesthesia is likely to be determined by commercial imperatives. (Sneyd, 2013, p. 732.) Auditing has become an integral part of the practice in hospitals. Auditing process is mainly carried out with regard to case reports in respect of mortality and morbidity, critical incidents relating to anaesthetic interventions, feedback of the patients about the service, complaints received, suggestions and grievances of the patients about anaesthetic services, review of the procedures, standards and comparison with the historical data for abnormalities. It could be observed that anaesthetic nursing is involved in every stage in providing service and the nurses are required to co-ordinate with the various participants in the process. Therefore, training to the anaesthetic nurses in dealing with the patients, administration of drugs, post-operative procedures and emergencies will improve the level of service. Mistakes in anaesthetic intervention have serious consequences to the patients as well as anaesthetists. In case of errors, it is important to report them promptly, analyse the causes for preventing them in future. Recommendations and conclusion Anaesthetic nurse should possess good knowledge about the protocols and important aspects of the practice such as classification of risks associated with anaesthesia, selection of appropriate anaesthetic drugs for use, administration of anaesthesia, dosage or levels and intubation techniques. Anaesthetic nursing is a challenging job since the anaesthetic nursing professionals need to be highly skilled and trained to ensure patients’ care during surgical procedures. In post anaesthesia care unit the patients have to be monitored for side effects and other complications. In the case of general anaesthesia there are complications such as suffocation and organ failures or death. Since the science and technology relating to anaesthesia is rapidly changing, upgrading their skills on a continuous basis is prerequisite for a successful practice. The hospitals or other organisations should provide education and training facilities on a regular basis to the anaesthetic nurses. They should be encouraged to participate in conferences and seminars for being in touch with the latest developments in the field. Compliance with the protocols and standards by the anaesthetists and the anaesthetic nurses is very important and it should be ensured through internal auditing. The standards or protocols need to be revised based on the changes in the methods or procedures for discarding the obsolete standards to avoid ambiguity in the operations. The management should provide opportunities to the professionals for evidence based practice. Surveys and exit interviews should be conducted on a regular basis to know the experience and reactions of the patients for improving the level of services for sustainable growth and development of the organisation. References Brady, J. M., 2011. Evidence-Based Practice Application: A Goal for Anaesthetic and Recovery Nurses. British Journal of Anaesthetic and Recovery Nursing, 12(3-4) Aug. 2011, pp. 53-56. British Anaesthetic & Recovery Nurses Association (barna), 2013. Standards and position statements. [online] Available at [Accessed 28 Mau 2013]. Cheever, D. W., 1884. Some of the Dangers and Disadvantages of Anaethesia. Boston Med Surg J 1884; 110:509-511 May 29, 1884. Gary, C. and Yannick, L. M., 2013. Multivariable Risk Prediction Models: It’s All about the Performance. Anesthesiology, June 2013, 118(6) pp. 1252-1253. Gilani, S.M. and Sofi, K., 2008. Is nitrous oxide necessary for general anaesthesia? PubMed 2008 Oct-Dec;20(4):149-52. Jagannathan, N., Sobh, L. E. and Eidem, J. M., 2013. Use of the air-Q intubating laryngeal airway for rapid-sequence intubation in infants with severe airway obstruction: a case series. Anaesthesia 2013, 68, 636–638. Paolo, et al., 2013. Protective Mechanical Ventilation during General Anesthesia for Open Abdominal Surgery Improves Postoperative Pulmonary Function. Anesthesiology, June 2013, 118(6) pp. 1307-1321 Ponde, V. C., 2012. Recent Developments in paediatric neuraxial blocks. Indian Journal of Anaesthesia, 56(5), Sep-Oct 2012. pp.470-478. Science News, 2013. New Anesthesia Drugs Developed to Be 'Fast, Clean, and Soft' July 31, 2012. http://www.sciencedaily.com/releases/2012/07/120731123251.htm Sneyd, J. R., 2004. Recent advances in intravenous anaesthesia. British Journal of Anaesthesia 93 (5): 725–36 (2004) The Royal College of Anaesthetists, 2013. Recommended Standards of Clinical Practice. [online] Available at [Accessed 28 May 2013]. Read More