The relationship between the perioperative nurse and the patient has suffered a long process of mutation throughout the last decades. If before all the dynamics experienced within an operating theatre were based upon organizational and logistical aspects, these days the focus lies on the patient and all the comfort and security demanded throughout a process that already reveals itself aggressive for the patient.
Being the front-line person in this dynamic, the anaesthetic nurse plays a crucial and intense role on the patient’s experience. An anaesthetic nurse is knowledgeable and technically skilled. However, as Flin and colleagues extensively analysed (2008), the way to safety and efficiency is the combination of technical with non-technical skills.
The following analysis is based upon three non-technical skills considered essential for the practice of anaesthetic nursing and for the appropriate use of knowledge and technical skills: communication, situation awareness and teamwork; additionally this essay will consider the way these three aspects influence and complement each other. Due to the lack of extensive literature upon the anaesthetic nurse, many examples and correlations are supported on literature from either other fields of profession or other professionals who also work within the healthcare environment.
Communication Communication, from the Latin root communicare, means to share or make common (Valpy 1828).
Circular transactional models of communication refer to this complex phenomenon as a continuous and interactive process of information exchange in which crucial elements such as sender, receiver, channel and context are greatly influenced by biological, psychosocial and environmental factors (Arnold & Boggs 2011).
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However it is fundamental to understand that communication is not restricted to words.
Body language, posture, facial expression, voice tone and touch are key elements referred to as non-verbal communication (Knapp & Hall 2010).
This type of communication can have a greater impact on the message than the words conveyed through verbal communication (Argyle 1988), for example holding patients’ hands for reassurance. Furthermore, when verbal and non-verbal communication sides of a message are not cohesive, the non-verbal cues could become more reliable than verbal information (Mehrabian 1981).
Helping patients throughout the perioperative period requires the anaesthetic nurse to identify their specific needs and anxieties, such as fear of pain or awareness during anaesthesia (Kindler et al. 2000), hence the importance of communicating effectively with the patient whilst adopting a patient-centred approach. Moreover, an open and honest communication approach can be beneficial on patients’ reassurance and compliance with treatment or procedures (National Patient Safety Agency 2007).
For instance, warning the patient he might feel some discomfort upon cannulation can avoid unexpected movements as the patients knows what to expect. The interprofessional relationship between the anaesthetic nurse and the anaesthetist also demands effective communication, particularly during stressful situations, for example induction of and emergence from anaesthesia. During these events airway management is crucial and major complications might arise as a result of communication skills (Cook et al. 2011).
The case of Elaine Bromiley is a widely known example of how failure of non-technical skills such as communication can overthrow technical expertise and lead to catastrophic outcomes (Bromiley 2009).
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Similar same skills should be evident with the remaining multidisciplinary team. The National Patient Safety Agency (2007) mentioned communication breakdown events, such as poor patient handover and inaccurate written documentation, as a contributing factor to patient deterioration. For example in the anaesthetic room, a hypoglycaemic episode could be avoided by effective patient handover.
Lingard (2004) has studied communication failures in the operative room, concluding that approximately one third of communication events are a failure; additionally, a high percentage of these failures effectively have an undesirable consequence such as inefficiency, delays or mistakes during procedures. In addition, Lingard and colleagues have studied and supported the idea of preoperative checklist and team briefings to prevent or decrease communication failures (Lingard et al. 2008).
In fact, the World Health Organization has standardised a surgical safety list (appendix 1) that through effective communication ensures the right patient, right procedure and the necessary steps/actions are guaranteed (World Health Organization 2008).
On the other hand, although a team briefing is not a requirement it enhances communication and teamwork and highlights possible issues that can be dealt more effectively if all the team members are aware and help (for example sharing with the team members an anticipated difficult intubation).
Situation Awareness Situation awareness has been explained as a three stage process: perception, comprehension and projection (Endsley 2012).
According to Endsley, situation awareness begins by perceiving the elements of the environment (Level 1) after which an integration and understanding of those elements (Level 2) will then generate a prediction of near-future events (Level 3).
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Situation awareness is one of the non-technical skills that were first acknowledged to play a crucial part in safe task performance by the aviation industry, after research on commercial plane crashes concluded that 70% of these were attributed to flight crew failure in non-technical skills (Helmreich 1993).
Understanding that aviation and anesthesia shared some concepts (as safety) Gaba et al (1995) transposed situation awareness to anaesthesia which was later referred to as an essential non-technical skill in anaesthesia (Fletcher et al, 2002).
Situation awareness is currently integrated in many marker systems that assess non-technical skills performance of several professionals in the perioperative environment such as surgeons (Yule et al. 2008), scrub nurses (Mitchell et al. 2012) and anaesthetists (Fletcher et al. 2003).
Although no specific marker system for anaesthetic nurses’ non-technical skills has been implemented, the anaesthetic nurse is part of the anaesthetic team (The Association of Anaesthetists of Great Britain and Ireland 2010) caring for the same patient with the same determination.
Therefore, non-technical skills such as situation awareness are also as fundamental for anaesthetic nursing practice as are for anaesthetists. Complementing Endsley 3 level theory, the ANTS taxonomy referred to patients, time and equipment as elements of the theatre environment. Moreover, an additional part of having situation awareness is to be alert to what the co-workers are doing – team awareness (Tenney & Pew 1995).
All these fundamental aspects of situation awareness will enable the anaesthetic nurse to deliver good patient care and skilled assistance.
For instance, in a scenario of induction of anaesthesia, first stage of situation awareness will allow the nurse to identify the patient’s inability to breathe by looking at the lack of chest movements or maybe the patients colour and alarming monitor for low O2Sats. Level 2 of situation awareness means the nurse integrates this with the fact the anaesthetist injected a paralysing agent into the patient. Finally if level 3 is reached, the nurse will anticipate that the patient will need a patent airway and the anaesthetist will require assistance to establish this.
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All three levels of situation awareness can be affected or influenced at any point by individual factors such as capacity, memory or mental models (Endsley 2012).
Following the scenario aforementioned, for example, lack of knowledge about anaesthetic drugs will prevent the development of a mental model that relates a paralysing drug to respiratory depression. Another situation that creates an obstacle to situation awareness and vice-versa, is fixation.
Fixation errors, described as the concentration of attention on one aspect in detriment of other relevant elements, also impair situation awareness, and therefore ability to deliver efficient care (Fioratou et al. 2010).
An example of a fixation error the case of Elaine Bromiley (Bromiley 2009) where lack of situation awareness or awareness of only certain elements (in detriment of elements such as length of hypoxia time) lead to the inability to identify a failed ventilation (appendix 2) situation (Henderson et al.2004).
Situation awareness lives together with communication. When Martin Bromiley (2009) illustrated his wife’s anaesthetic incident, a relevant mention was made to the situation awareness of the nurses who knew what was happening and what needed to be done. Unfortunately, communication issues within the team made any positive contribution from the nurses unsound.
