Table 3: Themes and subthemes
Developing competence in clinical anaesthesia practice
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Barriers and facilitators of collaboration and teamwork
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Improving patient safety and outcomes through structured assessments
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Organisational factors affecting delivery of healthcare to surgical patients
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Aspects that influence everyday work of anaesthesia personnel
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Increased learning through the assessment of patients
Increased responsibility when working in PAC
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Internal teamwork
Interdisciplinary collaboration
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Patient knowledge, experience, and involvement
Improvement of patient outcomes
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Implementation of PAC
Effects of having a PAC
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Logistical challenges and time factors
Increase in workload pressure
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PAC, preanesthetic assessment clinic
Developing competence in clinical anaesthesia practice
The participants said that the PACs were an arena for learning more about anaesthesia, especially for anaesthesia nurses and anaesthesia residents, and they perceived an increase in their competence.
“For my own part, I learn a lot. The fact that you must complete it [anaesthesia form] yourself, I think it is very instructive to find out what is important to obtain good quality information” (Participant 11).
Anaesthesia nurses felt that they understood the anaesthesiologist’s job better when they worked in the PAC, making it easier for them to understand the arguments provided after patient assessment. Anaesthesia personnel learned a lot about different medications, which they considered important knowledge. However, they reported experiencing a rapid development in different type of medications with missing national guidelines on some type of medications in relation to surgery.
“In addition…for some things, there are bad national guidelines on what is correct. Where you see that in England, for example, surgery is performed in a completely different way than us with a different approach to the new antidiabetic drugs, and that it is a work that is terribly difficult to do locally. So, I miss some updated national guidelines on regular medications in relation to surgery” (Participant 7).
Anaesthesiologists pointed out that anaesthesia nurses learned from assessing ASA 1 and 2 patients, but it was also very important that they participated in assessing the ASA 3 and 4 patients due to the learning experience. Anaesthesia nurses were also recognised for being good at talking to the patients and their notes were well written in the medical records. In addition, anaesthesia nurses thought that their work at the PAC reflected their competence and that they would achieve a higher professional status. Participants also said that with time, they will gain experience from their work, making it easier to perform.
“You must get used to the work, learn how to work efficiently and smoothly with the system that is used in the PAC. And when you gain control and feel that you have mastered it, then I really think it's a very decent way to work” (Participant 1).
Anaesthesia nurses described that working in a PAC involved a lot of responsibility. They encountered different settings compared to what they were used to in the anaesthesia wards. They signed the documents and were more responsible for their own assessments of the patients. Additionally, they were afraid of making mistakes or forgetting something important.
“In the past, it was the anaesthesiologist’s responsibility to perform the assessment on the patient preoperatively either on the ward or only on paper. So, when I am in charge of the assessment, I feel very responsible. I am very scared of not catching things that I should have” (Participant 3).
However, anaesthesia nurses emphasised that they had good competence as anaesthesia nurses, and that they trusted this competence. The teamwork with the anaesthesiologist made the job easier because they knew that they could ask for help and that the anaesthesiologist double-checked their assessments and documentation. They felt collaboration was an extra safety measure.
“I am an anaesthesia nurse, and I have a lot of knowledge as an anaesthesia nurse, and I trust it. I notice it holds up the work and challenges I face while working in the PAC. Because I have the anaesthesiologist as my closest partner who happily helps me, I feel that I can bear the responsibility” (Participant 4).
Anaesthesia personnel also mentioned the shared responsibility between the surgeon and the anaesthesiologist, and that today there are no clear lines regarding the division of labour.
“The line between the surgeon's responsibility and anaesthesiologist’s responsibility… it is also important that it becomes… that you have clear lines there” (Participant 6).
Barriers and facilitators of collaboration and teamwork
Anaesthesiologists and anaesthesia nurses explained that they were depending on each other to ensure that the PAC functioned properly. Some said that they got to know each other better, not only as professionals, but also on a personal level. However, all pointed out that you connect better with some colleagues than with others.
“There will always be a system component and personal component. It will be a bit variable between the nurses and doctors that are working on a given day” (Participant 7).
For the most part, the teamwork functioned well, but sometimes, the anaesthesiologist was needed elsewhere/had other assignments and the anaesthesia nurse had to call another anaesthesiologist for help. Some anaesthesia nurses said that some anaesthesiologists were more engaged in the work at the PAC because they all saw the advantage of having a PAC. However, some anaesthesiologists pointed out that it made sense to them that they should collaborate with anaesthesia nurses in the PAC, because they worked so closely in the OR.
“It gives a new arena of collaboration with the anaesthesia nurses, which I think is positive. Mostly the anaesthesia nurses write better preview forms than I do. My assessments are perhaps more thorough or better professionally based. We find a good partnership” (Participant 8).
Several participants said that they missed feedback from their colleagues working in the anaesthesia ward (both anaesthesia nurses and anaesthesiologists). However, when they did not get feedback, they assumed that everything was good and that they had done a good job with the assessments. However, some participants said that they had only experienced positive feedback, and especially from the anaesthesiologist on whom anaesthesia nurses rely for their daily work.
The PAC was experienced as a place where collaboration between surgeons, wards, nurses, and interns was important during daily procedures to achieve the best outcomes for the patients even though they all have a different focus.
“I think it has been a good arena to collaborate [teamwork] with the surgeons. One is almost forced to have more contact with each other, and I think it has been very positive” (Participant 10).
However, anaesthesia nurses and anaesthesiologists said that they sometimes had to make sure that surgeons did their job. For instant, if they did not remind them to stop the medications preliminarily, they knew that the planned surgery would be postponed. They also pointed out that sometimes the surgeon did not understand their work and focus.
“I used to refer to Lorentz Grahn, the master of anaesthesia in Norway. He starts the textbook by saying that there are small and large procedures in surgery, but not small and large anaesthetics. And I think we find that it is not always the surgeons who thinks about these consequences” (Participant 6).
Improving patient safety and outcomes through structured assessment
Anaesthesia personnel focused on the conversations with the patients and how the information given to the patients could influence the patient’s feeling of safety.
“We had an adult lady with intellectual disabilities who needed surgery. She had surgery at a local hospital earlier with coercive measures. She told us she was afraid of people in green clothes. We then asked her if it was better if we used blue clothes. She liked blue, so it went very well” (Participant 6).
PACs provide an excellent opportunity for patients to ask questions, obtain information about anaesthesia, correct misunderstandings, and talk about former anaesthesia experiences.
“There are a lot of patients who say that they were not afraid of the surgery, but they were afraid of never waking up again. I think it is very nice that we can inform them about what anaesthesia in the 20th century means and how it works. I think it is an advantage for the patients to get this information” (Participant 6).
Patients could come with a request for the anaesthesia they wanted and be a part of the decision-making process. However, anaesthesia personnel always prioritised safety; therefore, for instance, if the patient wanted general anaesthesia and the safest option was spinal anaesthesia, they tried to convince the patient with professional arguments to accept the spinal anaesthesia.
“And then they tell us about previous experiences, both good and bad. And then we try to find something that fits them. So, they can come with their own views” (Participant 9).
Anaesthesia personnel talked about the advantages of having a PAC related to patient safety and felt that it was a lot easier to identify patients at risk when they had time to sit down, and physically see and talk to the patients with the journal and self-declaration form in front of them before surgery. Some potential complications could be discovered just by looking at the patient’s neck, mouth, hands, and body.
“You absolutely identify the risk factors. There are many things like allergies for instance, it does not have to be in the journal. Then it sort of comes in a subordinate sentence from the patient. Yes, I had a terrible reaction to penicillin once. You know, things like that can just pop-up when we interview them. So, you may get information that has not been noted in the journal” (Participant 13).
The participants said that their experience was that if the anaesthesia assessment was done on the day of the surgery, the patient could more easily forget to inform them about certain conditions because their focus was elsewhere. Some cases needed to be referred to other specialties for further examination before it was safe to perform the surgery, thus avoiding cancellations on the day of surgery or an unwanted incident in the OR.
Anaesthesia personnel stated that the implementation of PAC had led to the development of protocols that improved the follow-up of premedication and identification of pain and nausea, which was described as positive.
“One of the advantages of a PAC is that almost everyone is prescribed a premedication, which has a lot of impact postoperatively. In relation to many patients coming from the wards or emergency patients who have not received premedication, they obviously have a lot more pain postoperatively” (Participant 3).
According to participants, the journal notes of all patients assessed in the PAC contributed to quality assurance. Anaesthesia personnel working in the anaesthesia wards used these journal notes to obtain information about the patient on the day of surgery (together with previous hospital admission notes and blood tests), and it gave them a quick overview of the most important data that were important for anaesthesia.
“Maybe the patient has been in the hospital 10 times in the last two years, so you could scroll back the previous hospital notes, but you are unsure if you can capture everything; however, here you have a note that captures the essence. I think it is obvious, if I have a patient who has been to the PAC, then I learn a lot from that note and I use it a lot” (Participant 2).
They all felt that this journal note saved time and contributed to safe practice, and it was easier to focus on the patient on the day of the surgery.
“We get good feedback from those who read the PAC notes. It makes the everyday life in the OR easier as I can quickly get an overview of the patient's health” (Participant 5).
It was time consuming if the same patient came back for surgery later, and they had to search for the old journal to find out if something new had appeared. In the journal notes, it was suggested what kind of anaesthesia the patient should get. However, this could be changed on the day of the surgery by the responsible anaesthesiologist.
Organisational factors affecting delivery of healthcare to surgical patients
Many participants had worked in hospitals without a PAC. They felt that when the anaesthesia assessments were performed at an earlier stage, it was easier to discover unresolved medical conditions that required further investigations, which helped in reducing the long traveling time for patients. Moreover, the workflow with the surgical patients was streamlined, resulting in an increased efficiency of surgery.
“Yes, it was probably to get a better patient flow, to avoid situations where the patients were not well prepared when they came to the OR. They could get the assessment they needed in advance and there would be less cancellations of surgery because of poor preoperative assessment. Additionally, it probably helped to organise us a little better as well” (Participant 5).
Challenges appeared when the PAC was implemented. Some hospitals did not have enough space to establish the PAC. Anaesthesia personnel had different opinions on what kind of patients should be assessed at the PAC, and the organisational structure regarding patient groups differed among the hospitals. Some hospitals referred all patients to the PAC, including children, while others referred only specific surgical and orthopaedic specialties. Some participants said they felt that the available resources decided what kind of patients could be seen in the PAC.
“Then there are some who think that it has less to do with healthy patients, that if the self-declaration is unproblematic then there is little point in calling them in. But at the same time, for example people can give a very bad self-declaration on potentially difficult airways” (Participant 7).
Some participants felt that the PAC reduced the length of hospital stay. Everything was prepared in advance; consequently, the patients did not need to be admitted before the day of surgery. Some participants pointed out that a shorter stay in hospital contributed to a lower risk of being colonised with the hospital microbiological flora before surgery, thus preventing infection.
“Shorter hospital stays are one thing, but it also reduces the risk of infection because they are not colonised with the hospital flora before the operation. I think it prevents infections (Participant 1).”
Participants said that cancellations of surgery and delays in the operating room (OR) were reduced when patients attended the PAC. Therefore, the hospital could utilise the operating capacity and fit in another elective surgery. Participants mentioned that this must be financially advantageous for the hospitals.
“Different surgical specialties said they got more patients through because they attended the PAC, and they could avoid cancelations of surgery because of lack of correct preparations” (Participant 4).
Aspects that influence the everyday work of anaesthesia personnel
To have enough time scheduled for each patient was an important factor to make the work situation optimal. It is difficult to know in advance what kind of patients were coming in regarding the health status, medical history, and planned surgical procedure.
“The time required is not easy to predict; therefore, we need to understand that some patients need more time than the others. There must be some possibilities to make room for demanding patients that need more time” (Participant 1).
Participants mentioned that PAC was time consuming, particularly on the day of surgery. However, the patient was decently prepared in advance, and the anaesthesiologist or/and anaesthesia nurse could focus more on the patient and his/her well-being.
“We see a patient with a short neck, we know we will get an intubation problem. It has been identified; it says in the PAC note. Yes, then we prepare for it in the OR. So, I think we save time and increase patient safety” (Participant 5)
Availability of anaesthesiologists was important for the workflow in the PAC. Sometimes, they had other tasks such as being responsible for a surgical room in the OR, and this made the job difficult for anaesthesia nurses working in the PAC in a different location.
How participants experience the workload varied, partly because of the different organisational structure of the hospitals. Some of the working days could be busy, stressful, and tiring.
“It is sometimes so tiring that one dreads the day on the PAC, because you sometimes have up to 16 patients” (Participant 13).
Others mentioned that the days in the PAC could be slow and gave them energy for the rest of the week when they experienced busy working days at the anaesthesia ward. They wished that days at the PAC could be more predictable. However, some participants highlighted that working in the PAC was a good change from other days when they were working in anaesthesia wards. Nevertheless, most participants said that they would not work at the PAC fulltime, while others considered working there as a duty because they saw how important PAC was for anaesthesia patients and anaesthesia ward. Participants also pointed out that a lot of resources were spent on the PAC, but they were worth it.
“It was not like I was cheering when I got that job, and when people are put in the PAC, it is often with some reluctance because it is not something they perceive as fun work, but most people realise that it is useful work” (Participant 7).
The COVID-19 pandemic stopped many activities in the PAC, and some participants felt that these activities did not necessarily have to be performed in a physical room in the hospital but could perhaps be completed on a digital platform. For patients travelling long distances, they suggested that this could be a better solution.