International Perspectives on Perienesthesia Nursing and Competence

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58: International Perspectives on Perienesthesia Nursing and Competence

Ulrica Nilsson; Karuna Dahlberg; Maria Jaensson


competence; education; international perspective; perianesthesia nursing; quality; safety

International perspective

Perianesthesia nursing and perianesthesia care differ globally and the similarities and differences are sparsely described in the literature. What is known is that there are large variations and inequalities in perianesthesia care globally. Some countries have highly equipped postanesthesia care unit (PACUs) and specialist-educated perianesthesia nurses, whereas other countries lack existing PACUs and consequently have no perianesthesia nurses.


Competence More than knowledge, a person’s characteristics, and capacity to perform a task.

ICPAN International Collaboration of PeriAnaesthesia Nurses, Inc.

QSEN Quality and Safety Education for Nurses, developed from the Institute of Medicine.

Technical Skills and Nontechnical Skills Combining technical and nontechnical skills is necessary for providing safe, secure perianesthesia care. Examples of technical skills are management of drugs and infusions, use of medical equipment, airway management, perianesthesia assessment, monitoring, and interpretation. Examples of nontechnical skills are communication, teamwork, situational awareness, leadership, and decision-making.

There is no common title for the profession; some examples are recovery nurse (United Kingdom and Ireland) and perianesthesia nurse (North America). In Australia and New Zealand, the perianesthesia or perioperative nurse includes both the anesthesia nurse and the PACU nurse. In Sweden, for example, perianesthesia nursing is not yet a registered nurse specialty. In Sweden, nurses can continue second-cycle higher education and become a specialist nurse including an operating room nurse, critical care nurse, or a registered nurse anesthetist. All of those described can work in the PACU, but it is not necessary, as nurses without specialist nurse education also work in PACUs.1 No international consensus exists as to what education is needed in perianesthesia nursing. Education towards perianesthesia nursing differs, from shorter in-clinic training to a postgraduate diploma in perianesthesia nursing.2 In contrast, many low- and middle-income countries (LMICs) lack postoperative care facilities,3 perianesthesia nurses, and the ability to handle basic critical care. The lack of perianesthesia nurses and education for perianesthesia nursing in LMICs is highlighted by International Collaboration of PeriAnaesthesia Nurses (ICPAN). Therefore, an initiative to develop an educational program for nurses has been initiated by the board of directors in ICPAN.4

ICPAN was established 2015 and is a nonprofit organization. To date, 11 countries and their national organizations are members of the organization (Table 58.1). ICPAN’s mission is “To facilitate international nurse networking and sharing of practice standards, encourage collaborative research and evidence-based practice, and advance nursing expertise, voice, and participation in global safe surgery initiatives”(p. 338). The vision of ICPAN is “To promote global excellence in perianaesthesia nursing.”4

Table 58.1

Overview of Current Countries with Membership in ICPAN and Its Organizations
Country Organization Perianesthesia Nursing Recognized as Nursing Specialty Formal Education for Nurses Working in the PACU
United States of America American Society of PeriAnesthesia Nurses (ASPAN) Yes No
Canada National Association of PeriAnesthesia Nurses of Canada (NAPANc) No No
Australia Australian College of PeriAnaesthesia Nurses (ACPAN) Yes Yes
New Zealand Perioperative Nurses College of the New Zealand Nursing Organization (NZNO) No No
The Netherlands Beroepsvereniging Recovery Verpleegkundigen (BRV) Yes Yes
United Kingdom British Anaesthetic and Recovery Nurses Association (BARNA) Yes No
Denmark Danish Association of Anesthesia, Intensive Care and Recovery Nurses (FSAIO) Yes No
Finland Finnish Association of Nurse Anaesthetists (FANA) No No
Greece Hellenic Perianesthesia Nursing Organization No No
Ireland Irish Anaesthetic & Recovery Nurses Association (IARNA) Yes Yes
Sweden Swedish Association of Nurse Anesthetists and Intensive Care Nurses (ANIVA) No No

ICPAN, International Collaboration of PeriAnaesthesia Nurses, Inc.

From Dahlberg K, Brady JM, Jaensson M, et al. Education, competence, and role of the nurse working in the PACU: An international survey. J PeriAnesth Nurs. 2021;36:224–231.

Considering the sparse literature, an investigation across the 11 national organizations represented in Global Advisory Council ICPAN was initiated.5 In the 11 countries, perianesthesia nursing as a professional specialty is recognized in 6 of the 11 countries and 3 countries have formal education for nurses working in the PACU (see Table 58.1). Often nurses are the main profession stationed in the PACU. Other professions such as anesthesiologists, surgeons, and physiotherapists are also stationed in some PACUs. In Sweden, nurse assistants (in some countries they are called auxiliary nurses/assistant nurses/enrolled nurses/licensed practical nurses) work alongside perianesthesia nurses in PACUs.5

Depending on organizational and contextual factors, perianesthesia nurses work independently and, in many cases, autonomously.5 When investigating 37 tasks related to perianesthesia care, this survey revealed that perianesthesia nurses were autonomously performing 13–31 tasks (Table 58.2). The tasks that perianesthesia nurses in all 11 countries performed autonomously were temperature assessment and suction of airways. Also, in 10 out of 11 countries, perianesthesia nurses performed the following tasks autonomously: postoperative nausea and vomiting (PONV) and pain assessment; monitoring ECG, heart rate, noninvasive blood pressure and SpO2, intravenous (IV) and intramuscular injections, and insertion of IV cannula. Other commonalities included nurse-led discharge from the PACU; in both Phase I and Phase II, nurses discharged patients from PACUs autonomously or according to protocol.5

Table 58.2

Frequency of 37a Job Tasks Performed Autonomously by the Perianesthesia Nurse in the PACU in 11 Countries
Country Number of Tasks Performed Autonomously
Canada 31
New Zealandb 31
Finland 30
United States of America 29
United Kingdomc 27
Denmark 26
Ireland 26
Swedenc 21
The Netherlands 20
Australia 14
Greece 13

a Monitoring of heart rate, ECG, SpO2, end-tidal CO2, noninvasive and invasive blood pressure, central venous pressure, pulmonary capillary wedge pressure, and intracranial pressure; pain assessment, postoperative nausea and vomiting assessment, temperature assessment, suction of airways, suction of tracheostomy, insertion of oropharyngeal airway, removal of oropharyngeal airway, insertion of nasopharyngeal airway, removal of nasopharyngeal airway, removal of laryngeal mask, removal of endotracheal tube, continuous positive airway pressure device, patient on ventilator, intravenous injections, intramuscular injections, injections into an epidural catheter, starting patient-controlled analgesia/epidural analgesia, insertion of intravenous cannula, insertion of a central venous catheter, insertion of arterial line, sampling blood for lab analyses, sampling arterial blood gas, bladder scanning, urethral catheters, bladder irrigation, mobilization of the patient in the PACU, connecting and adjusting a pacemaker, informing next of kin.

b Do not know = 2.

c Do not know = 6.

From Dahlberg K, Brady JM, Jaensson M, et al. Education, competence, and role of the nurse working in the PACU: An international survey. J PeriAnesth Nurs. 2021;36:224–231.

Challenges for perianesthesia nurses

A threat to the perianesthesia community is that a shortage of health care workers is seen globally. High-income countries often rely on recruiting staff from LMICs, with the consequence that competence and human resources are drained from countries where perianesthesia nursing is already insufficient.6 Globally, perianesthesia nurses also share challenges of strained workplace environments, staffing shortages, effectiveness with shorter length of stay (LOS), and nurse fatigue.4,7,8 All these factors affect patient safety and quality of care. International collaboration can improve equity in global health care and gives new insights in perianesthesia care, sharing of best practices and cross-cultural understanding.6 To address all these issues, there is a need to pinpoint the unique competence, to investigate and disseminate the competence, and to support one another as colleagues and between countries.

Perianesthesia competence

There is a knowledge gap in research investigating perianesthesia competence. As far as we know, our research about education, competence, and the role for perianesthesia nurses from an international perspective5 is the first and hopefully more is to come. Nurses around the globe differ in education, titles, and organizations. Despite obvious differences between countries, we all share a joint competence.

Competence is sometimes used interchangeably with knowledge and this can contribute to a misconception about what is meant. In this chapter, we propose that competence is more than knowledge and it involves a person’s characteristics and capacity to perform a task.9

In the literature, the reader can meet myriad concepts often describing the same thing, namely, competence. Perianesthesia nursing competence can be described as technical and nontechnical skills.10 The latter involves decision-making, problem-solving, and prioritizing. These skills are all included in the concept clinical reasoning (CR). Also, CR is often mentioned interchangeably with clinical judgment or critical judgment.11 There is no overall definition of CR for all health professionals, but Simmons has described CR in nursing “as a complex cognitive process that uses formal and informal thinking strategies to gather and analyze patient information, evaluate the significance, and weigh alternative options” (p. 1156).11

In the perianesthesia context, nurses need to be autonomous and independent and continuously work with patient centeredness and CR to deliver safe and effective care. CR is forward thinking, from a patient encounter to information gathering, collecting cues, processing information, establishing goals, taking action, and finally evaluating outcomes.12 CR is an ongoing process, in which new cues can be added and new goals can be established. Both novice and expert nurses use CR; however, experts are more skilled at collecting cues to identify problems.13

Core competences

The care in the perianesthesia setting is complex in its nature, and nurses must adopt a holistic view combined with competence in clinical physiology, pharmacology, postoperative medicine, and nursing.14 Perianesthesia nurses’ competencies also include quality and safety competencies. In 2005, the Quality and Safety Education for Nurses (QSEN) was developed from the Institute of Medicine.15 QSEN integrates quality and safety competencies into nursing; competencies that are based on six domains: patient-centered care; teamwork and collaboration; evidence-based practice; safety; quality improvement; and informatics.16

Patient-Centered Care

At the heart of nursing is patient-centered care, patient safety, and improved patient outcomes. The concept of person-centered care can be traced back to Florence Nightingale, who differentiated between nursing and medicine through nursing’s focus on the ill person rather than the illness. Patient-centered care comprises a holistic focus, including respect, empathy, relationship, engagement, communication, shared decision-making, individualized focus, and coordinated care.17,18 It also includes initiating, integrating, and protecting the partnership with the patient and acknowledging the patient as a unique person, treating the patient with respect, giving time and space for the patient to express their personal needs, and considering the patient as a resource.14,17,19

The perianesthesia nurse must respect the patient’s values, preferences, resources, and needs; however, this has to be balanced against the specific care with regard to the specific surgery and anesthesia the patient has undergone. The nurse has to protect the patient’s life and body and engage with the patient. This commitment must be incorporated with a situational awareness of information that could be associated with potential problems, while postoperative adverse events also can occur in patients with mild or no coexisting disease. As nurses are generally the first persons to detect an adverse event, they must be observant and ready to respond urgently to patients.14,19,20

To secure person-centered care, the patient’s preferences have to be recognized when planning and performing care. As perianesthesia nurses care for and handle everything from healthy patients to unstable patients with life-threatening illnesses, they perform care ranging from wholly compensatory, to partly compensatory, to supportive/educative compensatory, as described by Orem in the Self-Care Theory in Nursing.21 Most of the care in perianesthesia settings is partly compensatory, meaning that the nurse conducts some degree of care. To engender a sense of security and reduced anxiety, the perianesthesia nurse prepares the patient by explaining the care that is going to be conducted.14 By receiving appropriate information, sharing decision-making, and treating the patient with respect and dignity, patient satisfaction and the quality of recovery can increase,14,22 and postoperative symptoms such as pain can be kept under control. Person-centered postoperative care also includes providing support towards a successful recovery; for example, the importance of early mobilization and oral hydration.14 Early oral hydration can also decrease oropharyngeal discomfort23; perhaps the most important need of the patient is to have something to drink. In person-centered postoperative care, the patient’s needs and decisions should be respected and supported as far as possible without jeopardizing the patient’s safety.14

Teamwork and Collaboration

May 20, 2023 | Posted by in NURSING | Comments Off on International Perspectives on Perienesthesia Nursing and Competence

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