Current practice in the United Kingdom (UK) dictates that the administration of a general anaesthetic is undertaken by a physician. However, for several years now the controversial question has been raised as to whether other practitioners, primarily nurse anaesthetists, should also be allowed administer general anaesthetics. The ensuing debate has been refueled in recent times resulting from the trend towards providing cost-effective health care delivery combined with concerns over current and anticipated further shortages in anaesthetic manpower. This paper discusses some of the arguments both for and against the introduction non-physician anaesthetists in the UK, also drawing on the debate in other parts of the world, concluding with a call for more research to address the controversy. First though, because there appears to be some confusion over the difference between the meaning of the titles ‘Anaesthetic Nurse’ and ‘Nurse Anaesthetist’, it will be helpful to provide brief definitions of these terms.

The Changing Workforce Programme (CWP) has established a national pilot that is focusing on roles within anaesthesia, in the context of new ways of working. The pilot is building on the joint evaluation work undertaken by the Changing Workforce Programme, Department of Health and the Royal College of Anaesthetists (RCA) visits to the USA, Sweden and Holland, which looked at the role of nonmedical staff in the delivery of anaesthesia services. The document The Role of Non - Medical Staff in the Delivery of Anaesthesia Services is available on the RCA website www.rcoa.ac.uk.

With regard to the problematic use of opioid analgesic drugs, attention is focused not only on those who began using opioids for recreational purposes, but also on those who may become iatrogenically addicted to opioids administered for pain control. It has been suggested that narcotics opioids cause psychological and physical dependence after relatively small therapeutic doses, for a relatively short period of administration Glatt 1974 and that physical dependence may even start to manifest after a single therapeutic dose Qones 1980. Despite these claims, some patients report that they are able to benefit from relatively long-term opioid analgesia without experiencing the effects of problematic drug use that are associated with recreational drug users (Cowan et al 2001, 2002). This issue has obvious implications for anaesthetic and recovery room practitioners who routinely administer opioids to patients in their care. In view of this, the following case study report may be of interest to such practitioners.

ABSTRACT

The application of cricoid pressure may help reduce the incidence of pulmonary aspiration in at-risk patients. Research has shown that most clinicians have a cognitive deficit concerning the correct amount of pressure to apply, anatomical landmarks and apply the incorrect amount of pressure. Too much pressure may lead to an airway obstruction or distorted view for laryngoscopy. Too little pressure may lead to pulmonary aspiration. It is imperative that clinicians who apply cricoid pressure have a thorough knowledge of basic anatomy, have a basic understanding of regurgitation/aspiration, indications, complications, contraindications and common problems/mistakes when applying cricoid pressure. Various teaching strategies to help the clinician apply correct and effective cricoid pressure have been described in the literature. All clinicians should be formally trained in the proper technique for the application of cricoid pressure.

Historically speaking, nursing actions were often based on opinions or habits with very little scientific evidence available to guide practice. The nursing process has been widely employed in basic nursing education programmes for several decades. The subsequent addition of the critical thinking component has enabled the practitioner to apply reasoning and formulate appropriate judgments about his/her patient's needs. Although many nurses lack formal education in research and evidence-based practice (EBP), frontline practitioners occupy a perfect position to stimulate and impact adoption of EBP in practice. Incorporation of EBP education and guided instruction in the EBP process for 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.

The introduction of nurse prescribing to the Irish surgical setting is a positive move toward minimizing the fragmentation of care delivery. The social emotional and financial benefits of nurse prescribing have been identified by patients as important and significant in the present uncertain economic climate.

This opportunity for the patient and surgical nurse must be part of a common purpose, in the search for improved patient care delivery.

ABSTRACT

Much has been written about the role of the nurse within the operating department but much less has been uncovered about the role of the anaesthetic nurse within this area. By detailing research undertaken by the author, anaesthetic nurses' perception of their role is recounted and how they interact with other disciplines within the operating department – Operating Department Practitioners (ODPs). These two groups appear to work in relative harmony but there is need for examination and change to the training of both nurses and ODPs, and maybe looking at core training for perioperative staff, which could be accessed at differing levels and can be re-entered at a higher level for further qualifications.

Pulse oximeters are widely used in nursing practice. They are easy to read, need no user calibration and are simple to operate. The ease of use may give rise to the view that nurses have no difficulties using pulse oximetry monitoring in patient care because it is straightforward and only requires the ‘application’ of bioscientific knowledge gained in pre-registration education.

Peri-operative nursing practice is constantly changing and demanding specialist knowledge, skills and expertise to embrace these changes. All patients in need of anaesthesia are entitled to the same high quality peri-operative care and therefore those assisting the anaesthetist must be competent and effective practitioners. With this in mind the authors shall give a reflective account highlighting the role of Anaesthetic Nurse Specialist (ANS) in promoting leadership within the peri-operative environment and how it can be nurtured and facilitated to achieve professional autonomy and promote patient advocacy.

Consent for surgical procedures is in the public domain following the Bristol and Liverpool enquiries [Department of Health, 2001a; House of Commons, 2001]. A legal and ethical principle exists whereby consent must be obtained before commencing a physical examination, starting treatment or physical investigation, or providing care. Non-compliance with this requirement is treated most seriously and professionals who choose to do otherwise risk investigation by the relevant regulatory body and/or legal proceedings. Guidance for health and social care professionals, including students, relates specifically to physical interventions on living individuals. The following research investigated patient satisfaction with the process of declaring informed consent prior to surgery. In 2006, a retrospective descriptive survey of a random sample of 200 patients two months following surgery was conducted in a local hospital in Northern Ireland. Data analysis generated frequencies and percentages using the Statistical Package for the Social Sciences (SPSS). Results suggested that the majority of respondents expressed satisfaction with the amount of information they had received, and most preferred to receive information from a mixture of doctors and nurses. The majority wanted the same amount of information, though there was a significant number who wanted more information. The importance of ensuring the patient receives adequate information prior to surgery/procedure is imperative if the health service is to offer transparency in surgical service provision in line with government guidelines.

In a recent publication by the National Association of Theatre Nurses (NATN); their Chairman Vincent (1996, p.3) suggested “Support workers, when appropriately trained, provide tremendous support to operating department professionals, assisting with the provision of a good, cost effective service, cooperating to develop new ways of working in this rapidly changing environment to respond to the needs of the patient and the service.”

When high dependency and intensive care units are full, which occurs more and more often nationally, recovery wards are being utilised to hold critically ill patients. Recovery practitioners are often expected to assist in the care of these patients.

A small study established the views of a sample of recovery practitioners regarding the recovery unit being used as stop-gap, or ICU overflow. There were positive and negative opinions from recovery practitioners who were involved in the care of these critically ill patients. Recovery practitioners often reported feeling inexperienced and ill equipped, with increased levels of stress when working in the ICU bay. Only 20% of recovery practitioners in the study, expressed optimism about working in the ICU bay, and 60% identified that training and development was a strategy which may help to overcome some of their perceived problems.

This paper reports these concerns and identifies strategies which have been implemented to address some of these concerns.

This general audit on staffing the Post Anaesthetic Care Unit (PACU) was commissioned as a result of discussions around staffing held at two British Anaesthetic and Recovery Nurses Association (BARNA) Talks seminars in November 2009 and March 2010. Audit forms were sent to all BARNA members and made available on its website. One hundred audit forms were returned. The audit results clearly indicated that many problems exist in ensuring safe and appropriate staffing in the PACU at all times. The audit results highlighted the need for BARNA to take a lead in promoting information to inform PACU staff planning and to make this information freely available on its website.

Hypertension is the most common avoidable medical indication for postponing anaesthesia and surgery and although care guidelines exist for the medical patient with hypertension, there are no accepted guidelines for pre-operative evaluation and perioperative care of patients with hypertension who undergo non-cardiac surgery. Therefore management of hypertensive surgical patients remains unclear, whether blood pressure (BP) level or BP-related target organ damage at the time of surgery predicts perioperative cardiovascular complications in patients undergoing major surgery, and thus whether deferring surgery in order to improve BP control will lead to a reduction in perioperative cardiac risk. The literature review critically evaluates the current literature on the topics of hypertension and the surgical patient, white coat hypertension and hypertension and obesity. The literature review supports the uncertainty of patient's management prior to non-cardiac elective surgery as there are no published national guidelines as a direct association between pre-operative hypertension and the perioperative cardiac complications are unclear. Although there appears to be a general agreement that patients with mild-to-moderate hypertension can proceed with surgery because such hypertension poses little additional risk of perioperative cardiovascular complications. Severe hypertension and the presence of hypertension-induced end organ damage should be postponed until better BP control is obtained.

This article on the assessment and management of ventricular arrhythmias is the third in a series exploring cardiac monitoring in the perioperative care setting. Ventricular arrhythmias, which arise within the ventricular myocardium, can be potentially lifethreatening. Many of the causes of these arrhythmias can be found in the peri-operative setting and thus it is essential that practitioners are able to differentiate the rhythms and respond appropriately.