**2.3 Nurse anaesthetist and operating room nurses and their professional responsibilities**

In 40 low- and middle-income countries, NAs provide induction, maintenance and emergence of anaesthesia, independently, and in close collaboration with anaesthesiologists [13]. The International Federation of Nurse Anaesthetists (IFNA) identified the following components, among others, in the role described as "Nurse anaesthetist expert": anaesthetic management, pre-anaesthetic pain management, risk management, advanced life support, monitoring, termination of anaesthesia,

post-operative care and pain management, infection control, communication, collaboration and teamwork, task and quality management, patient information, patient education, patient advocacy, continuous professional development, research and education. IFNA is a global organisation, representing over 40 member countries and is an affiliate of the International Council of Nursing (ICN) [14].

The roles and education of nurse anaesthetists vary. The Nordic countries have different types of anaesthesia nursing education, ranging from non-degree supplementary programmes to master's degree programmes [15]. In Sweden, to become a specialist nurse in anaesthesia care or operating room nursing care requires a university training of 60 credits at an advanced level (in addition to a registered nurse degree, which is a three-year bachelor's degree in university education), and a master's degree in nursing. According to the competence description for nurse anaesthetists, they should have good knowledge in both nursing and medical sciences, ethics, medical technology, pedagogy, scientific theory, laws and regulations and working during major crises. According to their competency description, two nurse anaesthetists may independently start a case or terminate the anaesthesia when the patient is healthy (ASA 1–2), with approval from the responsible anaesthesiologist. Furthermore, the nurse anaesthetist may assess the patient's airway and intubate the patient. ASA stands for the American Society of Anaesthesiologists: ASA 1 is a healthy patient and ASA 2 stands for patients with a mild systemic disease without significant functional limitations. In Switzerland, the role of a nurse anaesthetist requires a 2-year nurse anaesthesia programme, and a nurse diploma is also mandatory. The education includes at least 900 h of additional didactic training. To become a Certified Registered Nurse Anaesthetist (CRNA) in the US, a master's degree from an accredited nurse anaesthesia educational programme is required [16].

According to the European Operating Room Nurse Association (EORNA), education for OR nurses should contain the following five core competencies: professional, ethical and legal practice; nursing care and perioperative nursing practice; interpersonal relationships and communication; organisational, managerial and leadership skills; and educational, research and professional development. As stated in the competence description for OR nurses (also called scrub nurses), their responsibilities include ensuring that the operating room is aseptic; being responsible for correct ventilation in the operating room; patient preparation and safety; control of instruments and instrumentation; infection prevention and complication prevention measures in connection with surgery and handling of biological material. OR nurses may work in operating rooms, ambulatory day surgery units, and in other fields where invasive techniques are used (Endoscopy Unit, interventional radiology, etc) [17]. OR nurses possess unique non-technical skills (which are decision-making, situation awareness, communication, teamwork and leadership); thus by listening to the tone of someone's voice, observing expressions in surgeon's eyes or paying attention to the changing sounds of the instruments, they anticipate what the surgeon will do next. NAs and OR nurses must work according to six competencies, besides verifying patient id, and ensuring that the correct body part is marked for surgery (NAs also verify fasting): a) person-centred care, b) teamwork, c) evidence-based care, d) improvement knowledge and quality development, e) safe care for the patients and f) informatics (IT and digitalisation).

#### **2.4 How do perioperative nurses work?**

The work of perioperative nurses starts when the patient arrives in the operating room. From preparation and start of anaesthesia till termination, and handover of

*What Makes It Tip Over and How Can It Be Prevented?: Challenges in Psychosocial and… DOI: http://dx.doi.org/10.5772/intechopen.109244*

responsibility of care to the post-operative ward nurse, NAs oversee anaesthesia care. They work independently, consulting anaesthesiologists and providing the patient with analgesia and anaesthesia. OR nurses are responsible for aseptic procedures and assisting the surgeons with suitable surgical instruments during surgeries. Both the professions are equally responsible for the patient's nursing care, for example, positioning the patient on the operating bed and patient safety. This means that perioperative nurses are locked in the operating room. Breaks are planned for lunch. NAs may have short coffee breaks, but OR nurses take their coffee breaks between patients or during preparation of anaesthesia. Work schedules include day work, afternoon and night shifts and during unsocial hours (e.g. between 4 p.m. and 7 a.m. and during weekends). The number of cases per operating room varies from one to multiple cases; also, during a work shift, perioperative nurses usually are responsible for one operating room, including all the cases planned for that room, but they can be removed to other operating rooms whenever needed. These unique working conditions in this unique environment, during long hours of work along with high demands on concentration, place high demands on both specialist nurses.

#### **2.5 Anaesthesiologists**

According to Matsusaki and Sakai [16], in 1910, in the USA, a campaign was started by physician anaesthetists in order for anaesthesia to become solely physicians' work, where NAs had already been working for 150 years in their profession. Studies indicate that specific knowledge and skills are required for anaesthesiologists to undertake perioperative patient care [18] and that a majority believe that their current training must advance to support this aspect of their professional development. Being airway experts, providing vascular access, performing triage and resuscitation, and managing hemodynamic triage are some of the work tasks performed by anaesthesiologists [19]. Moreover, Zacharowski and Filipescu [20] stated that anaesthesiologists in Europe care for approximately 70% and in Scandinavia for 100% of ICU patients, whereas the remaining 30% of the ICU patients are being managed by other medical or surgical specialities.

In perioperative settings in Sweden, anaesthesiologists are located outside the operating rooms [21], and they are responsible for more than one patient or operating room at the same time; in other words, they carry a heavy responsibility for patients' lives during anaesthesia and surgery [22]. They are responsible for assessment, preparation, maintenance and termination of anaesthesia and monitoring the patients. Moreover, they apply blockades. Anaesthesiologists work closely with nurse anaesthetists who are with the patient in the operating room. Parallel with their work in the operating room, anaesthesiologists assess new patients who are scheduled for surgery on the same day or in advance. In addition to working in operating departments and intensive care units, anaesthesiologists work in the radiology department, pos-toperative departments, acute and chronic pain management departments and emergency departments [21, 23]. In other countries, for example in the UK and in Germany, anaesthesiologists are the ones who stay with the patients in the operating rooms. Thus, the work tasks of anaesthesiologists vary in different countries.

The work environment for anaesthesiologists is characterised by working under time pressure, delayed or cancelled breaks, frequent overtime, high levels of stress and high risk of emotional exhaustion [24]. Burnout among anaesthesiologists and intensivists (who work in intensive care units) is one issue studied by Vittori and Marinangeli [25], who emphasised that one-third of the respondents scored at high risk of emotional exhaustion, and that anaesthesiologists who practised in intensive care had the highest rate of burnout. Female gender, high workload, younger physicians with children, academic physicians [6] and anaesthesiology residents [26] are, according to literature, at high risk of burnout. Female gender seems to be more at risk of higher stress levels than males; nonetheless, they tend to prioritise home/work commitments better than males [27]. Besides stress, burnout and high emotional exhaustion, high levels of depersonalisation, and low levels of achievement have been reported among anaesthesiologists [28]. On a more psychosocial level, anaesthesiologists reported fatigue, lack of collegiality and respect and lack of training, as areas of job satisfaction, of which lack of respect was a contributor to burnout [29].

#### **2.6 Nurse assistants**

There is a lack of literature studying nurse assistants, who are also called unlicensed assistive personnel (in Sweden) or nursing support workers. Nurse assistants provide basic care to patients and work under the direction of registered nurses. In Sweden, the training period is 1.5 years of high school education. Also, Nurse assistants may work in operating rooms as circulating nurses, assisting the operating room nurse with additional instruments needed during surgery (as the OR/scrub nurse cannot open nonsterile packages such as autoclaved packages with sterile tools inside), documentation, patient positioning, preparing the operating room or table and assisting with draping the patients. In anaesthesia care, the assistant nurse assists NAs and anaesthesiologists with the preparation and termination of anaesthesia. They do not have formal responsibility for patient care and work under delegation of the perioperative nurses. In operating room care, they always stay in the operating room together with the OR nurse. If they work with nurse anaesthetists, they leave the room after preparation and start of anaesthesia, and they come back for termination and transportation of the patient to the post-operative ward. During the maintenance of anaesthesia, nurse assistants supply the nurse anaesthetist with what is needed in the operating room and help with the analysis of blood samples taken/arterial gases. Additional training is offered on-site, in the department, where the nurse assistants work.

In summary, strict regulations of the work environment in operating rooms make it difficult for the perioperative nurses to open a window (if there is one) when it is hot or increase the room temperature when it is cold, or take a break when one feels the need for it. One eats or goes to the restroom when someone else decides or takes a break when it is allowed. As the perioperative nurses have too little to say about their physical environment in the operating rooms, the psychosocial environment becomes even more important in the nurses' and other staff's well-being.
