Tracheal Extubation of Patients Cared for in the Anesthesia Setting : Experiences Described by Registered Nurse Anesthetists and Anesthesiologists

Abstract: Background In Sweden, extubation is an interdisciplinary process involving teamwork between Registered Nurse Anesthetists (RNA) and Anesthesiologists, and comprehensive demands are placed on the professionals providing anesthesia. The extubation of the endotracheal tube after General Anesthesia (GA) is a critical moment for the patient. In that moment, the patient is in a vulnerable state and at risk of suffering severe complications, such as hypoxia, laryngospasm, aspiration, and hypertension. Anesthesia deals with identifying options, making risk assessments and reconsiderations. Clinical decision-making in anesthesia includes making decisions quickly and sometimes re-evaluating these just as quickly. In the often brief meeting prior to anesthesia, a relationship with the patient emerges and an unspoken demand arises: to care for the life that is placed in the hands of the anesthetists.Aim The overall aim was to gain an understanding of the Registered Nurse Anesthetists’ and Anesthesiologists’ experiences of their decision-making practices in the process of extubation of the endotracheal tube in the anesthesia setting with patients undergoing general anesthesia.Method This licentiate thesis consists of two studies (I, II), both conducted with a qualitative design using focus-group interviews (I) and Individual interviews (II) to collect data. A total of 20 RNAs from two hospitals and 17 Anesthesiologists from three hospitals were included, using a consecutive sampling strategy. Both studies were analyzed with qualitative content analysis and adopted an inductive approach to seek a deeper understanding of the phenomena, using manifest content analysis. In order to explore how the RNAs and Anesthesiologists experience the process of extubation and to identify nuances between them, the two studies were merged together in this licentiate thesis.Results When merging these studies (I, II) together by combining subcategories from both, six themes emerged. The theme, Assembling unique decisions, deals with the how the RNAs (I) and Anesthesiologists (II) assess, prepare, prevent and reconsider when planning for the extubation. Acting upon sensibilities consists of them recognizing patterns, leaning on their experience, and being receptive to different inputs from the patient and other professionals. The third theme, Being guided by intuition, included how the RNAs and Anesthesiologists relied on their feelings and were guided by emotions when deciding when to extubate. Safeguarding the patient deals with them protecting and acting as an advocate for the patient and how they focus on and are humble in the process of extubation. In the fifth theme, Being in a vulnerable position, the RNAs (I) felt they were on their own when making the decision on when to extubate, while the Anesthesiologists (II) felt as if they were one of the team. Using their own receptivity included how they established a connection with the patient and sensed the atmosphere.Discussion In their first encounter with the patient, or when obtaining knowledge about the patient, the RNAs and Anesthesiologists had already started to tailor a mental plan of the extubation unique to each patient. The plan consisted of small pieces of information being gathered and assembled together during the anesthesia, and this information is then combined with their experience of similar situations and with their intuition with the aim of safeguarding the patient. RNAs and Anesthesiologists act upon sensibilities when deciding on when to extubate. These strategies align with the concept of phronesis, a form of knowledge understood as practical wisdom that facilitates good clinical judgement in being rational, which is based on pre-understanding, experience, and interpersonal relationships and which is difficult to teach to someone else.