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Education, Competence, and Role of the Nurse Working in the PACU: An International Survey

Open AccessPublished:January 29, 2021DOI:https://doi.org/10.1016/j.jopan.2020.08.002

      Abstract

      Purpose

      The aim of this research project was to describe the education, competence, and role of nurses working in the postanesthesia care unit (PACU) in 11 countries having an established perianesthesia specialty nursing organization and membership on the International Collaboration of PeriAnaesthesia Nurses, Inc (ICPAN) Global Advisory Council (GAC).

      Design

      This is a descriptive international cross-sectional study.

      Methods

      A Web-based survey was distributed to members of the ICPAN GAC to be completed by the GAC representative or another expert perianesthesia nurse member from the organization (n = 11). The GAC has one representative from the following 11 ICPAN organizational members: ACPAN, Australian College of PeriAnaesthesia Nurses (Australia); BRV, Beroepsvereniging Recovery Verpleegkundigen (Belgium/The Netherlands); NAPANc, National Association of PeriAnesthesia Nurses of Canada (Canada); FSAIO, The Danish Association of Anaesthesia, Intensive Care and Recovery Nurses (Denmark); FANA, Finnish Association of Nurse Anaesthetists (Finland); Hellenic Perianesthesia Nursing Organization (Greece); IARNA, Irish Anaesthetic and Recovery Nurses Association (Ireland); PNC of NZNO, Perioperative Nurses College of the New Zealand Nurses Organisation (New Zealand); ANIVA, Swedish Association of Nurse Anesthetists and Intensive Care Nurses (Sweden); BARNA, British Anaesthetic and Recovery Nurses Association (United Kingdom); and ASPAN, American Society of PeriAnesthesia Nurses (USA).

      Findings

      Perianesthesia nursing was recognized as a professional nursing specialty in 6 of 11 countries, and 8 of 11 have established national guidelines or practice standards for perianesthesia nurses. The Netherlands, Ireland, and Australia are the only countries that have a formal education program for perianesthesia nurses. There were variations in nurse-to-patient ratios between the 11 countries, ranging from 2:1 to 1:3 in the Phase I recovery of critically ill patients; in Phase II recovery (day surgery) it was most common to have up to three to four patients per nurse. Perianesthesia nurses were mainly the only profession stationed in the PACU, with professions such as the anesthesiologist and surgeon on call. The nurses performed many job tasks autonomously; however, this differed between countries.

      Conclusions

      Perianesthesia nurse education, clinical guidelines, other professions working in the PACU, and job tasks differ between countries. This knowledge can be used in international collaboration to further develop education and training for nurses working in the PACU. Continued international perianesthesia nursing partnership can only bring us closer and strengthen our specialty practice with the focus not on our differences but on our common denominators.

      Keywords

      All patients undergoing surgical interventions and anesthesia experience a postoperative recovery period. Recovery can be divided into three phases: Phase I (early recovery) occurs when the patient leaves the operating room (OR) until the patient is discharged from the Phase I postanesthesia care unit (PACU); transition to Phase II (intermediate recovery) occurs when the stable patient is ready to progress toward discharge from the hospital or surgery center
      • Ead H.
      From Aldrete to PADSS: Reviewing discharge criteria after ambulatory surgery.
      ,
      • Lee L.
      • Tran T.
      • Mayo N.E.
      • Carli F.
      • Feldman L.S.
      What does it really mean to “recover” from an operation?.
      ; extended care
      American Society of PeriAnesthesia Nurses
      2019-2020 PeriAnesthesia Nursing Standards, Practice Recommendations, and Interpretive Statements.
      or Phase III (late recovery) generally occurs after the patient is discharged from the hospital, but in some cases the patient remains under the observation of a nurse until usual functions and activities have returned.
      • Ead H.
      From Aldrete to PADSS: Reviewing discharge criteria after ambulatory surgery.
      ,
      • Lee L.
      • Tran T.
      • Mayo N.E.
      • Carli F.
      • Feldman L.S.
      What does it really mean to “recover” from an operation?.
      All surgical specialties and patients of all ages from pediatric to advanced age are cared for in the PACU.
      • Odom-Forren J.
      • Drain C.B.
      Nurse staffing in the PACU depends on acuity of the patient, competency of the nurse, and flexibility of patient throughput.
      • Clifford T.
      Staffing Ratios.
      ,
      • Dexter F.
      Why calculating PACU staffing is so hard and why/how operations research specialists can help.
      It is suggested that care in the PACU during Phase I recovery requires nurse-to-patient ratios among 2:1, 1:1, and 1:2.
      • Clifford T.
      Staffing Ratios.
      ,
      • Preston N.
      • Gregory M.
      Patient recovery and the post-anaesthesia care unit (PACU).
      To ensure keen observation of the patient at all times, the PACU treatment environment is open, spaced with curtains or foldable walls separating the beds.
      • Odom-Forren J.
      • Drain C.B.
      ,
      • Whitaker D.
      • Booth H.
      • Clyburn P.
      • et al.
      Immediate post-anaesthesia recovery 2013: Association of Anaesthetists of Great Britain and Ireland.
      Anesthetic drugs and the physical nature of surgery affect the patient's respiratory functions, muscle activity, temperature, consciousness, mental status, and hemodynamic functions, as well as possibly result in postoperative nausea and vomiting (PONV) and pain.
      • Ecoff L.
      • Palomo J.
      • Stichler J.F.
      Design and testing of a postanesthesia care unit readiness for discharge assessment tool.
      Therefore, the focus of early postoperative care is to detect surgical or anesthetic complications, which require monitoring of respiratory function, cardiovascular function, neuromuscular function, mental status, temperature, pain, PONV, intravenous (IV) fluids, urine output and voiding, and wound drainage and bleeding.
      • Apfelbaum J.L.
      • Silverstein J.H.
      • Chung F.F.
      • et al.
      Practice guidelines for postanesthetic care an updated report by the American Society of Anesthesiologists task force on postanesthetic care.
      To enhance a safe and successful recovery after surgery, the nurse working in the PACU should have special training in postoperative care.
      • Barone C.P.
      • Pablo C.S.
      • Barone G.W.
      A history of the PACU.
      Ruth et al
      • Ruth H.S.
      • Haugen F.P.
      • Grove D.D.
      Anesthesia study commission: Findings of eleven years' activity.
      reported in 1947 that preventable postoperative deaths occurred because of inadequate nursing care and that caring for the patient in a PACU after surgery prevented deaths. Lowenthal and Russel
      • Lowenthal P.J.
      • Russell A.S.
      Recovery room: Life saving and economical.
      supported those findings in 1951 and emphasized the need for a separate PACU and specialized education in the PACU. However, there is no international consensus regarding the education and role of the nurse working in the PACU. Nurses with different competencies, education, and training provide PACU care, and the role and tasks that can be performed by the nurse differ across the globe. This issue has been illuminated by the International Collaboration of PeriAnaesthesia Nurses, Inc (ICPAN) during delegate forum discussions held at two past ICPAN conferences (2015 in Copenhagen, Denmark and 2017 in Sydney, Australia). One of the top clinical questions discussed by conference delegates was as follows: What are the competencies and training necessary to work in the PACU? Two areas were identified as important in the education and training of PACU nurses: critical care training and the competence to deliver basic and advanced life support.
      • Poole E.L.
      The Gathering of nations: From Copenhagen to Sydney!.
      Perioperative nurse competence has been described as technical and nontechnical skills.
      • Ead H.
      Perianesthesia nursing—Beyond the critical care skills.
      • Gillespie B.M.
      • Polit D.F.
      • Hamlin L.
      • Chaboyer W.
      Developing a model of competence in the operating theatre: Psychometric validation of the perceived perioperative competence scale-revised.
      • Jaensson M.
      • Falk-Brynhildsen K.
      • Gillespie B.M.
      • Wallentin F.Y.
      • Nilsson U.
      Psychometric validation of the perceived perioperative competence scale-revised in the Swedish context.
      In the present study, competence is mainly described related to technical skills and more specifically tasks performed by the nurse working in the PACU. Tasks performed by nurses vary depending on context, and tasks are a guide to education and training. Earlier studies have conducted task analysis to guide needs and gaps in education, practice and competence in anesthetists,
      • Kibwana S.
      • Teshome M.
      • Molla Y.
      • et al.
      Education, practice, and competency gaps of anesthetists in Ethiopia: Task analysis.
      and to describe nursing in acute care.
      • Battisto D.
      • Pak R.
      • Vander Wood M.A.
      • Pilcher J.J.
      Using a task analysis to describe nursing work in acute care patient environments.
      To our knowledge there are no earlier studies that have mapped the nurse working in the PACU from an international perspective; therefore the aim of this research project was to describe the education, competence, and role of nurses working in the PACU in 11 countries having an established perianesthesia specialty nursing organization and membership on the ICPAN Global Advisory Council (GAC).

      Methods

      This is a descriptive international cross-sectional study conducted from March 2019 to July 2019.

      Development of Survey

      A Web-based survey was developed by an international research team (the authors) with clinical, educational, and research expertise in perioperative care. The development of items was conducted after a review of the literature
      • Fayers P.M.
      • Machin D.
      and consideration of the Meeusen et al
      • Meeusen V.
      • van Zundert A.
      • Hoekman J.
      • Kumar C.
      • Rawal N.
      • Knape H.
      Composition of the anaesthesia team: a European survey.
      questionnaire used to describe the job tasks of nonphysician anesthesia team members in Europe. All authors reviewed the items, wording of the items, and answers until consensus was achieved. The survey was also evaluated for face validity by a researcher in perioperative care who was not part of the research group. No changes were made after the face validity evaluation. The survey was in English and consisted of 96 items covering education and training for nurses working in the PACU, other health care professions in the PACU, nurse-to-patient ratio, and job tasks performed. It also included questions about the preoperative context, which will be reported in a separate article. The 70 items reported in this article can be accessed in Supplementary Appendix 1. Questions were answered yes or no; on a four-point Likert scale such as never, in some PACUs, in most PACUs, in all PACUs; or never, or under direct supervision, supervision on call, autonomous; or free text. All questions had to be answered to submit the survey.

      Data Collection

      The survey was distributed to members of the ICPAN GAC to be completed by the GAC representative or another expert perianesthesia nurse member from the organization (n = 11). The GAC has one representative from the following 11 ICPAN member organizations: ACPAN, Australian College of PeriAnaesthesia Nurses (Australia), BRV, Beroepsvereniging Recovery Verpleegkundigen (Belgium/The Netherlands), NAPANc, National Association of PeriAnesthesia Nurses of Canada (Canada), FSAIO, The Danish Association of Anaesthesia, Intensive Care and Recovery Nurses (Denmark), FANA, Finnish Association of Nurse Anaesthetists (Finland), Hellenic Perianesthesia Nursing Organization (Greece), IARNA, Irish Anaesthetic and Recovery Nurses Association (Ireland), PNC of NZNO, Perioperative Nurses College of the New Zealand Nurses Organisation (New Zealand), ANIVA, Swedish Association of Nurse Anesthetists and Intensive Care Nurses  (Sweden), BARNA, British Anaesthetic and Recovery Nurses Association (United Kingdom), and ASPAN, American Society of PeriAnesthesia Nurses (USA). The survey was distributed via a Web-based survey platform called ORU-survey provided by Örebro University, Sweden. The survey was sent to each GAC member's e-mail, and it was possible to answer the survey using a computer, tablet, or mobile phone. All participants received written information about the study and agreed to participate in the study by answering and submitting the survey. Participants were asked to respond to the survey based on routines and policies in the country that their organization represented. Two reminders to answer the survey were sent out after 3 and 7 weeks. After the data collection, all respondents received a copy of their answers and were offered the opportunity to correct their answers if needed. Seven responded and, of those, five reported minor corrections.

      Data Analysis

      Data are presented with descriptive statistics and frequencies for nominal data. Responses are reported for each country or as a distribution of answers. The 37 job tasks included in the survey were summarized as frequencies of job tasks performed never, under direct supervision, supervision on call, or autonomous and sorted by number of tasks performed autonomously by the perianesthesia nurse.

      Results

      We received answers from all 11 organizations. The title of the nurse working in the PACU differs between the countries (recovery nurse, perianesthesia nurse, perioperative nurse, and in some countries the nurses have no specific title). In the results and discussion section in this article, the title is referred to as perianesthesia nurse because this is the formulation used in ICPAN. Perianesthesia nursing was recognized as a professional nursing specialty in 6 of 11 countries, and 8 of 11 had established national guidelines or practice standards for perianesthesia nurses (Figure 1). Local guidelines or policies (hospital or regionally driven) for the nurses working in the PACU existed in 10 of 11 countries.
      Figure thumbnail gr1
      Figure 1Overview of perianesthesia nursing specialty, national guidelines, and formal education. Perian spec, Perianesthesia nursing recognized as a professional nursing specialty; Formal Edu, formal education for the nurse working in the PACU; NG, national guidelines or practice standards for the nurse working in the PACU; PACU, postanesthesia care unit. This figure is available in color online at www.jopan.org.

      Education

      Education to practice as a registered nurse (RN) varied between 3 and 4 years. In the USA a 2-year Associate's Degree in Nursing is also available (Table 1). Three countries (3/11) reported that they have a formal education program for perianesthesia nurses (Figure 1 and Table 1). In the eight countries not having a formal education, the training to work as a nurse in the PACU was provided by the hospital or surgical facility and varied between 1 month, 5 weeks, and 7 weeks (n = 3). Four reported that length of training was based on the nurse's earlier experience, competence, and type of hospital, and one reported no answer.
      Table 1Education
      Length of Education to Qualify for Eligibility to Practice as a Registered NurseFormal Education for Perianesthesia Nurses
      NL4 yYes
      IRL4 yYes
      GR4 yNo
      CAN4 yNo
      DK4 yNo
      USA4 y (2 y Associate's Degree in Nursing)No
      FIN3.5 yNo
      AUS3 yYes
      NZ3 yNo
      SWE3 yNo
      UK3 yNo
      AUS, Australia; CAN, Canada; DK, Denmark; FIN, Finland; GR, Greece; IRL, Ireland; NL, The Netherlands; NZ, New Zealand; SWE, Sweden; UK, United Kingdom; USA, United States of America.

      Staffing in the PACU

      The Netherlands and Ireland were the only countries where perianesthesia nurses were the only profession stationed in the PACU, whereas in Sweden perianesthesia nurses worked together with nurse assistants (may also be called auxiliary nurse, assistant nurse, enrolled nurse, or licensed practical nurse. Commonly, these personnel work under supervision of the RN in all PACUs and the anesthesia provider was stationed in most PACUs. Nurse assistants were the personnel most commonly stationed in the PACU (in all PACUs, n = 1; in some PACUs, n = 5), followed by anesthesia provider (in some PACUs, n = 3; in most PACUs, n = 1) and advanced practice nurse (in some PACUs, n = 2; in most PACUs, n = 2). The anesthesia provider, surgeon, and pharmacist were available on call or as consultants in all 11 countries (Table 2).
      Table 2Other Professions in the PACU in 11 Countries
      Stationed at PACUOn Call/As Consultants
      NeverIn Some PACUsIn Most PACUsIn all PACUsDo not KnowNeverIn Some PACUsIn Most PACUsIn all PACUsDo not Know
      Anesthesia providerAUS

      DK

      FIN

      IRL NL

      NZ
      CAN

      GR

      USA
      SWEUKAUS

      CAN
      GR

      NZ

      USA
      DK

      FIN

      IRL

      NL

      SWE

      UK
      SurgeonAUS

      DK

      FIN

      GR

      IRL NZ

      NL

      USA
      CAN

      SWE
      UKAUS

      CAN

      GR
      NZ

      NL

      USA
      DK

      FIN

      IRL

      SWE

      UK
      Nurse assistant
      Can also be called auxiliary nurse, assistant nurse, enrolled nurse, or licensed practical nurse. Commonly, these professional roles work under supervision of the RN.
      CAN

      GR

      NL

      IRL
      AUS

      DK

      FIN

      NZ

      USA
      SWEUKAUS

      CAN

      DK

      FIN

      SWE

      NL

      USA
      NZIRLGR

      UK
      PharmacistAUS

      CAN

      DK

      FIN

      GR

      IRL

      NZ

      NL
      SWE

      USA
      UKAUS

      FIN

      NZ
      CAN

      DK

      USA
      IRL

      UK
      GR

      SWE

      NL
      Physical medicine/physiotherapistAUS

      CAN

      DK

      FIN

      GR

      IRL

      NZ

      NL

      USA
      SWEUKAUSFIN

      NZ

      NL
      CAN

      USA
      IRL

      UK
      DK

      GR

      SWE
      Respiratory therapistAUS

      CAN

      DK

      FIN

      GR

      IRL

      NZ

      SWE

      NL
      USAUKAUS

      DK

      FIN

      NZ

      SWE
      CAN

      USA
      IRL

      UK
      GR

      NL
      Occupational therapistAUS

      CAN

      DK

      FIN

      IRL

      NZ

      NL

      USA
      GR

      SWE

      UK
      AUS

      DK

      FIN
      NZ

      USA
      CANIRL

      UK
      GR

      SWE

      NL
      Advanced practice nurseCAN

      DK

      IRL

      NZ

      NL SWE
      UK

      USA
      AUS

      FIN
      GRCAN

      NZ
      USAAUS

      FIN
      IRLDK

      GR

      SWE

      NL

      UK
      OtherUSA: Social workers, child life specialists (pediatric specific settings), radiology
      AUS, Australia; CAN, Canada; DK, Denmark; FIN, Finland; GR, Greece; IRL, Ireland; NL, The Netherlands; NZ, New Zealand; PACU, postanesthesia care unit; RN, registered nurse; SWE, Sweden; UK, United Kingdom; USA, United States of America.
      Can also be called auxiliary nurse, assistant nurse, enrolled nurse, or licensed practical nurse. Commonly, these professional roles work under supervision of the RN.
      There were variations in nurse-to-patient ratios between the 11 countries, ranging from 2:1 to 1:3 in the Phase I recovery of critically ill patients. In Phase II recovery, it was most common to have up to three to four patients per nurse (Table 3).
      Table 3Common Nurse to Patient Ratio in 11 Countries
      Phase I Recovery, Critically Ill PatientsPhase I Recovery, Stable PatientsPhase II Recovery (Day Surgery)
      GR2:1-1:11:11:1-1:2
      UK1:11:11:1
      IRL1:11:11:2
      CAN1:11:11:4
      USA1:11:21:3
      NZ1:11:1-1:31:3
      SWE1:1-1:21:21:4
      AUS1:2 (Unconscious 1:1)1:21:3-4
      DK1:21:21:2
      NL1:3 (max)1:31:3-1:4
      FINDepends on unit and nurse experienceDepends on unit and nurse experienceDepends on unit and nurse experience
      AUS, Australia; CAN, Canada; DK, Denmark; FIN, Finland; GR, Greece; IRL, Ireland; NL, The Netherlands; NZ, New Zealand; SWE, Sweden; UK, United Kingdom; USA, United States of America

      Job Tasks in the PACU

      In all countries, perianesthesia nurses cared for pediatric patients, depending on the type of PACU and hospital, except in Ireland where perianesthesia nurses did not care for infants (0 to 1 year).
      There were variations between countries regarding how many job tasks were reported as performed autonomously by the perianesthesia nurse, minimum 13 to maximum 31 (Table 4). All responses regarding the 37 job tasks are reported in detail in Supplementary Appendix 2.
      Table 4Frequency of 37
      Monitoring heart rate, monitoring ECG, monitoring SPO2, monitoring end-tidal CO2, monitoring noninvasive blood pressure, monitoring invasive blood pressure, monitoring CVP (central venous pressure), monitoring PCWP (pulmonary capillary wedge pressure), monitoring ICP (intracranial pressure), pain assessment, PONV assessment, temperature assessment, suction of airways, suction of tracheostomy, insert oropharyngeal airway, remove oropharyngeal airway, insert nasopharyngeal airway, remove nasopharyngeal airway, removal of laryngeal mask, removal of endotracheal tube, CPAP device, patient on ventilator, IV injections, intramuscular injections, injections into an epidural catheter, starting PCA/PCEA, insert IV cannula, insert a central venous catheter, insert arterial line, sampling blood for laboratory 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.
      Job Tasks Performed Never, Under Direct Supervision, Supervision on Call, or Autonomously by the Perianesthesia Nurse in the PACU in 11 Countries (n)
      NeverUnder Direct SupervisionSupervision on Call And/or According to the ProtocolAutonomously
      CAN5131
      NZ
      Do not know = 2.
      3131
      FIN3430
      USA3529
      UK
      Do not know = 6.
      3127
      DK10126
      IRL8326
      SWE
      Do not know = 2.
      121121
      NL122320
      AUS71614
      GR69913
      AUS, Australia; CAN, Canada; DK, Denmark; FIN, Finland; GR, Greece; IRL, Ireland; IV, intravenous; NL, The Netherlands; NZ, New Zealand; PACU, postanesthesia care unit; PONV, postoperative nausea and vomiting; SWE, Sweden; UK, United Kingdom; USA, United States of America.
      Monitoring heart rate, monitoring ECG, monitoring SPO2, monitoring end-tidal CO2, monitoring noninvasive blood pressure, monitoring invasive blood pressure, monitoring CVP (central venous pressure), monitoring PCWP (pulmonary capillary wedge pressure), monitoring ICP (intracranial pressure), pain assessment, PONV assessment, temperature assessment, suction of airways, suction of tracheostomy, insert oropharyngeal airway, remove oropharyngeal airway, insert nasopharyngeal airway, remove nasopharyngeal airway, removal of laryngeal mask, removal of endotracheal tube, CPAP device, patient on ventilator, IV injections, intramuscular injections, injections into an epidural catheter, starting PCA/PCEA, insert IV cannula, insert a central venous catheter, insert arterial line, sampling blood for laboratory 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.
      Do not know = 2.
      Do not know = 6.
      Job tasks that were most commonly reported as performed autonomously by perianesthesia nurses were suction of airways (11/11), temperature assessment (11/11), pain assessment (10/11), PONV assessment (10/11), monitoring heart rate (10/11), monitoring electrocardiogram (ECG) (10/11), monitoring noninvasive blood pressure (10/11), monitoring SPO2 (10/11), IV injection (10/11), intramuscular injection (10/11), and insert IV cannula (10/11). The following job tasks were most commonly reported as never performed by the perianesthesia nurse: inserting a central venous catheter (10/11), insert arterial line (9/11), connecting and adjusting a pacemaker (6/11), and patient on ventilator (5/11).
      Epidural injections, removal of endotracheal tube, continuous positive airway pressure (CPAP) device, patient on ventilator, monitoring pulmonary capillary wedge pressure, and monitoring intracranial pressure were the job tasks that varied the most between the 11 countries (Figure 2).
      Figure thumbnail gr2
      Figure 2Job tasks performed by the perianesthesia nurse. Overview of job tasks that varied the most between the 11 countries. ∗Do not know (n = 2), ¤Do not know (n = 1).

      Resuscitation

      During resuscitation, heart compressions were performed autonomously by the perianesthesia nurse in 9 of 11 countries, ventilation in 8 of 11 countries, and defibrillation in 5 of 11 countries (Figure 3).
      Figure thumbnail gr3
      Figure 3Perianesthesia nurse during resuscitation, N = 11.

      Discharge from the PACU

      Perianesthesia nurses discharged patients from the PACU autonomously or with supervision on call, according to the protocol in both Phase I and II (from day surgery unit) recovery. The most common discharge scoring criteria used in Phase I recovery was the Aldrete or Modified Aldrete Scoring System (6/11), whereas local or national guidelines were the most common in Phase II recovery (6/11; Table 5).
      Table 5Overview Over Discharge Criteria's Used in Phase I and II Recovery and Discharge From the PACU
      Scoring/Discharge CriteriaDischarge
      Phase I recoveryPhase II recoveryFrom PACU, Phase I recoveryFrom day surgery unit, Phase II recovery
      AUSAldrete. Pain score, GCSFAS, ABC, activities scoringSupervision on call/according to the protocolSupervision on call/according to the protocol
      CANModified AldreteCriteria laid out by the managementSupervision on call/according to the protocolSupervision on call/according to the protocol
      DKNational recommendationsNational recommendationsAutonomousAutonomous
      FINLocal discharge criteriaLocal discharge criteriaSupervision on call/according to the protocolSupervision on call/according to the protocol
      GRSpontaneous breathingGood level of consciousness, hemodynamic stability and pain score <5AutonomousAutonomous
      IRLAldreteAldreteAutonomousAutonomous
      NLAldrete, VRNSAldrete, VRNSAutonomousAutonomous
      NZApgar/adjusted ApgarDischarge score.Supervision on call/according to the protocolSupervision on call/according to the protocol
      SWELocal guidelinesLocal guidelinesSupervision on call/according to the protocolSupervision on call/according to the protocol
      UKAlderete/NEWS2Depending on hospitalAutonomousAutonomous
      USAAldrete/local specific elementsPADSS/local specific elementsSupervision on call/according to the protocolSupervision on call/according to the protocol
      ABC, airway, breathing, circulation; AUS, Australia; CAN, Canada, DK, Denmark; FAS, functional assessment screening; FIN, Finland; GR, Greece; GCS, Glasgow Coma Scale; IRL, Ireland; NEWS2, national early warning score; NL, The Netherlands; NZ, New Zealand; PACU, postanesthesia care unit; PADSS, Postanesthetic Discharge Scoring System; SWE, Sweden; UK, United Kingdom; USA, United States of America; VRNS, visual numeric rating scale.
      Communication handover tools (ie, structured and standardized communication) were used in 10 of 11 countries, and the following communication handover tools were reported with some respondents reporting the use of multiple handover tools: SBAR (situation, background, assessment, recommendation; n = 3); ISBAR (identify, situation, background, assessment, recommendation; n = 2); iSoBAR (identify, situation, observations, background, agreed plan, read back; n = 1); AIDET (acknowledge, introduce, duration, explanation, thank you; n = 1); digital scoring list (n = 1), IPASS (illness severity, patient summary, action list, situation awareness and contingency planning, synthesis by receiver; n = 1); I PASS the BATON (introduction, patient name, assessment, situation, safety the background, actions, timing, ownership, next; n = 1); IDRAW (identify patient and most responsible practitioner, diagnose current problems, recent changes, anticipated changes, what to watch for; n = 1).

      Discussion

      To our knowledge, this is the first study describing the education, competence, and role of the nurse working in the PACU from an international perspective. The findings in this study demonstrate that there are similarities and differences between the 11 countries having membership in the ICPAN GAC. Without this information, it is challenging to discuss future international collaboration and development of education. Cross-country differences were reported by Meeusen et al,
      • Meeusen V.
      • van Zundert A.
      • Hoekman J.
      • Kumar C.
      • Rawal N.
      • Knape H.
      Composition of the anaesthesia team: a European survey.
      where large variations among education, length of education, job descriptions, responsibilities, and job tasks were observed. International similarities and differences regarding routines in a day surgical context are also described, such as preoperative assessment, which was performed by nurses in all or most of the reporting units in the United Kingdom and Finland, but never performed by a nurse in Denmark and Sweden.
      • Stomberg M.W.
      • Brattwall M.
      • Jakobsson J.G.
      Day surgery, variations in routines and practices a questionnaire survey.
      The preoperative context has also been explored by the research team and will be reported and further discussed elsewhere.
      Three countries reported that they had a formal education process for perianesthesia nurses. However, it is possible that the nurses had other specialty postgraduate education such as anesthesia care or intensive care, which are common specialty educations among nurses working in Swedish PACUs although not mandatory.
      • Juhász E.H.
      • Iversen M.
      • Samuelson A.
      • Bäckström R.
      • Nilsson U.
      Clinical practice and procedures for postoperative care in Sweden: Results from a nationwide survey.
      We could not see that the three countries having formal education reported a higher frequency of performing tasks autonomously. Rather it implies that we have organizational differences between countries that cannot be described solely in relation to education. In the present study nurses performed many tasks autonomously, whereas none of the job tasks included in this study were reported as never performed by all 11 responders. As mentioned previously, we did not ask for information about postgraduate education other than perianesthesia nursing, which can be one explanation why the nurses in the present study performed most tasks autonomously. We found that perianesthesia nurses typically were the only profession stationed in the PACU, with other professions such as the anesthesia provider and surgeon on call. This indicates that the perianesthesia nurse has an independent role and has to make judgments related to the patient's condition and when other health care professionals should be contacted. Furthermore, cultural differences
      • Gillespie B.M.
      • Harbeck E.B.
      • Falk-Brynhildsen K.
      • Nilsson U.
      • Jaensson M.
      Perceptions of perioperative nursing competence: A cross-country comparison.
      and education can have an impact on perceived perioperative competency.
      • Gillespie B.M.
      • Harbeck E.B.
      • Falk-Brynhildsen K.
      • Nilsson U.
      • Jaensson M.
      Perceptions of perioperative nursing competence: A cross-country comparison.
      ,
      • Greenfield M.L.V.
      • O'Brien D.D.
      • Kofflin S.K.
      • Mhyre J.M.
      A cross-sectional survey study of nurses' self-assessed competencies in obstetric and surgical postanesthesia care units.
      This implies that education for perianesthesia nurses is an area that needs further development. Compared with other nurse professions in the perioperative context, RNA and OR nurses in Europe have 1 to 4 years of additional education.
      • Jaensson M.
      • Falk-Brynhildsen K.
      • Gillespie B.M.
      • Wallentin F.Y.
      • Nilsson U.
      Psychometric validation of the perceived perioperative competence scale-revised in the Swedish context.
      ,
      • Meeusen V.
      • van Zundert A.
      • Hoekman J.
      • Kumar C.
      • Rawal N.
      • Knape H.
      Composition of the anaesthesia team: a European survey.
      In the United States the graduate level education to practice as a certified registered nurse anesthetist is 2 to 3 years,
      • Matsusaki T.
      • Sakai T.
      The role of certified registered nurse anesthetists in the United States.
      but there is no current education for OR nurses and a lack of sufficient knowledge of the perioperative context has been emphasized.
      • Beitz J.M.
      Addressing the perioperative nursing shortage through education: A perioperative imperative.
      On the basis of the factors mentioned previously, we recommend the development and proliferation of a foundational perianesthesia nursing education program to be cultivated through expert collaboration from all countries participating in the ICPAN GAC.
      Two of the nontechnical skills described for the perianesthesia nurse are communication and crisis management. During Phase I recovery, crises such as respiratory distress or hemorrhage can occur and place demands on the perianesthesia nurse to prioritize what actions to take and the need to use structured communication tools to enhance interaction with colleagues and other health care professionals.
      • Ead H.
      Perianesthesia nursing—Beyond the critical care skills.
      Structured and standardized communication handover tools are essential for increasing patient safety in the process of transferring a patient and delivering patient-specific information to the receiving nurse.
      • Bukoh M.X.
      • Siah C.J.R.
      A systematic review on the structured handover interventions between nurses in improving patient safety outcomes.
      Communication tools were reported from all countries in this study; however, variations existed in the tools that were used. The most common tool was SBAR (used in three countries) or modified versions of SBAR, ISBAR,
      • Thompson J.E.
      • Collett L.W.
      • Langbart M.J.
      • et al.
      Using the ISBAR handover tool in junior medical officer handover: A study in an Australian tertiary hospital.
      and iSoBAR
      • Porteous J.M.
      • Stewart-Wynne E.G.
      • Connolly M.
      • Crommelin P.F.
      iSoBAR—a concept and handover checklist: The National Clinical Handover Initiative.
      in two and one country, respectively. SBAR has been highlighted by the World Health Organization to increase patient safety,
      WHO Collaborating Centre for Patient Safety Solutions
      Communication during Patient Hand-Overs Patient Safety Solutions.
      and when implemented in perioperative practice had a positive effect on communication and patient safety.
      • Randmaa M.
      • Mårtensson G.
      • Swenne C.L.
      • Engström M.
      SBAR improves communication and safety climate and decreases incident reports due to communication errors in an anaesthetic clinic: A prospective intervention study.
      In the present study, the following nurse-to-patient ratios were reported: Phase I recovery 2:1 to 1:3 (critically ill) and 1:1 to 1:3 (stable patients). This is congruent with what has been described earlier during Phase I recovery—that nurse-to-patient ratios should be between 2:1 and 1:2 depending on acuity of the patient, competency of the nurse, and flexibility of patient throughput.
      • Clifford T.
      Staffing Ratios.
      Perianesthesia nurses discharge patients autonomously or with supervision on call, according to the protocol from the PACU and Phase II recovery. Nurse-led discharge is described in the literature, and to enhance a safe recovery and discharge, it is important to assess recovery and use discharge criteria.
      • Awad I.T.
      • Chung F.
      Factors affecting recovery and discharge following ambulatory surgery.
      All study participants reported that they use discharge criteria, and Aldrete or the modified Aldrete scoring was the most common assessment of recovery and discharge criteria. The Aldrete score has been widely used internationally since it was developed in the 1970s.
      • Aldrete J.A.
      The post-anesthesia recovery score revisited.
      ,
      • Aldrete J.A.
      • Kroulik D.
      A postanesthetic recovery score.
      However, it has been highlighted that the Aldrete score has never been validated.
      • Phillips N.M.
      • Street M.
      • Kent B.
      • Haesler E.
      • Cadeddu M.
      Post-anaesthetic discharge scoring criteria: Key findings from a systematic review.
      This is a research area requiring further exploration.
      Competence in perioperative nursing includes technical and nontechnical skills.
      • Ead H.
      Perianesthesia nursing—Beyond the critical care skills.
      • Gillespie B.M.
      • Polit D.F.
      • Hamlin L.
      • Chaboyer W.
      Developing a model of competence in the operating theatre: Psychometric validation of the perceived perioperative competence scale-revised.
      • Jaensson M.
      • Falk-Brynhildsen K.
      • Gillespie B.M.
      • Wallentin F.Y.
      • Nilsson U.
      Psychometric validation of the perceived perioperative competence scale-revised in the Swedish context.
      In this study, all skills related to perioperative competencies are not described, rather the focus was on technical skills and job tasks. Analyzing tasks are important when describing nursing in different contexts, what is expected of the nurse, and to develop education.
      • Kibwana S.
      • Teshome M.
      • Molla Y.
      • et al.
      Education, practice, and competency gaps of anesthetists in Ethiopia: Task analysis.
      This study is the first step to describe the competence and education for perianesthesia nurses from an international context. As Poole
      • Poole E.L.
      The Gathering of nations: From Copenhagen to Sydney!.
      highlighted, it is important to gain knowledge and understanding about perianesthesia nursing between different countries. Nurse competence is often studied using self-assessed questionnaires.
      • Gillespie B.M.
      • Polit D.F.
      • Hamlin L.
      • Chaboyer W.
      Developing a model of competence in the operating theatre: Psychometric validation of the perceived perioperative competence scale-revised.
      ,
      • Jaensson M.
      • Falk-Brynhildsen K.
      • Gillespie B.M.
      • Wallentin F.Y.
      • Nilsson U.
      Psychometric validation of the perceived perioperative competence scale-revised in the Swedish context.
      ,
      • Greenfield M.L.V.
      • O'Brien D.D.
      • Kofflin S.K.
      • Mhyre J.M.
      A cross-sectional survey study of nurses' self-assessed competencies in obstetric and surgical postanesthesia care units.
      With a self-assessed questionnaire it is possible to gather information about how often tasks were performed, the importance of different tasks, and if nurses feel they have sufficient knowledge and education to perform the tasks. This inquiry should be included in future studies.

      Implications for Global Practice

      The International Council of Nurses has advocated for global nurse education standards for over a century, but this goal remains elusive despite being a shared professional nursing vision. Today, international nursing regulation and education continues to differ in complexity and scope.
      Institute of MedicineCommittee on the Robert Wood Johnson Foundation Initiative on the Future of Nursing
      The Future of Nursing: Leading Change, Advancing Health.
      The perianesthesia nurse, as a key member of the surgical care team,
      • Meara J.G.
      • Leather A.J.
      • Hagander L.
      • et al.
      Global Surgery 2030: Evidence and solutions for achieving health, welfare, and economic development.
      requires the education and clinical skills needed to keep patients safe during a most vulnerable time after anesthesia administration. Since its inception in 2011, the International Conference for PeriAnaesthesia Nurses has connected professional nurses on five occasions and three continents to share research and best clinical practices through education sessions, global delegate networking, and information gathering. The analysis of data collected during two delegate forums by Poole
      • Poole E.L.
      The Gathering of nations: From Copenhagen to Sydney!.
      p 761 concluded that “although there appears to be consensus among forum attendees on perianesthesia nurse competencies, there remains a need for standardization and proliferation.”
      Currently, ICPAN and its 11 country members are commissioning an international team of experts to develop evidence-based perianesthesia nursing curriculum that can be tested through implementation in high-, middle- and low-income countries based on existing access to health care education and care delivery resources. Innovative use of technology can be designed to interact and share knowledge
      National Academies of Sciences, Engineering, and Medicine
      Improving Health Professional Education and Practice through Technology: Proceedings of a Workshop.
      with nursing students using a multimedia approach while guiding skills development through the use of in-person or videotaped clinical exemplars. This ambitious initiative supports the International Council of Nurses goal to standardize nurse education and can be accomplished because we share a world that is more connected than ever before through rapid travel options and virtual technology.

      Limitations

      The survey was not evaluated for content validity; it is possible that more or less items and answers would be found relevant if a content validity evaluation was conducted. If conducting a similar study, a content validity evaluation can be considered.
      In the present survey we did not ask if the nurses working in the PACU had any other formal education other than in perianesthesia nursing, meaning that we have no information about other postgraduate education in specialist nursing, which is a limitation. However, the main focus of this study regarding type of education was to identify countries with existing perianesthesia education for nurses.
      Participants were asked to respond to the survey based on routines and policies in the country that their organization represents. However, it is important to consider that there are variations within each country, depending on type of hospital and type of patients cared for in the hospital. In-country differences regarding day surgery routines in Europe have been reported earlier,
      • Stomberg M.W.
      • Brattwall M.
      • Jakobsson J.G.
      Day surgery, variations in routines and practices a questionnaire survey.
      and therefore, the results should be interpreted with that in mind.

      Conclusions

      Perianesthesia nurse education, clinical guidelines, other professions working in the PACU, and job tasks differ between countries. This knowledge can lead to more awareness of and insight into our different contexts and be used in international collaboration to further develop education and training for nurses working in the PACU. Continued international perianesthesia nursing partnership can only bring us closer and strengthen our specialty practice with the focus not on our differences but on our common denominators.

      Supplementary Data

      Supplementary data related to this article can be found at http://doi.org/10.1016/j.jopan.2020.08.002.

      Appendix 1. Copy of Items Included in the Survey

      • 1.
        Which country do you represent?
      • 2.
        Is perianaesthesia nursing recognized as a professional nursing specialty in the country by governance board?
        • □Yes
        • □No
      • 3.
        Are there established national guidelines or practice standards for the nurse working in the PACU?
        • □Yes
        • □No
      • 4.
        Are there local guidelines or policies (hospital or regional driven) for the nurses working in the PACU?
        • □Yes
        • □No
      • 5.
        Length of education completed to qualify for eligibility to practice as a registered nurse (please answer in years)
      • 6.
        In your country, is there a formal education for the nurse working in the PACU?
        • □Yes
        • □No
      Please specify name of that formal education.
      Please specify length of that formal education (months).
      Please specify who is responsible for the formal education (eg, university, clinic)
      • 7.
        What kind of training is offered for nurses working in the PACU?
      • 8.
        Length of that training? (months)
      • 9.
        Please specify who is responsible for that training? (eg, University, clinic, unit educator)
      • 10.
        The common nurse patient ratio in PACU in Phase 1 recovery, critically ill patients.
      • 11.
        The common nurse patient ratio in PACU in Phase 1 recovery, stable patients.
      • 12.
        The common nurse patient ratio in PACU in Phase 2 recovery (day surgery)
      Tabled 1
      Caring for the Pediatric PatientNeverIn Some PACUsIn Most PACUsIn all PACUsDon't Know
      13. Infant (0-1 yr)
      14. Toddler (1-3 yr)
      15. Preschool age (3-6 yr)
      16. School age (6-12 yr)
      17. Adolescent (12-20 yr)
      Tabled 1
      Tasks performed by the nurse working in the PACUNeverUnder direct supervisionSupervision on call and/or according to the protocolAutonomous (without supervision)Don't know
      18. Suction of airways
      19. Suction of tracheostomy
      20. Insert oropharyngeal airway
      21. Remove oropharyngeal airway
      22. Insert nasopharyngeal airway
      23. Remove nasopharyngeal airway
      24. Removal of laryngeal mask
      25. Removal of endotracheal tube
      26. CPAP device
      27. Patient on ventilator
      28. Insert IV cannula
      29. Insert a central venous catheter
      30. Insert arterial line
      31. Sampling blood for lab analyses
      32. Sampling arterial blood gas
      33. Bladder scanning
      34. Urethral catheters
      35. Bladder irrigation
      36. Mobilization of the patient in the PACU
      37. Monitoring heart rate
      38. Monitoring ECG
      39. Monitoring SPO2
      40. Monitoring end tidal CO2
      41. Monitoring noninvasive blood pressure
      42. Monitoring invasive BP
      43. Monitoring CVP (central venous pressure)
      44. Monitoring PCWP (pulmonary capillary wedge pressure)
      45. Monitoring ICP (intracranial pressure)
      46. Connecting and adjusting a pacemaker
      47. Temperature assessment
      48. Pain assessment
      49. PONV assessment
      50. Informing next of kin
      51. Intravenous injections
      52. Intramuscular injections
      53. Injections into an epidural catheter
      54. Starting PCA/PCEA
      Tabled 1
      ResuscitationNeverUnder supervisionAutonomousDon't know
      55. Heart compressions
      56. Ventilation during resuscitation
      57. Defibrillation
      Tabled 1
      DischargeNeverUnder direct supervisionSupervision on call and/or according to the protocolAutonomous (without supervision)Don't know
      58. From PACU
      59. From day surgery unit, Phase 2 recovery
      60. What kind of scoring/discharge criteria's are used for Phase 1 recovery?
      61. What kind of scoring/discharge criteria's are used for Phase 2 recovery (day surgery)?
      62. Are communication tools used for handover?
      63. Please specify the type of communication tool.
      Tabled 1
      Other professions in the PACUStationed at PACUOn call/as consultants
      NeverIn some PACUsIn most PACUsIn all PACUsDon't knowNeverIn some PACUsIn most PACUsIn all PACUsDon't know
      64. Anesthesia provider
      65. Surgeon
      66. Nurse assistant
      67. Pharmacist
      68. Physical medicine/physiotherapist
      69. Respiratory therapist
      70. Occupational therapist
      Appendix 2Job Tasks Performed by the Perianesthesia Nurse in the PACU
      AustraliaCanadaDenmarkFinlandGreeceIrelandNew ZealandSwedenThe NetherlandsUnited KingdomUnited States of America
      Suction of airwaysAutonomousAutonomousAutonomousAutonomousAutonomousAutonomousAutonomousAutonomousAutonomousAutonomousAutonomous
      Suction of tracheostomyAutonomousAutonomousAutonomousAutonomousAutonomousSupervision on call and/or according to the protocolAutonomousAutonomousSupervision on call and/or according to the protocolAutonomousAutonomous
      Insert oropharyngeal airwayAutonomousAutonomousAutonomousAutonomousAutonomousAutonomousAutonomousSupervision on call and/or according to the protocolNeverAutonomousAutonomous
      Remove oropharyngeal airwayAutonomousAutonomousAutonomousAutonomousAutonomousAutonomousAutonomousSupervision on call and/or according to the protocolAutonomousAutonomousAutonomous
      Insert nasopharyngeal airwayAutonomousAutonomousAutonomousAutonomousAutonomousAutonomousAutonomousSupervision on call and/or according to the protocolUnder direct supervisionAutonomousAutonomous
      Remove nasopharyngeal airwayAutonomousAutonomousAutonomousAutonomousAutonomousAutonomousAutonomousSupervision on call and/or according to the protocolAutonomousAutonomousAutonomous
      Removal of laryngeal maskAutonomousAutonomousNeverAutonomousUnder direct supervisionAutonomousAutonomousUnder direct supervisionAutonomousAutonomousAutonomous
      Removal of endotracheal tubeNeverAutonomousNeverSupervision on call and/or according to the protocolUnder direct supervisionNeverAutonomousUnder direct supervisionNeverDo not knowAutonomous
      CPAP deviceDo not knowAutonomousAutonomousAutonomousUnder direct supervisionSupervision on call and/or according to the protocolAutonomousSupervision on call and/or according to the protocolAutonomousDo not knowSupervision on call and/or according to the protocol
      Patient on ventilatorNeverSupervision on call and/or according to the protocolNeverAutonomousSupervision on call and/or according to the protocolNeverNeverDo not knowNeverDo not knowSupervision on call and/or according to the protocol
      Insert IV cannulaSupervision on call and/or according to the protocolAutonomousAutonomousAutonomousAutonomousAutonomousAutonomousAutonomousAutonomousAutonomousAutonomous
      Insert a central venous catheterNeverNeverNeverSupervision on call and/or according to the protocolNeverNeverNeverNeverNeverNeverNever
      Insert arterial lineNeverNeverNeverNeverUnder direct supervisionNeverNeverSupervision on call and/or according to the protocolNeverNeverNever
      Sampling blood for lab analysesSupervision on call and/or according to the protocolAutonomousAutonomousAutonomousAutonomousAutonomousAutonomousAutonomousNeverAutonomousAutonomous
      Sampling arterial blood gasSupervision on call and/or according to the protocolAutonomousAutonomousAutonomousUnder direct supervisionAutonomousAutonomousSupervision on call and/or according to the protocolNeverAutonomousSupervision on call and/or according to the protocol
      Bladder scanningSupervision on call and/or according to the protocolAutonomousAutonomousAutonomousNeverNeverAutonomousAutonomousAutonomousSupervision on call and/or according to the protocolAutonomous
      Urethral cathetersSupervision on call and/or according to the protocolAutonomousAutonomousAutonomousNeverAutonomousDon't knowAutonomousAutonomousAutonomousAutonomous
      Bladder irrigationSupervision on call and/or according to the protocolAutonomousAutonomousAutonomousNeverAutonomousAutonomousAutonomousAutonomousAutonomousAutonomous
      Mobilization of the patient in the PACUSupervision on call/according to the protocol (safe moves mandatory assessment yearly)AutonomousNeverAutonomousNeverAutonomousDo not knowAutonomousAutonomousAutonomousAutonomous (per licensed provider (physician, APRN) orders)
      Connecting and adjusting a pacemakerSupervision on call/according to the protocol (magnet device)NeverNeverNeverNeverNeverSupervision on call/according to the protocol (specialized PACU care. reworking in cardiac unit)Do not knowNeverDo not knowSupervision on call/according to the protocol (variable based on location, dependent on patient type, procedures performed (cardiovascular surgery center vs freestanding ambulatory surgery center), skill and training of nurses).
      Informing next of kinSupervision on call/according to the protocol (with Dr orders. Depends on what information you are giving. We only inform that the patient is in the PACU)AutonomousAutonomousNeverSupervision on call/according to the protocolSupervision on call/according to the protocolAutonomous (in some PACUs)AutonomousNeverAutonomousSupervision on call/according to the protocol

      (Depends on the content that is being shared with the next of kin)
      Monitoring heart rateAutonomousAutonomousAutonomousAutonomousSupervision on call and/or according to the protocolAutonomousAutonomousAutonomousAutonomousAutonomousAutonomous
      Monitoring ECGAutonomousAutonomousAutonomousAutonomousSupervision on call and/or according to the protocolAutonomousAutonomousAutonomousAutonomousAutonomousAutonomous
      Monitoring SPO2AutonomousAutonomousAutonomousAutonomousSupervision on call and/or according to the protocolAutonomousAutonomousAutonomousAutonomousAutonomousAutonomous
      Monitoring end-tidal CO2NeverAutonomousNeverAutonomousSupervision on call and/or according to the protocolAutonomousAutonomousSupervision on call and/or according to the protocolNeverAutonomousAutonomous
      Monitoring noninvasive blood pressureAutonomousAutonomousAutonomousAutonomousSupervision on call and/or according to the protocolAutonomousAutonomousAutonomousAutonomousAutonomousAutonomous
      Monitoring invasive blood pressureSupervision on call and/or according to the protocolAutonomousAutonomousAutonomousSupervision on call and/or according to the protocolAutonomousAutonomousAutonomousAutonomousAutonomousAutonomous
      Monitoring central venous pressureSupervision on call and/or according to the protocolAutonomousAutonomousAutonomousSupervision on call and/or according to the protocolAutonomousAutonomousAutonomousNeverAutonomousAutonomous
      Monitoring pulmonary capillary wedge pressureSupervision on call and/or accordingto the protocolNeverNeverSupervision on call and/or according to the protocolUnder direct supervisionAutonomousAutonomousSupervision on call and/or according to the protocolNeverDo not knowAutonomous
      Monitoring intracranial pressureSupervision on call and/or according to the protocolAutonomousNeverAutonomousUnder direct supervisionNeverAutonomousSupervision on call and/or according to the protocolUnder direct supervisionDo not knowAutonomous
      Intravenous injectionsSupervision on call and/or according to the protocolAutonomousAutonomousAutonomousAutonomousAutonomousAutonomousAutonomousAutonomousAutonomousAutonomous
      Intramuscular injectionsSupervision on call and/or according to the protocolAutonomousAutonomousAutonomousAutonomousAutonomousAutonomousAutonomousAutonomousAutonomousAutonomous
      Injections into an epidural catheterNeverNeverSupervision on call and/or according to the protocolAutonomousUnder direct supervisionNeverAutonomousAutonomousAutonomousNeverSupervision on call and/or according to the protocol
      Starting PCA/PCEASupervision on call/according to the protocolAutonomousAutonomousSupervision on call and/or according to the protocolUnder direct supervisionAutonomousAutonomousSupervision on call and/or according to the protocolAutonomousAutonomousAutonomous
      Temperature assessmentAutonomousAutonomousAutonomousAutonomousAutonomousAutonomousAutonomousAutonomousAutonomousAutonomousAutonomous
      Pain assessmentAutonomousAutonomousAutonomousAutonomousAutonomousAutonomousAutonomousAutonomousSupervision on call and/or according to the protocolAutonomousAutonomous
      PONV assessmentAutonomousAutonomousAutonomousAutonomousDo not knowAutonomousAutonomousAutonomousSupervision on call and/or according to the protocolAutonomousAutonomous
      IV, intravenous; PACU, postanesthesia care unit; PONV, postoperative nausea and vomiting; APRN, advanced practice registered nurse; PCA, patient controlled analgesia; PCEA, patient controlled epidural analgesia.

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