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• W3179676724 abstract "Editor—About one in three anaesthetics is performed in non-operating room anaesthesia (NORA) locations, with increasing frequency and complexity of procedures.1Chang B. Kaye A.D. Diaz J.H. Westlake B. Dutton R.P. Urman R.D. Interventional procedures outside of the operating room: results from the National Anesthesia Clinical Outcomes Registry.J Patient Saf. 2018; 14: 9-16Crossref PubMed Scopus (41) Google Scholar Care for patients in NORA locations is associated with well-described challenges, including working with unfamiliar equipment and teams in a location distant from the resources of the main operating rooms (ORs).1Chang B. Kaye A.D. Diaz J.H. Westlake B. Dutton R.P. Urman R.D. Interventional procedures outside of the operating room: results from the National Anesthesia Clinical Outcomes Registry.J Patient Saf. 2018; 14: 9-16Crossref PubMed Scopus (41) Google Scholar, 2Chang B. Urman R.D. Non-operating room anesthesia: the principles of patient assessment and preparation.Anesthesiol Clin. 2016; 34: 223-240Abstract Full Text Full Text PDF PubMed Scopus (27) Google Scholar, 3Wong T. Georgiadis P.L. Urman R.D. Tsai M.H. Non-operating room anesthesia: patient selection and special considerations.Local Reg Anesth. 2020; 13: 1-9Crossref PubMed Scopus (9) Google Scholar Working under such conditions may contribute to stress and burnout among anaesthetists.4Lapa T.A. Carvalho S.A. Viana J.S. Ferreira P.L. Pinto-Gouveia J. Stressors in anaesthesiology: development and validation of a new questionnaire.Eur J Anaesth. 2016; 33: 807-815Crossref PubMed Scopus (7) Google Scholar To date, no qualitative studies have described the impact of these challenges on anaesthesia clinicians. Our institution is uniquely positioned to examine the impact of the NORA environment in our hybrid MRI-OR suite, which is located several minutes' walking distance from the main ORs, because craniotomy and spine surgery cases are performed in both locations. This provides an opportunity to isolate the effect of the environment rather than the procedure on anaesthesia clinicians' perceptions of stress. We conducted semi-structured interviews to explore factors perceived as stressors or barriers to optimal patient care in the two environments. Our objective was to describe workload, emotions, and stress experienced by anaesthesia clinicians during similar surgical cases in two different environments. Based on the literature about human factors and challenges in remote anaesthesia care locations,1Chang B. Kaye A.D. Diaz J.H. Westlake B. Dutton R.P. Urman R.D. Interventional procedures outside of the operating room: results from the National Anesthesia Clinical Outcomes Registry.J Patient Saf. 2018; 14: 9-16Crossref PubMed Scopus (41) Google Scholar, 2Chang B. Urman R.D. Non-operating room anesthesia: the principles of patient assessment and preparation.Anesthesiol Clin. 2016; 34: 223-240Abstract Full Text Full Text PDF PubMed Scopus (27) Google Scholar, 3Wong T. Georgiadis P.L. Urman R.D. Tsai M.H. Non-operating room anesthesia: patient selection and special considerations.Local Reg Anesth. 2020; 13: 1-9Crossref PubMed Scopus (9) Google Scholar,5Leedal J.M. Smith A.F. Methodological approaches to anaesthetists’ workload in the operating theatre.Br J Anaesth. 2005; 94: 702-709Abstract Full Text Full Text PDF PubMed Scopus (66) Google Scholar,6Helmreich R.L. Davies J.M. Human factors in the operating room: interpersonal determinants of safety, efficiency and morale.Baillière Clin Anaesthesiol. 1996; 10: 277-295Abstract Full Text PDF Scopus (99) Google Scholar we developed an open-ended interview guide (see Supplementary material) to explore the following key areas that may influence experiences in providing anaesthesia care: (1) Environment (physical characteristics); (2) Culture and Processes (how things are done, workflow, regulations); (3) Technology (equipment); (4) People (anaesthesia and OR team factors). In addition, we asked anaesthesia clinicians about their emotions, stress, and workload during the same hypothetical case in MRI-OR compared with OR. Sampling was purposive, that is only clinicians with relevant expertise (providing care in both the regular OR and MRI-OR) were eligible, with the goal to enrol a sample of attending anaesthesiologists, supervised anaesthesiology residents, and supervised certified registered nurse anaesthetists (CRNAs) to understand a range of potential experiences. Interviews were recorded and transcribed, then coded using a qualitative data management programme (Dedoose, SocioCultural Research Consultants LLC, Los Angeles, CA, USA). We used a hybrid thematic analysis approach described by Fereday and Muir-Cochrane,7Fereday J. Muir-Cochrane E. Demonstrating rigor using thematic analysis: a hybrid approach of inductive and deductive coding and theme development.Int J Qual Methods. 2006; 5: 80-92Crossref Google Scholar which incorporates both the deductive a priori codes approach outlined by Crabtree and Miller8Crabtree B. Miller W. A template approach to text analysis: developing and using codebooks.in: Crabtree B.F. Miller W.L. Doing qualitative research. 2nd ed. Sage Publications, Thousand Oaks, CA1999: 163-177Google Scholar and the data-driven inductive approach of Boyatzis.9Boyatzis R.E. Transforming qualitative information: thematic analysis and code development. Sage Publications, Thousand Oaks, CA1998Google Scholar Briefly, some of our codes were pre-determined based on literature-derived challenges of working in remote anaesthesia locations and covered aspects within the key areas mentioned above (‘deductive’), and additional codes were identified through in-depth coding and iterative analysis (‘inductive’). The interviews ranged from 18 to 44 (median 24.5) min. Saturation of major themes was achieved after 10 interviews,10Guest G. Bunce A. Johnson L. How Many interviews are enough? An experiment with data saturation and variability.Field Methods. 2006; 18: 59-82Crossref Scopus (7898) Google Scholar involving two residents, four attending anaesthesiologists, and four CRNAs (7 males/3 females reflecting the gender distribution among ~30 eligible clinicians). The most commonly identified factors influencing delivery of anaesthesia care included the remoteness of the MRI-OR, team factors, culture, unfamiliarity with both environment and equipment, and safety rules (Table 1, upper panel). These identified themes often spanned several of the key areas covered in the interview guide, such as ‘unfamiliarity’, which was mentioned in the context of people, culture, and equipment. Similarly, team factors were discussed in the people and culture domains, with nuanced views on anaesthesia clinicians' ability to trust the MRI-OR team, team qualifications, and interprofessional team relations. Within the anaesthesia team, MRI-OR-specific experience and skill level of the anaesthesia team counterpart (an attending is typically supervising a resident or CRNA) was felt to be important. Each interviewee experienced higher workload, anxiety, and stress in MRI-OR compared with OR (Table 1, lower panel). The most commonly reported ‘top determinant’ of stress and emotions was ‘team factors’, both within the anaesthesia care team and in the relationship with the OR team, whereas remoteness and unfamiliarity with the environment were less frequently reported. Member-checking (a process where individuals in similar roles as the interviewees review the findings and indicate if they seem accurate and representative of their experience) validated our findings.11Korstjens I. Moser A. Series: practical guidance to qualitative research: Part 4. Trustworthiness and publishing.Eur J Gen Pract. 2018; 24: 120-124Crossref PubMed Scopus (632) Google ScholarTable 1Factors influencing delivery of anaesthesia care. Upper panel: the most commonly mentioned themes influencing delivery of anaesthesia care described by 10 anaesthesia clinicians when providing care in the non-operating room environment, an MRI-hybrid operating room (MRI-OR), compared with the regular operating room (main OR). Lower panel: workload and emotions affecting anaesthesia clinicians in the MRI-hybrid operating room (MRI-ORI). ∗Relevant to non-OR anaesthesia (NORA) in general. †Unique to an MRI environment.n (interviews, excerpts)Representative quotesTheme/sentimentRemoteness and Isolation Owing to its distant location from the regular OR, help or supplies arrive later to MRI-OR.* Communicating to/from MRI-OR is difficult because use of personal devices and pagers is restricted in MRI-OR.#10, 36‘You're further from help, should something kind of go wrong’ (A, nurse anaesthetist)*‘In the main OR, we have access to multiple phones […] in the MRI-OR sometimes, that's a little bit more challenging. We don't have our beepers. We don't have cellphones’. (C, resident)#Team Factors The MRI-OR-relevant skills and availability of the anaesthesia team members and the OR personnel, familiarity with the surgeon, and quality of teamwork influence the workday of anaesthesia clinicians.*,#9, 54‘So the circulating nurse may not be paying attention quite as much to what I'm doing […] in the MRI-OR because they're focused on their own part.’ (C, resident)*,#‘it just raises the stress level of the room if there are people who aren't comfortable being there’ (G, CRNA).*Culture The MRI-OR team is generally perceived as helpful, yet some interviewees describe being an ‘outsider’ to that team.* The workflow is slow with extra attention given to safety protocols.*,#9, 38‘I'm always a visitor to that team, […]. There's not a feeling of exclusion, but I'm clearly a visitor down there’. (B, attending)*‘You know, the main OR is slow. MRI-ORIs even slower’. (F, CRNA)*Unfamiliarity with Environment and equipment The differences in equipment and environment* and the presence of environment-specific rules/restrictions# creates a sense of unfamiliarity and distraction.8, 36‘People operating […] in an environment that they're not 100% comfortable I think poses a risk to the patient in general’. (H, CRNA)*‘with the MRI cases we can't use the syringe pumps so […] you have to sort of adjust how you're […] running your infusion’. (G, CRNA)#safety protocols/processes Safety rules and protocols in MRI-OR, such as ferromagnetic item counts and restricted use of non-MRI-compatible equipment, are viewed as important for safety, but also as difficult, distracting, or arbitrary.#8, 24‘Well, you have the steps that are required because you are working in with an MRI and I think those are reasonable’. (J, attending)#‘So there certainly is a very sort of stringent adherence to some regulations that don't always make a lot of sense to me’. (I, resident)#Perception of workload and emotions in the MRI-OR compared with the main ORWorkload Higher in the mri-or Workload in the MRI-OR is described as higher, in part because of the need to follow protocols and to plan ahead for any additional needs.10, 20‘I think overall the workload of the entire team is quite a bit more. Positioning, making sure there's no metal […]’ (H, CRNA)‘having to be […] mindful of having sort of every piece of equipment and every medication that one could foreseeably need […] requires more preparation up front’. (I, resident)Stress and Anxiety Higher in mri-or Working in MRI-OR is associated with feelings of stress, anxiety, and frustration, despite positive feelings about some aspects.10, 39‘The mental work […] is much higher, and that's where the stress comes from’. (B, attending)‘I think when I'm working in the MRI-OR, my guard is a little bit higher. My threshold to call for help is a little bit lower. I think my adrenaline sympathetic system is a little bit more in overdrive’. (C, resident) Open table in a new tab Our findings corroborate that known challenges of remote anaesthetising locations contribute to higher workload, anxiety, and stress for anaesthesia providers. Some of these challenges, such as the physical location within the healthcare institution, can hardly be changed. However, the large emphasis on team skills and relations is notable and points towards team training and educational initiatives as opportunities to alleviate stress experienced by clinicians in the NORA environment. Unfamiliarity among team members and lack of trust in the team's capabilities can be addressed by interprofessional location-specific crisis simulation training, which we are implementing.12Schroeck H. Boone M.D. Rubenberg L.A. Bryan Y.F. Anesthesia emergencies in hybrid operating rooms: multidisciplinary crisis resource management. APSF NewsFlash, 2020https://www.apsf.org/article/anesthesia-emergencies-in-hybrid-operating-rooms-multidisciplinary-crisis-resource-managementDate accessed: December 11, 2020Google Scholar This study has several limitations. The sample size is small, but we believe adequate given that we focus on major themes reported within a relatively homogeneous sample, and small samples can support saturation.10Guest G. Bunce A. Johnson L. How Many interviews are enough? An experiment with data saturation and variability.Field Methods. 2006; 18: 59-82Crossref Scopus (7898) Google Scholar Social desirability could have played a role, as the interviewer (HS) had previously participated in a process improvement project involving the MRI-OR, which was likely known to some subjects who might have downplayed negative feelings about the MRI-OR. We mitigated these limitations by applying a balanced interview guide allowing positive or negative feelings and having an experienced qualitative researcher with no relationship to the study participants (KS) conduct coding and analysis. Finally, we undertook member-checking of our findings, which also align with previously described challenges of the NORA environment.2Chang B. Urman R.D. Non-operating room anesthesia: the principles of patient assessment and preparation.Anesthesiol Clin. 2016; 34: 223-240Abstract Full Text Full Text PDF PubMed Scopus (27) Google Scholar,3Wong T. Georgiadis P.L. Urman R.D. Tsai M.H. Non-operating room anesthesia: patient selection and special considerations.Local Reg Anesth. 2020; 13: 1-9Crossref PubMed Scopus (9) Google Scholar Although some aspects of the MRI-OR, such as the presence of an MRI scanner, may be unique to this particular environment, many other features are common for most NORA environments, including the remote location and working with less familiar equipment and teams. As our institution performs identical surgical procedures in both the OR and MRI-OR, this setup allowed us to explore the effect of the environment, rather than the procedure, on anaesthesia clinicians. Thus, we believe that our results are likely to be similar in other NORA locations and at other institutions, although this remains to be investigated. The finding that clinicians experience the lack of familiarity within the interprofessional care team as a major contributor to stress appears plausible. With NORA procedures currently constituting about one-third of anaesthesia cases, it is imperative to address modifiable contributors to clinician stress in this environment. Department of Anesthesiology, Dartmouth-Hitchcock Medical Center , Lebanon, NH, USA, supported this pilot study with seed funding." @default.
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• W3179676724 title "Team factors influence emotions and stress in a non-operating room anaesthetising location" @default.
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