Team factors influence emotions and stress in a non-operating room anaesthetising location

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