Care for elderly : a challenge in the anaesthesia context

Sammanfattning: Anaesthesia care involves bioscience and technical knowledge. Provision of anaesthesia care for elderly surgical patients can be a significant challenge when promoting patient comfort, safety, and satisfaction in a high-tech context with time constraints. Many patients in anaesthesia care are old and frail and have multiple illnesses and other problems, such as delicate skin, malnutrition, and pain. All this must be accounted for when caring for the elderly. Extra time in anaesthesia care is required to prepare elderly surgical patients for anaesthesia and surgery. And surgical patients have limited opportunities to influence their situations while in anaesthesia and surgery. So the overall aim of the research was to obtain insight into what anaesthesia care means in the lifeworld of anaesthesia - through accounts of experiences of nurse anaesthetists (NAs) and elderly patients. Research objectives were to: qualitatively identify and describe ways in which new NAs experience and perceive anaesthesia (I), describe the essence of the problematic anaesthesia-care situation phenomenon (as it relates to NAs) that involves elderly patients (II), illuminate what it means for a nurse anaesthetist to be in a problematic anaesthesia care situation (III), and illuminate what it means for elderly patients to be in intra-anaesthesia care and surgical situations (IV). The research takes a phenomenological approach to facilitate understanding of human beings (nurse anaesthetists and elderly patients) in a specific context (anaesthesia care). Three analysis methods were used in an effort to find congruence between research. questions and methods: phenomenography (I), descriptive phenomenology (II), and interpretive phenomenology (III and IV). In study I, nine newly graduated nurse anaesthetists had one month of clinical experience when they responded to four open-ended questions. The questions dealt with their views on anaesthesia care, and they provided clinical examples that further clarified their written answers. In studies II and III, seven experienced nurse anaesthetists were interviewed. Their narrations focused on concrete experiences in problematic anaesthesia care situations. In study IV, seven elderly patients (ages 61-79) were interviewed within six months after they had had hip replacement surgery or femur fracture surgery with regional anaesthesia. All participants were told that participations were voluntary and that they could withdraw from the studies at any time. The results show three ways of approaching anaesthesia care. Two ways were patient centred, while the third emphasised demands on efficiency. The favoured approach (patient centred) was selected because of each newly graduated nurse anaesthetist's understanding of care-giving in an anaesthesia situation. This meant that similar situations could be approached differently (I). Unforeseen situations were an inevitable part of anaesthesia care and proved to be problematic because they could not be predicted. They were accentuated in acute anaesthesia care situations with little time to come to terms with what was happening. Re-lived memories from former unpleasant situations affected and reshaped the present anaesthesia care situations. In addition, conflicting views of values were problematic in anaesthesia care (II). Being in problematic anaesthesia care sit uations was experienced as highly morally demanding when involving elderly patients and raised moral distress that evolved from the experience of being prevented from acting on one's legal and moral duties. In addition,, moral distress occurred when they felt that they weren't authorised to use their professional expertise or when others did not authorise them to use it (III). Elderly patients comfort and well-being were shown to be substantially challenged in anaesthesia care and surgery. The cognitive and emotional experience of time made some waiting and pain episodes in anaesthesia care to be experienced as endless. Severe pain could preoccupy to them to such an extent that they could not co-operate with the team, e.g., they could not communicate. Lost control of their bodies made the elderly sense a distance with themselves and made the anaesthesia care and surgery situation seem unreal. Sensing distrust created situations in which the elderly felt unsafe, so they felt that they had to be on their guards (IV). The research illuminates anaesthesia care from two perspectives. The results describe what anaesthesia care means and its consequences from the perspective of care providers (NAs) and what anaesthesia means from the perspective of care recipients (elderly patients). The research points out consequences of unforeseen problems and consequences for different approaches to anaesthesia care. Problematic anaesthesia care situations, i.e., experiences of difficult situations that require solutions seemed to be an inevitable in anaesthesia care and effect anaesthesia care-giving and conditions for receiving anaesthesia care. Further, the importance of recognising the experience of temporality as linear and nonchronological was put forward through NAs' recollections and elderly patients' experiences of pain and waiting. The research describes the need to articulate NAs' legal and professional authority in relation to given practice mandates. It also gives an account of elderly patient' needs to be understood - from an insider perspective - to help overcome challenges such as pain and wait in anaesthesia care and surgical situations. Finally, the research calls for further study of the experience of time in relation to care providers and patients in anaesthesia care as well as more research about moral distress and its consequences in anaesthesia care.

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