ORIGINAL ARTICLE

Interaction Between Nurse Anesthetists and

Patients in a Highly Technological
Environment
Karin Aagaard, MScN, Birgitte Schantz Laursen, PhD, MScN,
Bodil Steen Rasmussen, PhD, MD, Erik Elgaard Srensen, PhD, MScN

Purpose: To explore the specific interactions between patients and nurse

anesthetists in the highly technological environment of anesthesia
nursing, focusing on the time interval between patient entrance into
the operating room and induction of general anesthesia.
Design: Focused ethnography was used for data collection.
Methods: Participant observation and interview of 13 hospitalized pa-
tients being admitted for major or minor surgical procedures and 13
nurse anesthetists in charge of their patients and anesthetic procedures.
Photographs were taken of specific situations and technological objects
in the observation context. The analysis was inspired by grounded theory.
Finding: A core variable of creating emotional energy is presented, and two
subcore variables are delineated: instilling trust and performing embodied
actions.
Conclusion: Creating emotional energy has an important impact on the
interaction between patients and nurse anesthetists. Furthermore, the
motives underpinning nurse anesthetists interactions with patients are
a central constituent in developing anesthesia care.
Keywords: anesthesia care, patient-nurse interaction, general anes-
thesia, focused ethnography.
2016 by American Society of PeriAnesthesia Nurses

THE PERIOD BEFORE THE INDUCTION of

Karin Aagaard, MScN, is a PhD Student, Department of
Anesthesiology and Intensive Care Medicine, Aalborg Univer-
sity Hospital, Aalborg, Denmark; Birgitte Schantz Laursen,
PhD, MScN, is a Senior Lecturer, Aalborg University Hospital
and Aalborg University, Aalborg, Denmark; Bodil Steen Ras-
mussen, MD, PhD, is a Professor, Department of Anesthesi-
ology and Intensive Care Medicine, Aalborg University
Hospital and Clinical Lecturer, Clinical Institute of Medicine,
Aalborg University, Aalborg, Denmark; and Erik Elgaard
Srensen, PhD, MScN, is a Professor in Clinical Nursing, Aalborg
University, Head of Clinical Nursing Research Unit, Aalborg
University Hospital, Aalborg, Denmark.
Conflict of interest: None to report.
Address correspondence to Karin Aagaard, Department of
Anesthesiology and Intensive Care Medicine, Aalborg Univer-
sity Hospital, Borger Alle 10, 9210 Aalborg S, Denmark;
e-mail address: kaag@hst.aau.dk.
2016 by American Society of PeriAnesthesia Nurses
1089-9472/$36.00
http://dx.doi.org/10.1016/j.jopan.2016.02.010
anesthesia can be stressful for patients, and they
may feel vulnerable.1 When engaging with pa-
tients in the operating room (OR), nurse anesthe-
tists (certified registered nurse anesthetists
[CRNAs]) prepare patients for the procedures
and actions related to the anesthetic induction.
Many patients are frightened of the anesthetic, be-
ing unconscious, the surgical outcome and poten-
tial for postoperative pain.2 Thus, a significant
challenge for CRNAs in this highly technological
environment is to maintain balance between pa-
tient safety and control of the technical aspects
of the procedure, while caring for the emotional
needs of the patient.3 Time constraints impinge
on the interval from patients entering the OR
and induction. During this short period, a complex
interaction involving the patient, CRNA, and high-
ly technological procedures takes place.4 Here,

Journal of PeriAnesthesia Nursing, Vol -, No - (-), 2016: pp 1-11 1

2 AAGAARD ET AL
CRNAs can meet patients specific concerns, mini-
mize their discomfort during instrumental proced-
ures while, concurrently, facilitating patient
cooperation with the instrumental and anesthetic
procedures.5
In many countries, anesthesia falls within the
domain of medicine and uses highly technological
procedures.4 Although anesthesia nursing practice
is well established in Denmark, CRNAs are chal-
lenged by working in environments in which there
is limited time for establishing a relationship with
their patients.6 Furthermore, working in a high tech-
nological area being incorporated in the care of the
patient, nurses often find themselves delicately
balancing between approaching the patients body
as an object of medical care while also perceiving
the patient as a subject with whom a relationship
needs to be established.3 Thus, the challenge facing
CRNA is to be conscious of and deliver humane and
dignified care in a highly technological environ-
ment.7 In this specific preoperative environment,
CRNAs work to establish a relationship with pa-
tients and assess their implicit and explicit needs
for physical and psychosocial care within the
limited time available. Given the paucity of research
in this field, the purpose of this study was to identify
and explore the interaction between patients and
CRNAs in a highly technological environment of
nursing, focusing on the time interval from patients
entering the OR and until induction.
Methods
Focused ethnography is chosen as the methodology
for data collection as the purpose of this study is to
explore the interaction between patients and CRNAs
in a specific environment. Furthermore, the research
design encompasses both patients and CRNAs ex-
plaining and elaborating on selected observations
of their interactions. Knoblauch8 emphasizes that
the entities studied in focused ethnography are situ-
ations, interactions, and activities. Focused ethnog-
raphy in health care research can be applied when
the research concerns a context-specific and
problem-focused framework. The research motive
of this method is to develop nursing knowledge
and practice.9 Focused ethnography8 allowed focus
on everyday social interactions between patients
and CRNAs from the time interval between patient
entrance into the OR and induction of anesthesia.
Setting and Informants
The study was carried out in the Department of
Anesthesiology at a university hospital in
Denmark. The Department of Anesthesiology
was represented by several medical subspecialties,
for example, gastrointestinal anesthesia and
cardiothoracic anesthesia. Two wards represent-
ing these subspecialties were chosen. Gastrointes-
tinal cancer surgery represented major cancer
surgery, and breast cancer surgery represented mi-
nor cancer surgery.
The criteria for selecting patients for this study
were 18 years of age or older and admitted for elec-
tive cancer surgery. Patients received premedica-
tion, excluding benzodiazepines, according to
local hospital guidelines. The patients ages ranged
from mid 50s to late 70s.
The CRNAs in charge of the patients agreed to be
observed and to participate in subsequent inter-
views. The CRNAs were all females, registered
nurses with 2 years of special anesthesia training,
compromising both theoretical and practical edu-
cation.10 The CRNAs practical experience ranged
from 1 to 40 years.
Ethics
The project was reported to the Danish Data Pro-
tection Agency (journal no. 2008-58-0028). Partic-
ipants were informed verbally and in writing,
regarding the purpose of the study. All participants
gave written consent. The study met ethical guide-
lines for nursing research in Scandinavia.11 Head
nurses at the Department of Anesthesiology and
Department of Surgery were appointed gate-
keepers, granting physical access for making field
observations and in contacting potential partici-
pants.12 Head nurses and CRNAs were met with
beforehand, with the intention of information
sharing and expectations of each professional out-
lined. Anesthesiologists and OR nurses were
informed in writing about the study taking place.
Data Collection
Data were collected in three phases, each during
which episodic data were collated (Figure 1).13
While collecting phase 1 data, patient familiarity al-
lowed subject separation into differing groupings.
INTERACTION BETWEEN NURSE ANESTHETISTS AND PATIENTS 3

Phase 1 Phase 2
Phase 3
May, June and August October 2013 February
January - October 2014
2013 2014, April 2014
Observed and Ten field observations Photographs taken of
participated in practice and postoperative the observation
for a total of ten days interviews with ten context: January and
at two surgical wards nurse anesthetists and March 2014
Observed the practice ten patients Postoperative
of different nurse A total of 73 hours of interviews with three
anesthetists for six data collection nurse anesthetists and
days three patients:
A total of 96 hours of September- October
data collection 2014
A total of 19 hours of
data collection

Figure 1. Phases in the episodic data collection with a specification of the total number of hours spent.

Observations were made of the daily routines in
the nursing environments of the two surgical
wards and the work domains of the CRNA. The
first author accompanied the nurses on the surgi-
cal ward when making daily rounds on patients
preoperatively and postoperatively. In addition,
direct observation of the CRNAs in their primary
caregiving role enhanced the appreciation of a
nonanesthetist professional for their particular
specialty. This can be seen as both a strength and
a limitation in relation to being objective in
connection to anesthesia and being subjective as
a nurse. Knowledge of the specific nursing field
made it possible to focus and understand their
perspective perioperatively.8 Phase 1 extended
from May to August 2013.
In phase 2, patients were observed on the day of
surgery up until anesthesia induction. The first
author attended the surgical report during the
nurses morning shift and sat by the patients who
were being prepared for surgery. The observation
focus was patients verbal and nonverbal interac-
tions with health care professionals on the ward.
Ten CRNAs interactions with different patients
were observed during preparation for the anes-
thetic procedure. Field notes were written after
each observation. Both patients and CRNAs were
interviewed separately after the anesthetic and
surgical procedures. CRNAs were interviewed
the day of observation, but patients were inter-
viewed on either the first postoperative day or
the second postoperative day, dependent on their
stated level of postsurgical discomfort. A semi-
structured interview guide was prepared based
on field notes observed during CRNAs-patients in-
teractions. Furthermore, the individual patient and
CRNA reflections on the situation were a focus
point. Phase 2 data collection extended from
October 2013 to February 2014. Duration of
each interview was between 20 and 60 minutes,
which were audio recorded and then transcribed
verbatim.
Data in phase 3 were collected to show how mean-
ing of the context of the OR affected the CRNA-
patient relation. Thus, symbols in interaction and
CRNAs routines in performing highly technolog-
ical procedures were explored. Photographs
were taken of the observation context and instru-
mental setup in the OR by a hospital photogra-
pher.14 These photographs were used during
interviews as a method for mapping patterns in
the observations and interviews of the CRNAs
and patients.15 Three CRNAs and three patients
were interviewed, each group being presented
with the same photographs. Duration of the inter-
views was from 20 to 60 minutes, which were
audio recorded and later transcribed verbatim.
Phase 3 extended from January to October 2014.
Data Analysis
The data set was analyzed across the three phases
of the study and informed by the analytical tools of
grounded theory.16 The analytical tools used were
open, selective and theoretical coding, and con-
stant comparison. In the process of coding,
memos were written as ideas emerged. Memos
encapsulated written ideas about the codes and
4 AAGAARD ET AL

relationships between the codes, which led to sub-
sequent theorizing.17
The audio recordings were transcribed consecu-
tively, then iteratively went from data to analysis,
coding the data inductively. Each phase of data
collection was coded before further collection
continued. Codes, known as in vivo codes, were
developed from the data itself, whereas other co-
des were developed from the meanings embedded
in the transcribed interview texts.18 Constant com-
parison allowed exploration of similarities and dif-
ferences in the collected data.18 Photographs
facilitated understanding of patterns and routines
during the interaction between CRNA and patient.
Showing photographs of anesthetic-specific situa-
tions and instruments in the OR was used to sup-
port and illustrate codes and patterns emerging
from the observations and interviews.19
Development of the study in phase 3 led to identi-
fication of the core variable creating emotional
energy, which was grounded in the data and
captured the characteristics of the interactions be-
tween CRNAs and patients in a highly technolog-
ical environment. Two subcore variables were
also delineated: instilling trust and performing
embodied actions. The characteristics of the two
subcore variables are further elucidated by two
categories (Figure 2).
Different combinations of sampling, that is, col-
lecting data through the three aforementioned
phases, coding and memoing, resulted in a satura-
tion of emerging categories and variables, meaning
that collecting more data would contribute neither
to further development of emerging categories
and variables nor to development of further the-
ory.16
Findings
Analysis led to development of creating emotional
energy as the core variable. The core variable was
discerned through two subcore variables:
instilling trust and performing embodied actions
and their associated categories and properties.
Findings are illustrated in Figure 2. When photo-
graphs are presented as evidence, the reference
point is Figure 3. To illustrate dynamics of the find-
ings and their relation to the photographs, findings
are illustrated in Figure 3, which shows the linear
process of preparing the patient for a surgical pro-
cedure, ending with the patient being anesthe-
tized. This linear process, a dynamic interaction,
takes place between CRNAs and patients. This
interaction is embedded in CRNAs ability to instill
trust in patients while performing embodied ac-
tions during routine procedures (Figure 3).
In this section, each citation of observations and
interviews has a specific reference number as-
signed for each of the 13 patients and 13 CRNAs.
Participants from phase 2 (Figure 1) have a number
from 1 to 10. Participants from phase 3 (Figure 1)
are numbered 11, 12, and 13.

Creating
emotional
energy

Performing
Instilling trust embodied
actions

Depending on
Offering a
routines in
lifeline
interaction

Integrating
Controlling
technology and
interaction Figure 3. Dynamic patterns of creating emotional
humane care
energy when preparing patients for general anes-
Figure 2. Presentation of findings: the core vari- thesia. This figure is available in color online at
able, two subcore variables, and their categories. www.jopan.org.
INTERACTION BETWEEN NURSE ANESTHETISTS AND PATIENTS
Creating Emotional Energy
Creating emotional energy emerged as the core
variable and was further conceptualized through
two subcore variables: instilling trust and per-
forming embodied actions (Figure 2). Creating
emotional energy encompasses CRNAs ability
to perceive patients physical and psychosocial
needs during induction for the purpose of estab-
lishing a relationship with each patient while
maintaining their necessary professional dis-
tance. The intended outcome of creating
emotional energy is to instill trust and confi-
dence in patients. By focusing first and foremost
on safety procedures, CRNAs were emotionally
prepared to respond to patients physical and
psychosocial needs. This sensitivity results in
CRNA consciously organizing and performing
technical procedures, while taking patient needs
into account. The six photographs in Figure 3
illustrate how creating emotional energy was re-
flected in preparation and interaction between
CRNAs and patients. Creating is important for es-
tablishing relationships with patients. Embedded
in the construction of creating is a conscious
way of acting that may well challenge the CRNAs
routines when performing technical procedures.
The authors found different levels of emotional
energy in CRNAs during interaction with pa-
tients. Moreover, the findings showed that
emotional energy was embedded in instrumental
actions and routines, perhaps at the expense of
being sensitive toward patients psychosocial
needs, when some CRNAs would ordinarily
interact with patients. This, in turn, affected
the way CRNAs instilled trust in patients while
performing embodied actions. A CRNA in the
following citation expressed the core variable
creating emotional energy: The CRNA is
describing a specific sensibility and mutual focus
of attention in an OR environment among the
CRNA, the patient, OR nurses, and anesthesiolo-
gists. Emotional energy was embedded in this
sensibility, thus affecting the way actions were
performed. And in fact you can sense if there
is someone in the room who does not have this
specific sensibility. There is a sort of situational
awareness. Either you walk in and pick up on
this sensibility right away, or you just walk in,
perform a task and leave (CRNA 11).
5
Instilling Trust
The first subcore variable was designated
instilling trust, characterized by CRNAs interac-
tions with each patient. The key process in
instilling trust was the patients and CRNAs mutual
focus on the procedure, which was affected by
each others emotional state. The CRNA was
affected by the patients signals of physical and
psychosocial needs in a vulnerable situation.
Communicating this awareness verbally or nonver-
bally to the patient resulted in the patient feeling
trust and confidence in the situation. CRNAs and
patients mutual focus of attention, and their
mutual response to each others signals and ac-
tions, feed on one another and resulted in
emotional energy that led to a feeling of trust and
confidence in the patient. CRNAs and patients
were dependent on being able to sense each
others signals and, at the same time, focus on
the mutual trajectory of preparing for the anes-
thetic and/or operative procedure. To instill trust
in the patient, one CRNA used touch while prepar-
ing for the instrumental procedure, saying:
Touching the patient on his/her shoulder or arm
is my way of being human while remaining a pro-
fessional, in other words, You can total count
on me; Ill take care of you (CRNA 4). The fourth
picture in Figure 3 illustrates this quotation. The
CRNA placing her hand on the patients shoulder
while placing the face mask over the patients
mouth and nose imparted trust.
Two distinct categories emerged in unfolding the
subcore variable instilling trust: offering a lifeline
and controlling interaction (Figure 2).
Offering a Lifeline
A CRNA, reflecting on a key issue for the interdisci-
plinary team members, expressed offering a life-
line: how was the contact and care of the patient
organized? I think that some CRNAs say that it is
the CRNA who is entitled to this contact. But it
doesnt matter, as long as the patients feel that
they have a lifeline. In this context, a lifeline means
a health care professional who takes the responsi-
bility of staying in contact with the patient during
the procedure; someone who comforts and guides
the patient through the entire procedure. Too
6 AAGAARD ET AL
many health care professionals offering a lifeline
make the situation confusing and insecure [the pa-
tient]. I think that the most important thing is to
signal to the patient that we are working together
in taking care of you. The atmosphere among col-
leagues is very important (CRNA 1). Embedded
within offering a lifeline was partly a concern
for patients needs for trust and confidence, partly
CRNAs and OR nurses being able to take the role of
comforting and guiding the patient through the
procedure, which, in turn, may challenge the pro-
fessional identity of each group of health care pro-
fessionals. Offering a lifeline was also an outcome
of CRNAs professional training in maintaining
control of the situation.
Also involved in offering a lifeline was a tacit
commitment by the CRNA and secondary CRNA,
who was assisting during the preanesthetic pro-
cedure, to coordinate among themselves who is
going to be the patients lifeline during the anes-
thetic procedure. The following situation illus-
trates the ambiguities of this particular
interaction. A patient is lying in a hospital bed,
outside the OR. The CRNA responsible for the
anesthetic procedure walks by and greets the pa-
tient. Immediately, the patient takes hold of the
CRNAs hand while staring intently. The CRNA
and patient continue to hold hands while they
are talking (observation 3). This situation mani-
fests an obvious appeal for a lifeline by the patient,
which is illustrated in the third photograph in
Figure 3. Later, the patient verbally expressed a
need for hand holding during the anesthetic pro-
cedure: The patient asks the CRNA: would you
hold my hand while Im sleeping? The CRNA an-
swers: I would like to, because Im sitting here
anyway (observation 3). The patients appeal for
a holding hand was not taken into account before-
hand by the CRNA or coordinated with the inter-
disciplinary team: The CRNA stands by the
patients headboard holding the face mask. The
secondary CRNA gives the patient intravenous
medicine. The patient is lifting the right hand.
The secondary CRNA, who is busy infusing the
medicine, leans over and puts the hand down
again. The patient lifts the hand again, and the
anesthesiologist, who has been standing in the
rear of the OR, walks to the opposite side of the
operating table and takes the patients hand (obser-
vation 3). The challenge in this situation was the
CRNAs impression of the patient being easy to
talk to and having the emotional energy to small
talk with the entire interdisciplinary team. This
misled the CRNA into not following the patients
appeal for a comforting handhold during the pro-
cedure. Furthermore, time constraints and priori-
tizing the performance of technical procedures
were important factors in the equation. The
CRNAs wish to have primary contact with the pa-
tient was not coordinated with the interdisci-
plinary team beforehand. Im the one to have
the main contact with the patient and then I do
want it. Im not the one to stand back. It is the
OR nurse who must stand back. Im dependent
on the fact that the OR nurses sense the same as
I in connection with the patient (CRNA 3).
Thus, the primary challenge in offering patients a
lifeline was the coordination between interdisci-
plinary team members in the OR of who would
take responsibility to be the patients lifeline.
Controlling Interaction
CRNAs control interactions with patients when
preparing and guiding them through the anes-
thetic induction. Guiding patients with words
and voice tone were specific ways of giving pa-
tients back some control in this vulnerable situa-
tion. A CRNA explained how she guided patients
while positioning the face mask: I know that the
patients are about to surrender control of their vi-
tal functions to me, so I feel that I need to give
them back some control. The patient is not able
to ask questions, so Im thinking, What would
the next possible question from the patient be?
How may the patient experience these proced-
ures? And then I explain that (CRNA 11).
Embedded in these guiding and controlling actions
was also the CRNAs way of relying on routines,
while performing instrumental procedures and in-
teracting with their patients. Patients were uncon-
ditionally leaving responsibility for their lives in
the hands of the CRNA. Their decision to entrust
CRNAs with this, and the specific treatment, was
further supported by intradisciplinary and inter-
disciplinary team members being physically pre-
sent when they guided and informed patients
during the procedure.
Maintaining OR turnover and limited time be-
tween preparation for the next anesthetic proced-
ure and surgery motivated CRNAs in using
different levels of controlling interaction. For
INTERACTION BETWEEN NURSE ANESTHETISTS AND PATIENTS
example, CRNAs would fend off patients ques-
tions by letting them know that this was neither
the time nor the place to discuss their thoughts
on the specific situation. This is illustrated by the
following CRNAs interview response: I dont what it is Im going to do in various phases and
think it is appropriate for patients to be asking a
lot of questions at the last minute - some have a ten-
dency to do that. Then, I think, it is time to move
on. Of course thats my assessment of the situa-
tion (CRNA 9).
Case observations also brought to light how
CRNAs took control by overhearing patients finish-
ing their answers to the CRNAs questions. This
was because the CRNA was professionally engaged
with moving on to the next task and changing her
place in the OR, as in the next example. The CRNA
asks the patient if he has slept well and is ready for
todays hardship. The patient tells the CRNA that
he has slept for 5 hours. The CRNA asks if the pa-
tient took a sleeping pill. The patient explains
that he didnt, but he used some pills prescribed
by his general practitioner. he is not able to finish
his sentence because the CRNA turns away from
the patient to read her journal (observation 2).
CRNAs verbal communication and physical posi-
tion in the room in relation to the patients indi-
cated great nuances in their thoughts and
priorities when interacting with patients. There
appeared to be a conflict between prioritizing
and thinking about the meaning of this particular
interaction, on the one hand, and the instrumental
and practical tasks overriding CRNAs being
consciously present in their interaction with pa-
tients, on the other. The second photograph in
Figure 3 illustrates how patient safety procedures
are a central task. The aforementioned excerpt
from an interview and an observation shows two
different ways of controlling the interaction.
Performing Embodied Actions
The second subcore variable, performing
embodied actions, was evident from observations
that CRNAs had specific embodied and tacit ways
of acting while preparing patients for the anes-
thetic induction. CRNAs descriptions of embodied
actions were characterized by being tacit and
dependent on clinical experience and routines.
Use of the word performing captures a prereflex-
ive way of acting and performing instrumental pro-
cedures. Hence, clinical experience contributed to
7
embodied actions being integrated parts of a
routine. This subcore variable was expressed by
a CRNA: It is not a conscious act of reflection
every time, but earlier on in my career I decided
what Im going to say (CRNA 11). This statement
also illustrates the importance of technical and
interactional routines. The fifth photograph in
Figure 3 shows the mutual effect of these two
types of routines used to perform embodied ac-
tions. I deliberately hold the hand of the patients
arm Ive chosen for venous cannulation. I think
that Im able to signal professional competency
by using touch as I perform the task (CRNA 11).
The categories for describing this subcore variable
are depending on routines in interaction and
integrating technology and humane care.
Depending on Routines in Interaction
The depending on routines in interaction cate-
gory contains both routines in technical proced-
ures and routines in performing embodied
actions. Embodied actions are part of CRNAs rou-
tines when performing technical procedures,
while simultaneously interacting with patients.
These routines support CRNAs feelings of confi-
dence and control during their interaction with pa-
tients and help them remain alert and prepared.
One CRNA points out the symbolic importance
of the first photograph in Figure 3. This is such
an illustrative picture for me. It indicates how
you go through everything once again before the
patient arrives and confirm to yourself that youre
confident about the procedure youre about to
perform. This is prerequisite for being sufficiently
receptive towards the patient (CRNA 11). CRNAs
depend on familiar routines in their daily work to
be able to deal with time constraints, patient
safety, and effective performance in preparing for
the anesthetic procedure. You are under this
time pressure, and then you need your rhythm,
and, at the same time, I also believe that the
rhythm lies in the things you say to the patient
(CRNA 8). In this work, routine is embedded an im-
plicit challenge, namely that CRNAs risk mini-
mizing their emotional energy and sensitivity
toward patients individual physical and psychoso-
cial needs. The risk was to use small talk and a min-
imum of embodied actions without reflection and
sensibility toward the patient, thus adversely
affecting the possibility of establishing a
8 AAGAARD ET AL
relationship embodying trust and confidence with
the patient. CRNAs interaction strategy may then
be characterized as a production-centered action,
in contrast to a patient-centered interaction, as in
the following interview excerpt: It is not only
time that controls us [laughter], but today there
are 12 acute patients waiting for surgery, and I
am on duty tomorrow, so I have told my colleagues
to work efficiently to minimize the number of pa-
tients by tomorrow (CRNA 2).
Integrating Technology and Humane Care
Integrating technology and humane care is a core
element of CRNAs daily clinical practice. This inte-
grating practice demands that CRNAs attention be
divided between the technological procedures
and their interaction with patients, before and dur-
ing these procedures. Furthermore, patients
cooperation during the procedures and CRNAs
cooperation with the interdisciplinary team are
two salient components in the integrating tech-
nology and humane care category. CRNAs atten-
tion before and during a specific technological
procedure focuses on juggling multiple tasks to
ensure patient safety while being vigilant and guid-
ing them through anesthetic induction. This is ex-
pressed by a newly CRNA: I think it comes with
time and it depends on the experience you have.
In the beginning, and even now, I need to check
the values on the screen. I do not have that intui-
tive feeling yet. I need to turn my head away
from the patient, and Im a person who wants to
see what my assistant is doing. For that reason,
the patient gets about a third of my attention,
and, I think, with growing experience you focus
more on the patient. As a newly CRNA you are
more technically oriented (CRNA 8). In this state-
ment, the CRNA expresses a conscious way of
working with technology when being newly certi-
fied, which may be at the expense of interacting
with patients. This is expected to change with
growing experience in clinical practice. Thus,
the aforementioned example indicates that there
is a specific way of working with technological in-
struments, which was characterized by CRNAs
performance of embodied actions when interact-
ing with patients and cooperating with interdisci-
plinary team members. A latent risk here is to
objectify the patient, if CRNAs do not succeed in
consciously reflecting and sensing patients phys-
ical and psychosocial needs when performing
technical tasks. A patient expresses this in the
following: It is a bit like a factory when there
are three [health professionals] standing here.
you do this, and you do that, and then, next patient
[laughter] (patient 2).
Discussion
This study delineates the complexity of CRNAs
interaction with patients in a highly technological
environment. The core variable of the findings is
conceptualized as creating emotional energy
and is further elaborated through two subcore vari-
ables: instilling trust and performing embodied
actions.
Different domains of activity and performing
instrumental and technical procedures are inter-
woven during CRNAs interaction with patients.
This studys findings point to the critical impor-
tance of analyzing embodied actions. By doing
so, CRNAs are able to create emotional energy as
an outcome of the specific interaction with pa-
tients before induction of general anesthesia.
This emotional energy may then result in instilling
trust in patients. Previous researches on communi-
cation between patients and health care profes-
sionals in the anesthetizing area20 and the
embodiment and ephemeral teamwork in anes-
thesia21 stress the importance of analyzing
embodied conduct and embodiment in the work-
place. In line with this research is a study on pro-
fessional activity in the OR,22 which focuses on
how surgical work is accompanied by talk and
bodily conduct. Hindmarsh and Pilnick21
concluded in one study that the body is a central
site for organizing work and recognizing how par-
ticipants in a social interaction see bodies with re-
gard to the material contexts of tools and
technologies. In light of these three studies, it is
therefore extremely relevant for CRNAs to reflect
on the importance of using embodied actions
when performing technical procedures. Touch,
physical placement in the room, eye contact, and
tone of voice are thus ways to create emotional en-
ergy and trust during the necessary technical steps
in preparing patients for induction of the anes-
thetic.
Trust in professionals is characterized as an im-
plicit contract between professional and
layperson, in this case between a CRNA and a
INTERACTION BETWEEN NURSE ANESTHETISTS AND PATIENTS
patient. Professionals have an ethical and legal
obligation of instructing patients on their best in-
terests. Trust is supported by patients feeling of
confidence in CRNAs future tasks. Furthermore,
patients have confidence in their own way of
judging CRNA professional actions. Thus, there
is a double confidence in building trust between
patients and CRNA.23 In addition, Engdahl and Lid-
skrog24 have argued that trust does not develop
through information but through emotional
involvement. This means that patients are
emotionally involved by taking an active part in
and having a say during their preparation for gen-
eral anesthesia. According to this study, an
emotional understanding of trust implies the
importance of the CRNA being aware of an implicit
trusteeship when interacting with each patient. In
connection to the presented articles on trust, this
study supports the emotional understanding of
trust by emphasizing the importance of CRNAs
emotional involvement through touch, eye con-
tact, physical placement in the room, and verbal
guidance of each patient.
CRNAs instrumental and verbal routines during
the preparation of patients for general anesthesia
are characterized as formal rituals. Formal rituals
are defined as rituals that build up mutual focus
and emotional entrainment initiated by a
commonly recognized apparatus of ceremonial
procedures.25 These types of rituals generate feel-
ings of membership and clear group boundaries.
Emotional entrainment may be challenged, howev-
er, depending on CRNAs reflections on and use of
verbal and embodied actions when performing rit-
uals related to the instrumental procedures. For
instance, in the examination of emotional labor
in nursing by Theodosius,5 she studied the instru-
mental character of nursing. Theodosius5 found
that this kind of nursing facilitates the clinical pro-
cedure in a way that minimizes discomfort and
maximizes the healing process in the patients
body. The patients are concerned with the poten-
tial threat to their bodies and, therefore, con-
cerned with their personal safety. The nurse,
meanwhile, is concerned with her performative
achievement, reflected in her skill and clinical
competency, which is directly linked to her iden-
tity as a nurse.5 Thus, CRNAs motives for interac-
tion and performing highly technological nursing
are affected by the CRNAs professional identity.
To this, our study adds that CRNAs are not only
9
concerned with skills and clinical competencies
but also with the external expectations for effi-
ciency in the daily clinical setting. Varying ways
of using time optimally when interacting with pa-
tients and concerns for keeping production
running may affect CRNAs emotional involvement
in patients, thereby adversely affecting patients
feeling of trust.
Similar to our study, Karlsson et al3 found that pa-
tients were not always the center of CRNAs atten-
tion during regional anesthesia because of nurse
anesthetists attention to the more technical as-
pects of the procedure or their focus on a specific
area of the patients bodies. This resulted in an
asymmetric interaction between patients and
CRNAs. Our study also indicates an asymmetric
motive for this interaction. CRNAs were motivated
by patient-centered interaction and production-
centered interaction; the interaction was influ-
enced by which profession offered the patient a
lifeline and instilled trust. CRNAs level of sensi-
tivity while performing the clinical practice rou-
tines of their practices is affected by their
different motivations for interacting. This, in
turn, affects the emotional energy in their relation-
ship with the individual patient. Karlsson et al3
describe a similar situation where physical and
emotional distance between patients and CRNAs
resulted in a lack of interaction, thereby making
it difficult for CRNAs to respond to patients phys-
ical and psychosocial needs.
A study aiming to describe the interaction be-
tween CRNAs and patients immediately before cor-
onary artery bypass grafting surgery revealed the
concept of reassurance as a major finding. Reassur-
ance was achieved through performance of well-
structured nursing and continually informing
patients throughout the procedure.6 In contrast,
our study emphasizes the ambiguities and devia-
tions that are embedded in CRNAs interactions
with patients, thereby offering a more nuanced un-
derstanding of this specific type of nursing per-
formed in a highly technological environment.
During the presentation of the categories depend-
ing on routines and offering a lifeline, three mo-
tives for CRNAs interactions with patients
emerged: Time and operating turnover times,
CRNAs being the primary lifeline, and focusing
on the patient and not on which health care
10
professional offers a lifeline. Thus, different types
of motivation affect CRNAs level of emotional en-
ergy during interaction with patients. Emotional
energy gives CRNAs and patients energy to initiate
actions and interact socially.25 By focusing on the
patient during interaction, CRNAs are able to instill
feelings of trust, confidence, and safety in patients
in a vulnerable situation. However, when working
in a highly technological environment, there is a
great risk of failure during interaction if instru-
mental procedures and care are not well integrated
in nurse anesthetists routines. Bolton26 empha-
sizes that motivations are embedded in social situ-
ations and relationships, which are wedded to
actions that acknowledge institutionalized prac-
tices and hierarchical power relationships. Thus,
CRNAs motivation for preparing patients for the
anesthetic procedure is embedded in professional
competencies in performing instrumental proced-
ures, patients safety, patients feeling of trust, the
CRNAs professional position in the interdisci-
plinary team, and the culture and ethical standards
of the Department of Anesthesiology.
Strengths and Limitations
Focused ethnography was found to be an appro-
priate method for exploring the interaction be-
tween CRNAs and patients in highly
technological environments. Focused ethnog-
raphy is often used in applied research fields,
such as nursing.13 Conventional ethnography and
focused ethnography differ in the amount of time
used to collect data. Focused ethnography uses
short-termed field visits, a methodology that is
compensated for by an intensity in data collec-
tion.8 The data intensity of this project reflects a
combination of observations, interviews, and pho-
tographs. Furthermore, the participants in the
study have an in-depth knowledge of the area be-
ing studied,27 which allows a better understanding
of the complexities surrounding the interaction
between patients and CRNAs. By focusing on the
participants emic view on the interaction through
the etic lens of the first author, it is possible to
develop knowledge relevant for nursing.13
Using grounded theory tools in the analysis and in
the development of theoretical ideas was found to
be very appropriate. Observations were confirmed
through interviews of CRNAs and photographic
evidence illustrating central objects in the observa-
AAGAARD ET AL
tion context. The combination of observations, in-
terviews, and photographs facilitated multisite
comparison and an in-depth understanding of the
variables and categories. Thus, it was possible to
go beyond the merely descriptive to theory gener-
ation, which is seen as strength of the study.
Gathering data from only one hospital in Denmark
may be a limitation with regard to external validity.
A more comprehensive study of the different orga-
nizations and cultures of Departments of Anesthe-
siology in other regions of Denmark might have
influenced our findings and provided the study
with further nuances. A distinguishing organiza-
tional structure for Scandinavian CRNAs is that
they work under delegated responsibility from
the anesthesiologist, which means CRNAs are
themselves inducting patients in many situations.
Consequently, a limitation is that the responsible
anesthesiologist is not included in the study.
Another limitation may be that the patients
included in the study were in their late 50s to early
70s, which excluded younger patients perspec-
tives. The decision to focus solely on cancer pa-
tients was another limitation. Research shows that
patients undergoing surgery for benign and malig-
nant cancers expressed themselves differently in
relation to the outcome of their surgery.28 However,
because of this studys intense data collection, the
theorizing on creating emotional energy is useful
in explaining the complexity of nursing care in
highly technological nursing and how different
work cultures in the Department of Anesthesiology
may influence nurses professional identity.
Conclusion and Implications for Practice
Creating emotional energy and the motives behind
CRNAs interactions with patients are central ingre-
dients in developing anesthesia care. Furthermore,
CRNAs conscious reflections on creating
emotional energy associated with their motivations
have an impact on how CRNAs establish a relation-
ship with patients and show us how it is possible to
integrate technical procedures and care during
preparation of patients for general anesthesia.
Emotional energy is an integral component of
instrumental and highly technological nursing. Be-
ing linked to tacit emotions and embedded in clin-
ical procedure, it is a challenge for CRNAs to even
INTERACTION BETWEEN NURSE ANESTHETISTS AND PATIENTS
think to mention it. Because of these factors, the
development of the core variable creating
emotional energy may be useful in other nursing
settings when performing instrumental
procedures.
References
1. Smith AF, Mishra K. Interaction between anaesthetists,
their patients, and the anaesthesia team. Br J Anaesth. 2010;
105:60-68.
2. Mitchell M. Patient anxiety and modern elective surgery: A
literature review. J Clin Nurs. 2003;12:806-815.
3. Karlsson A-C, Ekebergh M, Larsson Maul
eon A, Almerud
Osterberg S. Patient-nurse anesthetist interaction during
regional anesthesia and surgery based on video recordings. J
Perianesth Nurs. 2013;28:260-270.
4. Schreiber R, Macdonald M. Keeping vigil over the patient:
A grounded theory of nurse anaesthesia practice. J Adv Nurs.
2010;66:552-561.
5. Theodosius C. Emotional Labour in Health Care. The Un-
managed Heart of Nursing, 1st ed. Oxon, UK: Routledge; 2008.
6. Berg K, Kaspersen R, Unby C, Hollman Frisman G. The
interaction between the patient and nurse anesthetist immedi-
ately before elective coronary artery bypass surgery. J Peria-
nesth Nurs. 2013;28:283-290.
7. Barnard A, Sandelowski M. Technology and humane
nursing care: (Ir)reconcilable or invented difference? J Adv
Nurs. 2001;34:367-375.
8. Knoblauch H. Focused ethnography. Forum Qual Soc Res.
2005;6.
9. Muecke M. On the evaluation of ethnographies. In:
Morse J, ed. Critical Issues in Qualitative Research Methods.
Thousand Oaks, CA: Sage Publications; 1994:187-209.
10. Curriculum description, education in anesthesia nursing
for registered nurses.; 2012.
11. Sygepleiernes Samarbeid i Norden, [Northern Nurses
Federation]. Ethical guidelines for nursing research in the
Nordic countries [Etiske retningslinier for sygeplejeforskning i
Norden Etiske retningslinjer for sykepleieforskning i Norden
Etiska riktlinjer f
or omvardnadsforskning i Norden Hoitoty on
tutkimuksen eettiset. 2003. Available at: http://old.sykepleien.
no/ikbViewer/Content/337889/SSNs etiske retningslinjer.pdf.
Last accessed 2003.
12. Hammersley M, Atkinson P. Ethnography: Principles
and Practice, 3rd ed. London, UK: Routledge. 2007. Available
at: http://www.worldcat.org/title/ethnography-principles-and-
practice/oclc/804544520&referer5brief_results. Accessed
March 18, 2013.
11
These findings can be used to further educate
nurses about interaction with patients in the
context of highly technological nursing and create
a self-awareness of the motives behind different
interaction patterns.
13. Higginbottom G. The use of focused ethnography in
nursing research. Nurse Res. 2013;20:36-43.
14. Riley R, Manias E. The uses of photography in clinical
nursing practice and research: A literature review. J Adv Nurs.
2004;48:397-405.
15. Magilvy J, Congdon J, Nelson J, Craig C. Visions of rural
aging: Use of photographic method in gerontological research.
Gerontologist. 1992;32:253-257.
16. Gibson B, Hartman J. Rediscovering Grounded Theory,
1st ed. London, UK; Thousand Oaks, CA: Sage Publications,
Ltd; 2014.
17. Glaser BG. Theoretical Sensitivity, 5th ed. Mill Valley, CA:
Sociology Press; 1978.
18. Glaser B. Basics of Grounded Theory, 1st ed. Mill Valley,
CA: Sociology Press; 1992.
19. Pink S. Doing Visual Ethnography, 3rd ed. London, UK;
Thousand Oaks, CA: Sage Publications, Ltd; 2013.
20. Pilnick A, Hindmarsh J. When you wake up itll all be
over: Communication in the anaesthetic room. Symb Interact.
1999;22:345-360.
21. Hindmarsh J, Pilnick A. Knowing bodies at work:
Embodiment and ephemeral teamwork in anaesthesia. Organ
Stud. 2007;28:1395-1416.
22. Bezemer J, Cope A, Kress G, Kneebone R. Scissors,
please: The practical accomplishment of surgical work in the
operating theater. Symb Interact. 2011;34:398-414.
23. Barbalet J. A characterization of trust, and its conse-
quences. Theor Soc. 2009;38:367-382.
24. Engdahl E, Lidskog R. Risk, communication and trust: To-
wards an emotional understanding of trust. Public Underst Sci
2012;1-15.
25. Collins R. Interaction Ritual Chains. Princeton, NJ:
Princeton University Press; 2005.
26. Bolton SC. Emotion Management in the Workplace, 1st
ed. Hampshire, UK: Palgrave Macmillan; 2005.
27. Higginbottom GMA, Pillay JJ, Boadu NY. Guidance on
performing focused ethnographies with an emphasis on health-
care research. Qual Rep. 2013;18:1-16.
28. Moene M, Bergbom I, Skott C. Patients existential sit-
uation prior to colorectal surgery. J Adv Nurs. 2006;54:
199-207.