Administering obstetric general anesthesia (GA) for emergency Cesarean delivery is challenging. The anatomical and physiologic changes in pregnancy render the patient at increased risk of airway complications during induction of GA.1 From the moment the pregnant patient enters the operating room, multiple steps must rapidly and correctly occur to facilitate a prompt operative delivery.2 During this time-pressed sequence of events, numerous human factors are at play that could influence safe and successful outcomes for the patient and neonate.3,4,5

In Canada, anesthesia assistants (AAs) are credentialed healthcare professionals who have pursued a defined period of didactic and clinical training. Anesthesia assistants are part of an anesthesia care team and execute medical orders and directives as prescribed by anesthesiologists.6 At our institution, a tertiary obstetric unit, an AA is usually the first-assist for the anesthesiologist during obstetric GA. A nationwide shortage of AAs has meant they are not always reliably present. In the absence of an AA or other anesthesia team members, operating room nurses are requested to act as first-assist; however, they are often unfamiliar with anesthesia assistance and are uncomfortable in this role because of an overall low institutional rate of obstetric GA and a high rate of nursing turnover.

To enhance the operating room nurses’ confidence and competence in acting as first-assist, we designed a prospective observational study to investigate the effects of an anesthesiologist-led, in-house, structured training program on operating room nurses’ knowledge and skills in providing anesthesia assistance during emergency Cesarean delivery under GA. We hypothesized that, following a structured training program, knowledge and skills would significantly improve from baseline with adequate retention at six months.

Methods

Setting and study population

Institutional ethics committee approval was sought and review was exempted because the project fulfilled criteria as a quality improvement study. This article adheres to the STROBE guidelines.

From 1 October 2018 to 31 May 2019, all nurses who worked in the operating rooms at BC Women’s Hospital were eligible and invited to participate following written informed consent. Recruitment of participants was promoted with the help of nurse educators at morning team huddles and via study information posters. As an incentive, all participants received a coffee gift card of CAD 10 for completing the structured training program.

At the time of the study, BC Women’s Hospital was a tertiary obstetric unit that only performed obstetric and ambulatory gynecological procedures with separate obstetrics and gynecology operating room nursing teams. The main clinical exposure to GA for nurses working in the obstetric operating rooms included GA for Cesarean deliveries, antepartum patients requiring cerclage placements, or postpartum patients requiring emergency surgeries for dilation and curettage procedures or management of postpartum hemorrhage. Study and participant flows are detailed in Figs 1 and 2, respectively.

Fig. 1
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Study overview

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Fig. 2
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Participant flow diagram

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Development of knowledge and skills objectives

A series of learning objectives around the provision of anesthesia assistance during GA were developed following a literature search and review of the Canadian Anesthesiologists’ Society Position Paper on Anesthesia Assistants.6,7,8

The objectives were then reviewed by three fellowship-trained obstetric anesthesiologists within the department and finalized into 14 knowledge and six skills objectives (Table 1). The objectives are primarily focused on intraoperative monitors (e.g., correct selection, placement and troubleshooting) and airway management (e.g., recognition of airway equipment, positioning of the patient, how to correctly preoxygenate, and how to perform cricoid pressure). Based on the objectives, a 30-min training program was developed, composed of a 20-min didactic lecture and a ten-minute skills station delivered to the participants in groups of two to three each time. No preparation work was necessary before the training. To minimize interindividual variation in teaching, the didactic and skills station were all taught by a single anesthesiologist.

Table 1 Knowledge and skills objectives for the provision of anesthesia assistance during obstetric general anesthesia
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Outcomes assessment

The primary outcomes of this study were adequate knowledge and skills retention by operating room nurses at six months. Secondary outcomes included knowledge and skills acquisition at baseline immediately after the training program, knowledge and skills retention at six weeks, operating room nurses’ level of comfort scores in assisting in obstetric GA, and the proportion of anesthesiologists feeling adequate assistance had been provided during obstetric GA.

Participants’ knowledge was assessed by a ten-item multiple-choice questionnaire (MCQ) with a maximum score of 14 that was devised from the knowledge objectives (see Electronic Supplementary Material [ESM] eAppendix 1). To assess knowledge acquisition of the course content, participants were asked to complete the MCQ at baseline immediately before and then immediately after the training session. To assess knowledge retention, the MCQ was readministered at six weeks and six months after the training session. The same MCQ content was used at each administration with the order of questions and answers randomized using a random sequence generator.

Adequate knowledge acquisition and retention were defined as a group mean MCQ score of ≥ 80% post-training (i.e., mean MCQ score ≥ 11.2 out of 14). As part of the MCQ, seven questions surveyed demographic information.

Participants’ skills were assessed by a 12-item checklist with a maximum score out of 12 based on the skill objectives (see ESM eAppendix 2). Each skill competency was shown by the training anesthesiologist during the skills component of the training session with opportunities for each participant to perform each task. Each nurse was assessed separately, in the operating room immediately after the knowledge MCQ test. Each correct performance of a skill was awarded 1 point and each incorrect action or non-attempt of a skill was given 0 points. Adequate skills acquisition and retention were defined as a group mean skills checklist score of ≥ 80% post-training (i.e., mean skills score ≥ 9.6 out of 12). Skills were assessed at the same time points (i.e., baseline, immediately after the program, six weeks, and six months). Answers to MCQs and skills assessments were provided to all participants at the end of the study period.

All participants were asked to report their comfort level at assisting the anesthesiologist during scheduled and emergency obstetric GA using a five-point Likert scale (5 = strongly agree; 4 = agree; 3 = neutral; 2 = disagree; 1 = strongly disagree) at baseline, 6 weeks, and 6 months post-training. Ten obstetric anesthesiologists were asked to rate their perception of the nursing staff’s knowledge and skills, and good teamwork with the nursing team during obstetric GA using a five-point Likert scale (1 = inadequate; 2 = neutral; 3 = adequate; 4 = good; 5 = excellent). The same anesthesiologists were surveyed at all time points.

Sample size

A list containing the full membership of all operating room nurses was obtained from the nursing lead; a total of 42 operating room nurses were eligible at BC Women’s Hospital. To maximize the impact of our training session, we recruited all 42 nurses.

Statistical analysis

Knowledge and skills acquisition and retention over time were estimated using longitudinal mixed-effects linear regression to account for repeated studies on the same person. Similarly, the subjective comfort scores of nurses in assisting with GA were estimated using longitudinal mixed-effects linear regression. Time was entered as the categorical variable, indicating the different study steps at baseline, immediately after, at six weeks, and six months after the training program. Results were adjusted for participants’ experience, years practising as a nurse, years practising in the operating room, average number of clinical shifts per week, completion of a recent airway training course, and number of GA cases nurses had previously assisted with.

Results

A total of 42 operating room nurses participated in the training program and had follow-up data at six weeks. At six months, data from 34 of these nurses were available. Participant flow is detailed in Fig. 2. Baseline participant characteristics are shown in Table 2.

Table 2 Baseline characteristics and participant experience
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Baseline knowledge, skills and comfort

Both knowledge and skills were low at baseline. Out of the highest possible knowledge score of 14, the mean MCQ score at baseline was 8.9 (95% confidence interval [CI], 8.5 to 9.4). Out of the highest possible skills score of 12, the mean checklist score was 5.5 (95% CI, 4.9 to 6.1). Out of the highest possible score of 5, the mean comfort scores for assisting elective and emergency Cesarean deliveries were 3.6 (95% CI, 3.2 to 3.9) and 3.1 (95% CI, 2.72 to 3.5), respectively. Survey results of anesthesiologists’ baseline perception of nursing staff assisting with obstetric GA are presented in Fig. 3.

Fig. 3
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Baseline and 6-month post-structured training program survey of anesthesiologists’ perception of nursing staff’s knowledge and skills during obstetric general anesthesia and perception of good teamwork with the nursing team during obstetric general anesthesia. The same anesthesiologists were surveyed for both periods

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Knowledge outcomes

There was a significant difference in the mean MCQ scores across the different study periods (overall P value < 0.001). Post hoc pairwise tests suggested that compared with baseline, there were significantly higher mean MCQ scores at all time points after the training program: immediately after training (11.9; 95% CI, 11.4 to 12.4 vs 8.9; 95% CI, 8.5 to 9.4; P < 0.001), at six weeks (11.9; 95% CI, 11.4 to 12.4 vs 8.9; 95% CI, 8.5 to 9.4; P < 0.001) and at six months (12.0; 95% CI, 11.5 to 12.4 vs 8.9; 95% CI, 8.5 to 9.4; P < 0.001).

For knowledge decay analysis, there was no difference in mean MCQ scores between the time points after training (e.g., immediately after, at six weeks, and six months after the training program) (see Fig. 4).

Fig. 4
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Knowledge acquisition and retention at baseline and after structured training program (immediately after, at six weeks, and six months). MCQ = multiple choice questionnaire; STP = structure training program

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Skills outcomes

There was a significant difference in the mean skills checklist score across the different study periods (overall P value < 0.001). Post hoc pairwise tests suggested that mean skills checklist scores were significantly higher immediately after the training program than at baseline (10.3; 95% CI, 9.7 to 10.9 vs 5.5; 95% CI, 4.9 to 6.1; P < 0.001), at six weeks (9.7; 95% CI, 9.1 to 10.3 vs 5.5; 95% CI, 4.9 to 6.1; P <0.001), and at six months after the training program (8.3; 95% CI, 7.7 to 8.9 vs 5.5; 95% CI, 4.9 to 6.1; P < 0.001).

For skills decay analysis, compared with immediately after the training program, there were significantly lower mean skills checklist scores at six weeks (9.7; 95% CI, 9.1 to 10.3 vs 10.3; 95% CI, 9.7 to 10.9; P = 0.048), and six months (8.3; 95% CI, 7.7 to 8.9 vs 10.3; 95% CI, 9.7 to 10.9; P < 0.001). The mean checklist scores at six weeks and six months were also significantly different (9.7; 95% CI, 9.1 to 10.3 vs 8.3; 95% CI, 7.7 to 8.9; P < 0.001) (see Fig. 5).

Fig. 5
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Skills acquisition and retention at baseline and after structured training program (immediately after, at six weeks, and six months). STP = structured training program

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Comfort outcomes

There was a significant difference in mean comfort values in assisting elective or emergency Cesarean deliveries cases across the different study steps (overall P value < 0.001). For comfort in assisting with elective obstetric GA, post hoc pairwise tests suggest that, compared with baseline scores, there were significantly higher mean comfort scores at six weeks (4.0; 95% CI, 3.7 to 4.4 vs 3.6; 95% CI, 3.2 to 3.9; P < 0.0029) and six months after the training program (4.13; 95% CI, 3.79 to 4.48 vs 3.56; 95% CI, 3.22 to 3.90; P < 0.001), with no difference between six weeks and six months (P = 0.48).

For comfort assisting in emergency obstetric GA, post hoc pairwise tests suggest that, compared with baseline scores, there were significantly higher mean comfort scores at 6 weeks (3.5; 95% CI, 3.2 to 3.9; vs 3.1; 95% CI, 2.7 to 3.5; P < 0.001) and at 6 months after the training program (3.6; 95% CI, 3.2 to 4.0 vs 3.09; 95% CI, 2.7 to 3.5; P <0.001), with no difference between 6 weeks and 6 months (P = 0.44) (Fig. 6).

Fig. 6
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Comfort scores at providing anesthesia assistance during emergency and elective Cesarean deliveries at baseline, at 6 weeks, and 6 months. STP = structured training program; CD = Cesarean delivery

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At 6 months after training, no anesthesiologists showed inadequate knowledge, skills, or teamwork (Fig. 3).

There were no changes to knowledge, skills, and comfort levels after adjusting for baseline and covariates (see ESM eTable 1 and eTable 2).

Discussion

In this prospective cohort study, we found that the knowledge and skills of operating room nurses in providing anesthesia assistance during obstetric GA at a tertiary obstetric unit were all low at baseline. Following a single 30-min, in-house, anesthesiologist-led, structured training program, scores in both dimensions significantly improved. Importantly, the improvements in knowledge were adequately retained for up to six months, but the improvements in skills decayed rapidly.

Inadequate skilled assistance has been identified as a contribution to significant patient safety events in anesthesia while the presence of trained assistants during anesthesia has been shown to reduce errors and adverse outcomes.3,4,5,9 Our results are particularly relevant given the current national shortage of AAs and the frequent turnover of nursing staff.10 Even centres that are well-staffed with AAs may not have an AA immediately available at the exact time when help is required during an emergency Cesarean delivery. Some institutions have recognized this need and developed an “above the waist” nursing role to assist the anesthesiologist to minimize task saturation and prepare for induction of GA.2 Adopting a local training program could prepare all nursing staff to assist, with the added benefit of improving interprofessional teamwork and collaboration.

Several factors influence the ability to retain new knowledge and skills, which may explain the diverging pattern of decay between knowledge and skills observed in our study. Substantial skill loss occurs when new skills are not used or practiced routinely.11,12 The more rapid decay in skills may be in part due to overall low exposure to a shrinking number of obstetric GA cases, creating little opportunity to reinforce new skills. The difficulty retaining skills with training interventions has been observed in several settings associated with low exposure events, including neonatal resuscitation and advanced cardiac life support.13,14,15

Prior experience also influences performance after training interventions and the ability to retain skills.16 Our participants had low baseline knowledge as shown on baseline MCQ scores and many had received no formal training in the technique of providing anesthesia assistance prior to our intervention. This may explain the difficulty some of our participants had in retaining skills. It may also explain why our results are in contrast to other studies in the area, including one study that showed anesthesia residents maintained competency in performing GA for Cesarean delivery at up to eight months17 and another study showing retention of both knowledge and skills among nurses and physicians in providing emergency obstetric care at 12 months.11 These studies involved participants already familiar with the techniques taught, which facilitated easier retention.

Importantly, our results showed improved comfort of participants in assisting with anesthesia. The confidence of caregivers in executing a task is a significant factor influencing performance and the patient experience.18 Improving staff comfort may, in turn, strengthen teamwork and reduce the risk of medical error, thus improving overall patient safety.19 Improvement of comfort levels also has important implications for staff wellbeing. Managing emergency situations that one has not previously been exposed to is psychologically distressing for staff,20 which may also influence performance in other routine tasks.21 We showed that a simple in-house anesthesiologist-led program helped some operating room nurses cope with the potential stress stemming from assisting with GA.

The ideal time to repeat a program such as ours depends on an array of factors, including the nature of the task being taught, the context in which it is being used, and the experience of participants.12 It is inevitable that both knowledge and skills acquired will decay significantly over time without periodic testing and refresher courses.12,22,23 Our results suggest that repeating sessions at six-week intervals is appropriate, at least initially. Such a schedule would require significant institutional support but could form part of regular obstetric interprofessional team training, which is recommended by several authors.16,24,25 Nevertheless, over time, the interval could lengthen as recall is augmented with repetition. Our program could be modified to include simulation training in non-technical skills, given the evidence to support this.24,26,27,28 In addition, the benefits of our intervention could be enhanced by providing structured feedback reports to participants.29

There are several limitations to our study. First, our program was undertaken at a single institution with small sample size, although this was limited by the number of nurses available in our institution. Second, we did not prospectively collect real-life clinical data from GA performed before or after the intervention and participants were allowed to look up information on their own between assessments to further their learning. Therefore, any improvement in scores may not be directly attributable to the structured training program. Third, our assessment tools were not validated and parts of our program, such as the correct sequence we recommend to apply monitors, are specific to our institutional workflow. It is possible we were simply measuring recall rather than knowledge synthesis and that retention of knowledge was attributable in part to the testing effect, where retrieval of information from memory by administering tests increases the long-term retention of that information.30,31 Finally, we adjusted for several baseline variables in our analysis but there may be residual confounders, which may impact performance. For example, it is plausible that the age of the participants may influence learning and thus knowledge and skills retention; however, we did not ask participants to report age in the study as we felt some participants may be sensitive to sharing this information.

Having dedicated skilled assistance during obstetric GA is a challenge faced by many Canadian obstetric units. We hope this study will highlight the important role served by operating room nurses, who may provide anesthesia assistance in some hospitals and the training required for them to mount sufficient knowledge, skills and comfort to aid the anesthesiologist during induction of GA for emergency Cesarean delivery. Hospital leads should recognize and address the shortage of AAs and facilitate efforts to develop clinically competent personnel to assist anesthesiologists. We believe implementing and replicating this quality improvement effort may be a simple, cost-effective, and worthwhile endeavour to boost interprofessional teamwork and patient safety.