Article from "Australian Anaesthetist": Addressing the PS08 elephant in the operating room.

Dr Jack Madden

Healthcare workers use many three-letter-acronyms. I’ve recently added CTA, SEO and API to the list. That’s because I started a business that relies on web traffic, funnels, organic search engine optimisation, automations, “Zaps” and triggers.

Let me rewind to 2021.

I was called in for a sick laparotomy in a private hospital one evening. I hadn’t met the anaesthetic nurse before, so I introduced myself and detailed the anaesthetic plan. The nurse stared blankly back at me and said, “what’s a rapid sequence induction?”.

“Huh? How long have you been an anaesthetic nurse?”

“Four weeks” was the response.

The look told me I don’t know what I don’t know, and it scares the hell out of me.

Having trained in public hospitals in Hobart and Melbourne, I took for granted the exceptional quality of training for anaesthetic nurses at the time. These centres had high standards of education, ample resources including a team of motivated educators, and a term of supervision that satisfied the ANZCA professional standards.

So, what has changed?

ANZCA PS08, Position statement on the assistant to the anaesthetist¹, does not specify which course should be undertaken, however, it does state that a minimum of 12 months full-time equivalent supervised practice is needed in addition to an undergraduate nursing degree prior to independent anaesthetic nursing. 

I often work with exceptional anaesthetic nurses. The knowledge, technical skills, communication styles, vigilance and situational awareness they bring to the operating theatre is partly responsible for the remarkably high standards of safety we enjoy in Australia. We all know that feeling of relief when entering the operating theatre to see a well-trained anaesthetic nurse. These nurses were trained when PS08 was still adhered to.

In 2023, we are failing the new generation of anaesthetic nurses. My enquiries have revealed a frightening reality that many hospitals are now offering less than three months of supervision for new anaesthetic nurses. Some are offering less than six weeks. And some have stopped training them all together, opting to employ anaesthetic technicians to comply with PS08 (anaesthetic technician courses in Australia satisfy PS08). Private hospitals have been impacted to a much greater extent². When I dug deeper, I found there were two obvious reasons (and one less obvious one).

1. The mass exodus of educators

According to the Australian College of Nursing³, COVID-19 led to a mass exodus of senior nursing staff, and the perioperative setting was one of the hardest hit areas. This broad and rapid change left departments without their experienced and motivated educators, and education has fallen down the list of priorities.

2. Cash flow

The pandemic had many private hospitals questioning their financial future, and this uncertainty is ongoing. Last year, there were 623,000 elective surgeries in Australia, a 10-year low according to the Australian Institute of Health and Welfare⁴. Even if the educators hadn’t left, it is no longer feasible for many hospitals to provide new anaesthetic nurses with 12 months of supervision.

3. The elephant in the room

The less obvious reason is that anaesthesia is too safe. Major adverse events are rare, and a well-trained anaesthetist can usually keep the patient safe without anyone realising there is a nurse competency issue. In the sick laparotomy example, I was able to safely get the patient through the case. But the nurse felt unsupported by their employer and unsatisfied by their own skillset. I felt frustrated and concerned.

This problem is difficult to demonstrate through KPIs at the monthly management meeting.

This week, I heard the phrases, “we are just too slammed to worry about education at the moment,” “I don’t know who is going to teach the new grads next year,” and my favourite, “it’s okay for them to be independent after 3 weeks, they always have an anaesthetist with them.”

The Structure Apprenticeship Model

Anaesthetic nursing requires a “structured apprenticeship” model over at least 12 months. The apprenticeship cannot be condensed into a matter of weeks. How do anaesthetic nurses develop the ability to anticipate the next step during an unexpected difficult airway? Build the confidence to overcome authority gradients to speak up for patient safety? Learn to recognise an emerging anaphylaxis and help initiate treatment? Understand the ways to detect drug errors before they happen? Hold a mask on a paediatric patient while the anaesthetist cannulates?

They learn through experience, over time.

The fact that anaesthesia in Australia is exceptionally safe is great for patients, but it is also one of the reasons that the structured apprenticeship of anaesthetic nursing is disappearing in many regions of Australia. The tangible value of high-quality training for new anaesthetic nurses is hard to demonstrate through traditional metrics.

Addressing the problem:

Like many Australian anaesthetists with a mix of public and private sector work, I anaesthetise patients across multiple centres – five hospitals governed by four different parent companies. I have been running airway simulations for perioperative nurses in these hospitals since obtaining my FANZCA in 2016. Most weeks I would be asked by a desperate educator to run a much-needed education session or simulation in a private hospital. However, eight hours of my time was only helping 8-12 nurses in one hospital, on one day.

So, with the view of improving access to high quality anaesthetic nurse education, I started making online content.

The power of online education

According to the American Heart Association⁵, online learning improves performance by 15-25%, reduces costs by 45% and leads to a 25-50% increase in retention rate. Online course material can be viewed over and over, in an environment that suits the learner’s needs and pace, and its acceptance has grown significantly since the COVID-19 pandemic⁵.

How does an anaesthetist with average IT skills develop an online course?

I started with an online course on how to make an online course (seriously). Then I purchased a microphone, downloaded Canva and borrowed one of those influencer halo lights. I engaged stakeholders, developed a curriculum, and started writing scripts. After hours and hours of editing and extensive testing on willing nurses and educators, I launched the Anaesthetic Assistant Starter Course – a 5-part course for new anaesthetic nurses complete with video lessons, PDF summaries and assessments.

I created a website, connected payment software, and started an Instagram page. Realising my limits on social media I hired my good friend Andrew Goyen, a registered nurse, to run the marketing side of the business. Outsourcing marketing and having Andrew’s vision on business strategy has been an important inflection point for the business. The company is called Periop Concepts Pty Ltd, and our motto is “build knowledge, improve safety.”

Fast forward 12 months and Periop Concepts is Australia’s only ACPAN (Australian College of Peri-Anaesthesia Nurses) accredited online education provider. It has 2 institutional contracts, 600 subscribers, 1200 Instagram followers and a global outreach segment recognised by the ASA and the Namibian Society of Anaesthesiology. We have a recently launched a comprehensive package for anaesthetic nurses that provides 20 hours of CPD each year, covering everything from drugs and monitoring to unexpected difficult airways to crisis management. The content is available on-demand, on any device with an internet connection.

The ravenous appetite for this kind of education in multiple countries has been both pleasing and concerning. It highlights a major gap in perioperative nurse education. Desperate educators still contact me on a weekly basis. Now I can genuinely help all of them.

The system for training new anaesthetic nurses in Australia is well and truly broken. Although Periop Concepts does not replace the supervision period prescribed by PS08, it does provide individuals and institutions with a reliable, ACPAN accredited method of ensuring new anaesthetic nurses have a safe knowledge base and a framework to learn the essential perioperative concepts in their first 12 months.

Andrew and I would love nothing more to be put out of business by virtue of a massive, positive system change for anaesthetic nurse education. Sadly, we are unlikely to see hospitals allocate time and funding to comply with PS08 any time soon. For now, we will continue building knowledge and improving safety for what we believe is one of the most important roles in healthcare.

Dr Jack Madden

References

1. Short title: Assistant for Anaesthetist - ANZCA (2016) Position statement on the assistant for the anaesthetist. Available at: https://www.anzca.edu.au/getattachment/473f7e0d-b14a-4939-aad1-034c0474c603/PS08-Statement-on-the-assistant-for-the-anaesthetist (Accessed: 16 July 2023).
2. Iannuzzi, A. (2022) Australia’s Private Hospitals: Victims of the pandemic? InSight+. Available at: https://insightplus.mja.com.au/2022/14/australias-private-hospitals-victims-of-the-pandemic/ (Accessed: 16 July 2023).
3. Ward, K. (2021) We need to urgently address the nursing crisis in Australia, Australian College of Nursing. Available at: https://www.acn.edu.au/post/we-need-to-urgently-address-the-nursing-crisis-in-australia (Accessed: 16 July 2023).
4. ‘COVID-19 disruptions led to lowest number of public elective surgeries performed in over a decade’ (2022) Australian Institute of Health and Welfare. Available at: https://www.aihw.gov.au/news-media/media-releases/2021/december/covid-19-disruptions-led-to-lowest-number-of-publi (Accessed: 16 July 2023).
5. (2018) eLearning Statistics and Value for your Organization. Available at: https://cpr.heart.org/-/media/cpr-files/course-formats/online-learning-stats-flyer-ucm-491651.pdf.