Nursing care in the anesthetic procedure : an integrative review *

3 Universidade de São Paulo, Escola de Enfermagem, Departamento de Enfermagem Médico-Cirúrgica, São Paulo, SP, Brazil. ABSTRACT Objective: To search for the scientific evidence available on nursing professional actions during the anesthetic procedure. Method: An integrative review of articles in Portuguese, English and Spanish, indexed in MEDLINE/PubMed, CINAHL, LILACS, National Cochrane, SciELO databases and the VHL portal. Results: Seven studies were analyzed, showing nurse anesthetists’ work in countries such as the United States and parts of Europe, with the formulation of a plan for anesthesia and patient care regarding the verification of materials and intraoperative controls. The barriers to their performance involved working in conjunction with or supervised by anesthesiologists, the lack of government guidelines and policies for the legal exercise of the profession, and the conflict between nursing and the health system for maintenance of the performance in places with legislation and defined protocols for the specialty. Conclusion: Despite the methodological weaknesses found, the studies indicated a wide diversity of nursing work. Furthermore, in countries absent of the specialty, like Brazil, the need to develop guidelines for care during the anesthetic procedure was observed.


INTRODUCTION
In 1984, anesthesiologists developed the concept of patient safety in the United States, at the International Committee for Prevention of Anesthesia Mortality and Morbidity.In the following year, the Anesthesia Patient Safety Foundation was created (1) .
In the early 1990s, an international group of anesthesiologists set the development of norms for the practice of anesthesia as their mission, to standardize actions and increase security of anesthetic procedure worldwide.The norms, which included perianesthetic assistance and monitoring, were approved in 1992 at the World Anesthesia Convention and adopted as global standards by the World Federation of Societies of Anesthesiologists.Revisions and updates of these norms occurred in 2008 and 2010, in pursuit of improvements and enhancement of the standards (2) .
In 2002, the World Health Organization National Assembly drew up a resolution for care safety during surgical procedures, due to high rates of morbidity and mortality related to them.The defined quality standards for health services were: prevention of surgical site infection; safe anesthesia; safe surgical teams; and surgical care indicators (3) .
In 2004, the World Health Organization released the safe surgery manual with the Safe Surgery Saves Lives program, in order to inform healthcare professionals and administrators about the function and surgical safety standards in public health; define measures or indicators for the national and international surveillance of health care; and identify safety standards in the operating room, according to a checklist (3) .
The surgical checklist includes actions to run before the anesthetic induction, prior to the surgical incision and before exiting the room.The actions aim to ensure the patient through proper interventions; the presence of a surgical team in room; operation, availability of equipment and supplies needed for the anesthetic and surgical intervention; a complete record of the interventions performed in the transoperative period; and identification of problems with equipment maintenance.
The Ministry of Health, under ordinance no.1377 of July 9, 2013, approved the protocol for safe surgery developed by the National Health Surveillance Agency (4) .This protocol guides the implementation of the checklist in all health facilities that perform procedures inside or outside the surgicenter, involving incision in the human body or introduction of endoscopic equipment by any health professional (5) .
The type of anesthesia is the responsibility of the anesthesiologist and varies according to the patient's clinical conditions: preexisting diseases; mental and psychological conditions; period of postoperative recovery; presence of postoperative pain; type and duration of surgical procedure; and the position of the patient during surgery (6)(7) .
Anesthesia is essential for the surgery's safe development.However, there are few data in the national scientific literature addressing safety during anesthesia from the perspective of nurses.The evaluation of nursing actions provided during anesthesia aims to identify the activities of the nursing staff in the operating room during anesthesia, and how these activities can contribute to patient safety and care planning.Thus, the question of the study was: What nursing actions are performed during the anesthetic procedure?
The aim of this study was to make an integrative literature review, searching for scientific evidence available on the actions of nursing professionals during the anesthetic procedure.

METHOD
This study consisted of an integrative literature review on publications in nursing and anesthesia about care in the operating room, in the anesthetic procedure.
The integrative review consists of six steps, in which summarized previous studies on the subject are, with an analysis of the knowledge produced and notes on questions that can be answered with further research (8) .
The first step of the review includes the identification of the theme and selection of the hypothesis or research question: problem definition, search strategies, definition of keywords and descriptors.The second step comprises the definition of the criteria for inclusion and exclusion from the study: use of databases and selection of the studies based on the criteria.In the third step, the identification of the preselected studies is done: through the reading of abstracts, keywords and titles of publications, and organization of the studies.The fourth step involves the categorization of the selected studies: development and use of synthesis matrix, categorization and analysis of information and selected studies.The fifth step covers the analysis and interpretation of the results.The sixth and final step corresponds to the presentation of the review and knowledge synthesis: creation of a document that describes in detail the review and proposals for new studies (8)(9) .
Currently, the scientific literature reveals that the best health interventions and actions are based on scientific evidence, which allow the development of protocols and care guidelines.The fundamental principles of evidence-based medicine are characterized by the identification of the clinical question that raises doubt, the execution of systematic reviews of contemporary scientific publications, critical analysis of the evidence found in the articles and the decision validated by the systematic reviews of the application in clinical practice (10) .
The search for articles was conducted from January to April of 2014.The study inclusion criteria were: publications written in Portuguese, English or Spanish, published between 1978 and 2014, indexed in MEDLINE, CI-NAHL, LILACS, National Cochrane, SciELO databases, the Virtual Health Library (VHL) and MEDLINE/ PubMed portal, about nursing care in the operating room during the procedure for adult patients undergoing general anesthesia.It is noteworthy that the purpose of this polling interval of 35 years was to rescue the start of perioperative nursing care and the action of nurses.This search period also allowed the understanding of how care processes were developed and how practices should be enhanced to improve care and ensure patient safety.
The study exclusion criteria were: studies defined as case reports and clinical cases; pediatric studies, due to singularities in child care; dissertations and theses that did not have articles published in journals, repeated articles in the databases and studies that were not fully published, since the maintenance of the methodological rigor, required for this type of methodology, was prioritized.
The descriptors used to search were selected according to the proposed theme, through the Health Sciences Descriptors (DeCS) and the Medical Subject Heading (MESH).
For search strategy, the Boolean operator AND was used, with the descriptors: nurse role, patient safety, anesthesia induction, anesthesia, nurse anesthesia practice; anestesia, enfermagem, perioperatório, papel do profissional de enfermagem, segurança do paciente.
For the location of articles in the CINAHL database, the titles "anesthesia" and "nurse anesthesia practice" were used, related to the proposed topic and the study issue.
Chart 1 illustrates the database and descriptors used for the search of the studies.The articles were selected through the reading of the title and abstract in the databases, relevant to the research question.The publications that did not present abstracts in the databases were selected by the full reading of the study.
The reading procedures for the selection of the articles were performed by three participants with degrees in nursing.In case of divergence on the exclusion or inclusion of an article, new reading would be carried out and, if there was still disagreement, they would take a vote.
To analyze the content of the articles, an adapted form was used (11) , called "instrument for data collection of the selected studies", with the following items: 1) identification (study title, journal title, database, authors, year of publication, language, study site); 2) theme; 3) descriptors or keywords; 4) abstract (introduction, objectives, methods, results, conclusions); 5) introduction (justification, objectives, literature review, hypothesis); 6) method (evaluation of the ethics committee and application of a Free and Informed Consent Form, type of research, study design, population and sample selection, study eligibility criteria, data collection instrument, variables studied, data analysis); 7) results (number of participants and justification of exclusion, sociodemographic description of the participants: graphs, tables, figures, statistical analysis of the data); 8) discussion (discussion of the data obtained in accordance with the proposed objectives, discussion of the results obtained compared to the current literature, study limitations, study implications); 9) conclusions (interpretation according to the justification and objectives of the study, recommendations); 10) references (standard used).
The analysis of the level of evidence of the selected studies was done through the Oxford classification.This classification categorizes the studies in five domains (therapy, prevention, etiology and damage; prognosis; diagnosis; studies of prevalence and differential diagnosis; economic and decision) and levels of evidence from one to five, which define the recommendation degree of care practices (12) .
The search in the databases resulted in 221 articles.Fifty-one studies found in MEDLINE/PubMed were excluded from the selected articles for not answering the research question; in the CINAHL database, eight dissertations that did not become articles, 40 studies that did not respond to the research question and three articles that did not have complete texts or abstract available were also excluded.In the databases LILACS and National Cochrane, 14 studies were unrelated to the research question; in the VHL, one of the studies was in Japanese, two were written in French and 60 studies were not related to the research question.
After evaluating the type of study, nine articles were excluded from the analysis for being characterized as literature review studies, thus seven articles remained.

RESULTS
Figure 1 shows the selection of the studies included in the review.
Chart 2 shows the characteristics of the selected studies.The CINAHL had the highest number of articles in the area of nursing in anesthesia.As per Chart 2, the articles can be considered from domain 1 (therapy/prevention/etiology/damage) with level of evidence 5 (expert opinion with no explicit critical evaluation or evaluation based on studies of physiology or initial principles), in accordance to the Oxford classification.
Study S7 is not part of the classification mentioned above, because, according to the method, it is considered a systematic review (level 1A).Nonetheless, the description and methodological follow-up carried out in the study are not consistent with the definition of levels of evidence used in this study.

DISCUSSION
The selected studies have shown a wide diversity of nursing work in anesthesia, with different types of legislation, vocational training and working guidelines.
The United States of America and some European countries have a clear legislation that defines the independent work of nurses in relation to the anesthesiologist, with care protocols that allow the development of the anesthetic plan and autonomy for assistance execution during the surgical procedure.The training program is recognized by educational and health institutions, with complete processes of validation and continuous evaluation of the professional.However, over the years, the specialty has experienced political movements from the government and the medical class as opposed to the practice of nursing in anesthesia, under the argument of reducing costs for health systems and failures in the quality of care offered by nurses.
Study S1 investigated the professional performance of American nurse anesthetists, considering the profile of their daily practice and knowledge required for the test of professional certification.Participants were divided into two groups: clinical and selected (directors, council representative, committee members of the American Association of Nurse Anesthetists -AANA).
In the US, the certification test to obtain the title of anesthetic nursing specialist consists of five categories, divided by a percentage of questions: 30% of basic sciences; 5% for equipment, instruments and technology; 30% for basic principles of anesthesia; 31% for advanced principles in anesthesia and 4% for professional issues (20) .Clinical nurses consider that basic anesthesia is more important in terms of matters to be evaluated (38%) than the advanced principles (19%) in the certification test.The selected nurses presented longer experience in anesthetic nursing, less professional practice with anesthesia groups composed by physicians, and increased participation in education programs.Thus, these data may suggest that the selected group had greater autonomy in the anesthesia practice, justifying the greater appreciation of the advanced principles of anesthesia when compared to the clinical group.S1 revealed that, among the activities performed, 87% of the clinical group provided direct patient care and 33% of the selected group worked in activities related to education.This result demonstrated that the clinical group was closer to the daily practice, being able to describe more clearly the principles and actions in the assistance.
The nurses reported performing all types of anesthesia (general and regional); control of airway access with orotracheal intubation or face mask; electrocardiogram basic monitoring, capnography, stethoscope and noninvasive arterial pressure.Patient monitoring during anesthesia is essential to provide parameters that direct the proper conduct of nurse anesthetists (21) .
The standards recommended by the AANA calls for the realization of the preanesthetic assessment and preparation of the anesthesia plan by certified nurses, considering that these professionals have sufficient knowledge and competence to perform these activities (22) .Article S7 indicated that institutional policies, administrative issues and the work of anesthesiologists are barriers to the full development of nursing skills.S3 showed that group nurses worked mainly in urban areas and had limitations to perform invasive procedures, due to medical work.
Increasing changes in the health policies of the states have hindered professionals from acting with autonomy, being limited to medical supervision or restricted to anesthesia groups (23) .A study found low participation of nurses working in anesthesia groups, in the execution of subarachnoid blocks, epidural anesthesia and brachial plexus blockade, revealing a limitation for nursing work when there is participation of the anesthesiologist in the assistance (24) .A systematic review evaluated studies comparing the anesthetic procedure performed by nurses and by anesthesiologists and was unable to identify differences in the quality of the services provided (25) .
In 1997, the American health care system Medicare determined that each state would decide on the application of the medical supervision rule of work performed by nurse anesthetists.In 1998, eight American states decided not to require medical supervision, followed in 2005 with the accession of 14 rural American states.Study showed no increase in complications or mortality related to anesthesia after these states dispensed medical supervision for the execution of nursing work in anesthesia (26) .
Article S5 indicated that rural nurses worked mostly in small communities, independently from health institutions and with little operation of sophisticated monitoring (intracranial pressure, pulmonary artery catheter), due to the types of surgery.S2 revealed a great performance of nurses in rural areas, regardless of supervision or working together with a physician.Nurses from rural areas have a fundamental role in their regions, especially in the United States, where they are responsible for more than three million anesthetic procedures a year, representing two-thirds of the procedures in rural hospitals (26) .
The autonomy of the nurse anesthetist in rural areas is not directly related to the recognition of the profession and to clear and defined legislations of the professional practice, but to the small number of physicians in outlying areas.Anesthesiologists are concentrated in urban areas, in institutions with greater complexity medical care and regions with more job opportunities and access to knowledge (27) .In S2, it was observed that professionals from European countries worked mostly in groups, with implementation of assistance www.ee.usp.br/reeuspNursing care in the anesthetic procedure: an integrative review in the operating room by nurses, and preanesthetic assessment and planning of the anesthesia by the physician.
A study that evaluated the cost of services provided by independent nurse anesthetists, anesthesiologists and nurses under medical supervision, demonstrated the lower cost of services provided by nurses when compared to anesthesiologists.In addition, there was a 16% increase in expenses on anesthesia when using the model of two to four nurses supervised by an anesthesiologist, and of 30% when one nurse was supervised by an anesthesiologist (28) .
The differences cited in S2, between training time and local policies of certification of the nurse anesthetist profession, indicate divergence in the daily practice among professionals and weaknesses in the regulation of the specialty.The study showed that only 40% of the professionals had a training course in anesthesia for more than 22 months, being that the AANA recommends training courses with an average of 28 to 36 months and the International Federation of Nurse Anesthetists recognizes the courses with an average duration of 2 years.The diversity in training and regulation of the profession is present even in countries that recognize the nursing specialty in anesthesia.
Regarding the quality of nursing care in anesthesia, the researchers from S4 evaluated the complaints of American health insurance systems related to adverse events in activities before the anesthesia induction.Therewith, it was possible to detect that the care related to preanesthetic assessment directly influenced nursing work during induction: lack of preparation to deal with a difficult intubation, difficulty in the control of hemodynamic changes and consequent death, associated with inadequate planning of anesthesia and absence of prior assessment of the airway.
Authors in S6 presented the opinion of the institutional coordination of nursing and anesthesiology, which reported a large participation of nurses in medical assistance during the anesthesia.The study showed a strong accordance between anesthesiology and nursing about the significant role of the nursing team in the conference of equipment and in the preparation of materials for care in anesthesia.Checking the functioning of the equipment and conference of the material availability directly influence care safety, preventing failures or unavailability during critical moments of the anesthesia; therefore, promoting better quality of care.A study analyzed the contributing factors to incidents during anesthesia, revealing that 26% of them were related to the failure in checking the equipment and malfunction (29) .
In the study S6, nurses and anesthesiologists claimed that, during the intraoperative period, nurses should assist in the anesthetic induction, patient monitoring, positioning for regional anesthesia and central access puncture.But there was a major disagreement among professionals about checking the preanesthetic assessment, intraoperative patient monitoring and ongoing support to the patient, which reveals the lack of autonomy of nurses to influence behaviors, which are planned and defined by physicians.
Europe has a great diversity of nurse anesthetist activities, with or without legislation in different countries, despite the conflicts between physicians and nurses.In Great Britain, the nursing role is not yet defined, which limits the understanding among other professionals.In addition, the emergence of anesthesia assistants, professionals who are not necessarily from the nursing field, raises the discussion on the real importance of nurses in anesthesia and the degree of autonomy of these professionals (30) .
In Brazil, according to article 4 of law no.12842 of July 10, 2013, the execution of deep sedation, anesthetic blocks and general anesthesia are exclusive medical activities (31) .However, Brazilian surgical center nurses may directly assist the anesthesiologist in patient monitoring, anesthesia, intraoperative controls and care after the reversal; but cannot program and control the anesthesia plan, like American nurses can (32)(33) .
The Brazilian Society of Surgical Center Nurses, Anesthesia Recovery, Sterilization and Center of Material Storage recommends that nurses collaborate in anesthesia if necessary (34) , but there is no assistance standard for them.Thus, each institution conducts a different practice, and care depends on the professional interaction between anesthesiologists and the nursing staff.Some Brazilian studies discuss the nurses' performance possibilities in anesthesia, with the organization of a service (35) and the creation of a nursing specialization (36) , so that they could act directly in the care before and during surgery.However, it would be necessary to change the curriculum of undergraduate nursing courses and specializations in nursing, as well as reformulate the legislation in nursing and anesthesia councils.
As in some countries in Europe and Brazil, the Chinese ministry of health still does not recognize the nursing profession in anesthesia.The training models are different; some nurses have theoretical training base and others learn about the profession in practical activities.The nurse assists the anesthesiologist in the execution of the anesthesia, in the preparation of equipment and medications, but has little autonomy over patient assessment, elaboration of the anesthetic plans and suggestions (37) .
There is strong resistance from government agencies and medical societies in defining the competences of nonmedical professionals in anesthesia due to the anesthesiologists' fear of devaluation of the specialty by the growing autonomy of other professionals and the significant reduction in the supply of anesthesiologists, with the consequent decrease in quality of care provided in health services (38) .
The absence of nursing practice in anesthesia in our country makes it difficult to carry out experimental studies such as randomized, controlled or well designed clinical trials, systematic reviews or meta-analysis on the subject.
The studies here analyzed showed limitations when considering the methodological design and structure, because the type of study is not well defined according to the Oxford classification.However, the articles offered subsidies for discussion of the nursing role in anesthesia and showed the factors that influence care, opening a new field for prospects of perioperative nurse performance and the possibility of research development with higher level of evidence for the professional exercise.
In countries where the nurse anesthetist profession is Regions that do not allow the practice of anesthesia by non-medical professionals, such as Brazil, need to draw up guidelines or protocols to guide professionals on how to assist the anesthesiologist, defining ducts for uniformity of care and acting with scientific knowledge.Hence, violations of the laws governing the professional practice are limited, thus promoting patient safety.
The development of this review may encourage and support further research on the work of surgical center nurses in anesthesia and how professionals can expand their practices.

CONCLUSION
This integrative review showed weakness in the levels of evidence found in the articles selected for analysis, but indicated different performances of nurses in anesthesia, from countries with legislations and defined protocols, to regions with assistance and exercise of anesthesia with no process whatsoever to define the competence of nurses and the boundaries of their work.
Given the international scenario and considering the current legislation in Brazil, the nursing work in the anesthetic procedure is essential for planning and organizing materials and equipment, working together with the anesthesiologist during the anesthesia and patient follow-up at the end of the anesthetic-surgical procedure.
The support offered by the nursing staff cannot rely solely on the interaction between nurse and anesthesiologist as auxiliary, but acting with scientific knowledge and guidelines for effective and quality care, promoting patient safety.
The definition of the nursing role in anesthesia, with established protocol for care, would guide the care plan and demonstrate the importance of this professional in operating rooms.
Chart 1 -Database and selected search strategy.
, like in the United States, class councils and specialist societies are challenged to keep their standards of care applicable to local conditions, with continuous assessment programs to improve daily practices and procedures of national certification with reassessment of the competence and appropriate training of professionals.