Anaesthesia the Norwegian way

If we are lucky, we are merely asked to do more with what we already have. But sometimes if we’re unlucky, it may be that we must do more but with even less. Such is life in the NHS. Shortfalls in the number of consultant anaesthetists are not new, and more consultants are working beyond the age of 60 than ever before [1].

But maybe there is a way we, as anaesthetists, can do more – we can be more effective in how we work but without compromising on personal burnout. We might even have a better quality of life in the process. Norway has been listed as the top nation for human development (the UK is placed 13th) [2] – could we also learn something from the Norwegian model of anaesthesia practice?

I count myself very lucky. I finished my anaesthesia training in 2016 and took up a consultant position enjoying a busy, varied practice. Four years and one child later the discussion was raised about moving to Norway (my wife is Norwegian). Six months later I would find myself in a different country, fumbling my way in a different language and also working very differently, but much more happily – I was working with anaesthesia nurses.

So surely there are downsides? Not really, but it is a different way of working.

Gone was the classic one anaesthetist, one surgeon, one patient and one operating theatre. I was now covering two theatres simultaneously. Standard practice is that we induce anaesthesia (in whatever form) with an anaesthetic nurse. Once the patient is stable I am free to attend to other things. The department is therefore much more dynamic and flexible, since we have the time between patients to dedicate to other things. We are freer to help each other with difficult cases. We are also more balanced in our capabilities, because as we learn new techniques it is much easier to teach others since we have the time to supervise and train. Having a colleague by one's side in theatre for induction of anaesthesia no longer means pulling them away from another theatre.

So surely there are downsides? Not really, but it is a different way of working. An anaesthetic isn’t going to work very well if it’s so complex that you have to be in the room with the nurse the whole time. Pre-operative assessment has to be robust. We are responsible for more patients, but that responsibility is shared with our nursing colleagues. Anaesthesia care is much more uniform and less dependent on any individual doctor; it reflects the department as a whole.

As a trainee I was sceptical about the implementation of anaesthesia associates. I was convinced that they would come to undermine training (stealing all the good bits) and the specialty as a whole (why bother with a doctor when a nurse can do the same job?). I believed that the triad of anaesthetist, surgeon and patient was irreplaceable. However, after two years of working with anaesthesia nurses I am convinced of their value. But you needn’t take my word alone for it – you can hear it from two trainees and a nurse themselves….

Anaesthesia nurse perspective

The career of an anaesthetic nurse is exciting, varied and comes with significant responsibility. It is also highly competitive. A minimum of two years experience working as a nurse is mandatory, and this must come in a related field (internal medicine for example) before applying for training. On average there are 30 applicants per training position. Study is usually carried out full time with financial support from the employing hospital, with a commitment to work as an anaesthesia nurse upon graduation for two years. Training lasts a minimum of 18 months, but can be extended to two years to complete a thesis and acquire a Masters.

Practice as an anaesthesia nurse is tightly regulated with defined standards of what an anaesthesia nurse can do alone or with a doctor present. These same guidelines also establish the areas of responsibility for anaesthesia nurses and physician anaesthetists [3]. Briefly, anaesthesia nurses are expected to be competent to assist with induction of anaesthesia (including preparation of medicines and equipment), maintenance of anaesthesia (both volatile and TIVA), airway control (mask ventilation, intubation and supraglottic airway insertion), and waking patients from anaesthesia. Anaesthesia nurses (working as a pair) can also induce anaesthesia in simple cases without a doctor. Additional skills (arterial lines, PICC lines and regional anaesthesia techniques) can be learnt, but this is dependent upon both the nurse and anaesthesia department approval.

New trainees in anaesthesia will often spend a good deal of time in the operating theatre with us to experience maintenance of anaesthesia as surgery progresses and to anticipate and handle to changes in physiology, patient position and surgical stress. There is a clear focus to prioritise training of new doctors, and it is the role and responsibility of anaesthesia nurses to facilitate this as much as possible. ‘Stealing’ procedures from trainees is culturally unacceptable and considered as completely against our ethos.

Anaesthesia trainee perspective

Anaesthesia is unique in Norway – in no other speciality do nurses and doctors work so tightly where it can at times seem difficult to differentiate between the two. Both can induce anaesthesia, intubate and wake patients. However, there are distinct differences. In the first phase of training, it can be daunting to work with anaesthesia nurses. They have more experience, better skills and overall command over anaesthesia. Instead of a threat, this is seen as an opportunity for learning and teaching. Anaesthesia nurses give an additional perspective and form an additional source of learning.

Naturally, competition around procedures can occur. However, there is an established culture that doctors in training take priority. At times it’s not the nurses that want to do things but our own bosses! Having anaesthesia nurses to maintain anaesthesia prevents us being tied to a specific operating theatre, and so we are then free to pick up procedures in other places. After the initial learning phase is over a new challenge occurs when we transition to taking on more responsibility and making decisions on our own. Normally this occurs gradually as we gain experience and demonstrate our capability, supported by our consultants.

We couldn’t imagine working without our nursing colleagues!

Summary

Anaesthesia practice in the UK has a long and established tradition. Worldwide it is extremely highly respected (I can vouch for that personally when I started working in Norway). Anaesthesia Associates may well mark one of the biggest changes in the provision of anaesthesia in the UK. If it’s anything like how it is here in Norway, it will most likely be a change for good.

This article represents the authors’ personal views and not those of any organisations in Norway or the UK

Jonathan Mathers
Overlege i Anestesi 

Espen Aune
Anaesthesisykepleier

Ingebjørg Bergerud
Lege i spesialisering (Anestesi) 

Karoline Andersen
Lege i spesialisering (Anestesi) 

Haraldsplass Diakonale Sykehus, Bergen, Norway 

References 

1. Royal College of Anaesthetists. Medical Workforce Census Report 2020. https://rcoa.ac.uk/training-careers/working-anaesthesia/workforce-planning/medical-workforce-census-report-2020 (accessed 1/6/2022). 
2. United Nations Development Programme. Human Development Data Center, 2022. https://hdr.undp.org/en/data (accessed 1/6/2022). 
3. Norsk Anestesiologisk Forening. Norsk standard for anestesi, 2019. https://www.nsf.no/sites/default/files/groups/subject_group/2019-12/norskstandardanestesi.pdf (accessed 1/6/2022).

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