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Background: Tracheal extubation is a critical risk phase for patients undergoing general anesthesia and is related to complications for the patient. In Sweden, registered nurse anesthetists and anesthesiologists perform extubations and share responsibility for the patient. While there is research regarding the medical and technical aspects of when to extubate, there is a lack of research regarding the experience of registered nurse anesthetists (RNAs) and anesthesiologists (ANs) and their reasons for deciding when to perform extubation. Clinical judgment is applied in making crucial decisions, and non-technical skills are essential in clinical practice.

Aim: To describe and explore registered nurse anesthetists’ and anesthesiologists’ experiences of tracheal extubation in the anesthesia setting.

Methods: This thesis was based on interviews with registered nurse anesthetists and anesthesiologists. In Study I, focus group interviews were performed with RNAs (n=20). Individual interviews were conducted with ANs (n=17) in Study II. Both studies employed qualitative content analysis to analyze data. In Study III, individual interviews were conducted with RNAs (n=20) to determine their main concerns during the extubation process. Observation and individual interviews were performed, and data were analyzed using grounded theory. In Study IV, the focus group interviews (Study I) with RNAs (n=20) and individual (Study II) interviews with ANs (n=17), were analyzed using reflexive thematic analysis, with Tanner’s model of clinical judgment as a lens.

Findings: The results showed that RNAs (Study I) and ANs (Study II) described extubation as a process that begins when preparing for the anesthesia procedure and meeting the patient. From then, they continuously assessed and prepared the patient for extubation and assembled a unique extubation plan to prevent extubation failure. At extubations, they acted upon recognizable patterns and relied on experience and intuition. The RNAs and ANs protected the patient by speaking for them and keeping them safe during the vulnerable situation of extubation. They shared the responsibility for the patient, but their roles differed. The RNA felt lonely during extubations despite other professionals being in the operating room. Conversely, ANs felt like a member of the team when entering the operating room during extubations. In Study III, the RNAs’ main concern was safeguarding the patient in a highly technological environment. This they managed by maintaining adaptability while moving between challenges and facilitators. In Study IV, the RNAs’ and ANs’ extubation process comprised putting the pieces together when holding responsibility for the patient. They noticed patient reactions and recognizable situations during extubations, which they interpreted and made sense of by using clinical reasoning. They responded to these interpretations based on clinical experience and intuition. They reflected during and after extubation, evaluating their actions and contemplating improvement.

Conclusion: In the extubation process, RNAs and ANs combine theoretical knowledge, clinical experience, and intuition with each patient’s uniqueness to make decisions on extubations. However, extubation decision-making does not rely solely on what is visible on the monitors or a prescribed technique. Instead, it involves professional skills, critical thinking, and clinical reasoning. At the point of extubation, there is a need for improvement in the working environment for theprofessionals who perform this critical task. The patient is in a  vulnerable phase, and the professionals need to be able to focus in order to safeguard the patient.

Background: Although extubation is a high-risk phase associated with risk of severe complications for patients undergoing general anaesthesia, there is a lack of research about this phenomenon from the perspective of anaesthesiologists’ experiences of the process of extubation in the anaesthesia setting.

Aim: To describe Swedish anaesthesiologists’ experiences of the extubation process in the anaesthesia setting.

Methods: A qualitative descriptive design study with individual semi-structured interviews was conducted in three hospitals in Sweden with a total of 17 anaesthesiologists. A qualitative manifest content analysis method was used to analyse the data.

Results: The anaesthesiologists’ experiences were described in two categories: To assemble sensibilities, where the anaesthesiologists are receptive to inputs, create tailored plans, are guided by emotions and experiences, and sense the atmosphere in the process of extubation; and To stay focused, where they understand the importance of preparation and being prepared, and of being calm and strategic, and of needing to trust the registered nurse anaesthetist in the process of extubation.

Conclusions: Decision-making regarding the process of extubation does not rely solely on monitoring signs; rather, the anaesthesiologists described how, by looking beyond the monitors and by being receptive to inputs from the patient and other professionals, their experience and intuition guides them through the process of extubation. 

Background: The process of extubation is complex as it takes place in the technical and challenging environment of the operating room. The extubation is related to complications of varying severity and a critical moment for the patient, who is in a vulnerable condition when emerging from anesthesia. Registered Nurse Anesthetists (RNAs) in Sweden have specialist training and performs extubations independently or in collaboration with an anesthesiologist.

Aim: To obtain a deeper understanding of Registered Nurse Anesthetists' main concerns and how they resolve these in the process of extubation when caring for a patient during general anesthesia.

Participants: A total of 17 RNAs, eight male and nine female, were included in the study. Twelve RNAs in the first step of data collection (I); and five RNAs the second step of data collection (II).

Method: A classic grounded theory approach with a qualitative design was used for this study.

Findings: The RNAs' main concern in the process of extubation were Safeguarding the patient in a highly technological environment, which the solved by Maintaining adaptability. Facilitators as well as challenges affected how the RNAs solved their main concern and represented the categories: 'Having a back-up plan', 'Getting into the right frame of mind', 'Evaluating the patient's reactions', 'Using one's own experience', 'Dealing with uncertainty', 'Pressure from others', and 'Being interrupted'. The theory, Safeguarding the patient in the process of extubation, emerged.

Conclusion: To be able to safeguard the patient in a highly technological environment, the RNAs must oscillate between facilitators and challenges. By maintaining adaptability, the RNAs resolved the difficulties of oscillating, indicating a need for finding a balance between maintaining attentiveness on what is important to keep the patient safe in the process of extubation and all of the disturbances present in the OR.

Purpose: To describe Registered Nurse Anesthetists' (RNA's) experiences of the process of extubation of the endotracheal tube in patients undergoing general anesthesia.

Design: A descriptive qualitative design.

Methods: This study was conducted in two hospitals with 20 RNAs in total. Data were generated from focus group interviews. Content analysis was used to analyze data.

Findings: The RNAs' experiences were described within four categories and eight subcategories. The category To be a step ahead includes assessment and preparation, and To be on my toes, their ability to recognize patterns and build a connection. To use situation awareness relates to their use of experience and feelings, and To be alone in a critical moment, to feeling alone in the team and protecting the patient.

Conclusions: The RNAs make decisions when to extubate by combining theoretical knowledge, clinical experience, and intuition with the uniqueness of each patient.