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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.