LEGAL FRAMEWORK AND CURRENT SITUATION OF ANESTHESIA NURSING IN SPAIN

In Spain there is no specific regulation regarding the roles and responsibilities of nursing in the field of Anesthesiology, and the lack of regulation makes it difficult to conceptualize these advanced practice nursing (APN) roles in the same way as in other countries, which is why, at present, they are framed in a paradigm of variable competencies. This is due to the lack of postgraduate specialty content (except for already recognized specialties (e.g., midwifery, mental health nursing...)), budgetary reasons and because the polyvalence of nursing has been promoted to the detriment of its specific training.

A FIGURE THAT HAS BEEN “MATURING”

However, although over the years there has been no normative evolution and we find ourselves in the same situation, progress has been made in improving the visibility and empowerment of the important role of nursing in society:

1. In the early 2000s, and coinciding with an increase in healthcare demand and the super-specialization and scope of anesthesiology, postgraduate training programs in anesthesia for nurses began to emerge and, at present, different Spanish universities offer postgraduate training with a master's degree in the field of Anesthesia, Resuscitation and Pain Therapeutics. We at Sedalux, aware of the importance of formal training, also created our own Expert Course in Nurse Anesthesia.

2. As of 2012, the competencies and functions in Spain of anesthesia nurses were defined by the Spanish Association of Anesthesia, Resuscitation and Pain Therapy Nursing (ASEEDAR-TD), in tune with those defined by the International Federation of Nurse Anesthetists (IFNA) because there are a large number of nurses working in the field of anesthesia coinciding with the role of a specialist nurse or EPA.

3. The conceptual change from Anesthesiology to Perioperative Medicine has led to the emergence of new opportunities for anesthesia nursing in Spain, which not only represent an aid to the anesthesiologist, but also entail an advanced practice of the profession that allows differentiating these roles from those of surgical nursing.
4. Morbidity and mortality, the aging of the population, the increase in life expectancy, the increase in the demand for care, as well as the development of technology and the expansion of the areas of work of anesthesiologists, among other factors, have resulted in an increase in the demand for anesthetic procedures and have led to an overload of work for the medical specialist. With training in line with existing needs and aimed at complementing the role of the anesthesiologist, the nurse anesthetist becomes an integral part of a team that manages to improve patient safety. The Minessota study in the USA compared outcomes and costs between anesthesia performed by nurse anesthetists alone or by anesthesiologists. This study found higher mortality when anesthesia was performed by nurses, but the best results were obtained when anesthesiologists worked as a team with nurses. These data were later confirmed and have encouraged the use of the term Anesthesia Team, a way of working that is being implemented in the USA and has advocates in Europe, based on the fact that “four eyes see more than two”, a popular saying that alludes to the fact that teamwork between doctor and EPA provides safer care and optimizes assistance by providing greater effectiveness in the diagnosis of irregular situations, adverse events or complications during anesthesia and thus providing greater safety to the patient.

SPECIALTY WITHOUT RECOGNITION, BUT WITH LEGAL COVERAGE

However, the nurse anesthetist, a role that has existed in our country for years but lacks legal recognition and accredited training, provides collaborative assistance in different areas to the anesthesiologist, which is not exempt from legal coverage.

According to the Law for the Regulation of Health Professions (LOPS) (BOE Law 44/2003 of November 21), in its article 9 “Interprofessional Relations and Teamwork” comes to give legal coverage to the “anesthesia team” and says in its points 3 and 4: 

3.- CWhen a healthcare action is carried out by a team of professionals, it shall be articulated in a hierarchical or collegiate manner, as the case may be, taking into account the criteria of knowledge and competence, and where appropriate the qualifications, of the professionals that make up the team, depending on the specific activity to be performed, the trust and reciprocal knowledge of the capabilities of its members and the principles of accessibility and continuity of care for the persons being attended. 

4.- Within a team of professionals, it will be possible to delegate actions, provided that the conditions under which such delegation or distribution of actions may take place are previously established within the team. A necessary condition for the delegation is the capacity to carry it out on the part of the person receiving the delegation, a capacity that must be objectifiable, whenever possible, with the appropriate accreditation.

Therefore, in accordance with the provisions of the aforementioned LOPS, it can be deduced that the performance of nurses in the field of anesthesiology should be governed by the following principles: 


1. Its performance will never be autonomous, always working under the delegation and supervision of functions by an anesthesiologist.
2. They should have specific training for the tasks entrusted to them, which should be objectifiable and with the consequent accreditation. This training should provide knowledge and training in airway management (the main cause of complications in sedation outside the operating room), in respiratory and cardiovascular physiology, in monitoring and in pharmacology, without entering into the disquisitions of which drugs should be used and which should not, as long as the staff is trained in their use. The debate should be limited to guaranteeing safety, regardless of the drug and who uses it.

Thus, there is an adequate legal framework to promote the change towards standardization and empowerment of multidisciplinary work teams, essential to develop the “new anesthesia” called Perioperative Medicine, at the same time that we have the positive experience in other countries that endorse the operation of this duality.

It is up to us to strive to further define competencies, to work every day for adequate training and to develop a plan to share tasks, creating a situation of mutual interest between nurse and anesthesiologist in order to take anesthesia to the next level.