Received: 8 January 2022 | Revised: 29 April 2022 | Accepted: 6 June 2022 DOI: 10.1111/jan.15348 ORIGINAL RESEARCH: EMPIRICAL R E S E A R C H - ­ Q U A N T I TAT I V E Defining competencies for nurse anaesthetists: A Delphi study Montse Sanclemente-­Dalmau1,2 | Paola Galbany-­Estragués3,4 | Xavier Palomar-­Aumatell3,5 | Esther Rubinat-­Arnaldo6,7,8 1 ESIMar (Mar Nursing School), Parc de Salut Mar, Universitat Pompeu Fabra-­ Abstract affiliated, Barcelona, Spain Aim: To define the competencies of nurse anaesthetists in the hospitals of Catalonia 2 SDHEd (Social Determinants and Health Education Research Group), IMIM on the basis of their clinical practice through a consensus-­building process. (Hospital del Mar Medical Research Design: We used the Delphi method to determine consensus among a group of 16 Institute), Barcelona, Spain 3 nurse anaesthetists. Research Group on Methodology, Methods, Models and Outcomes of Health Methods: Between February and June 2020, we administered a questionnaire of and Social Sciences (M3O), Faculty of 142 questions distributed among seven domains: expert, communicator, collabora- Health Science and Welfare, Centre for Health and Social Care Research (CESS), tor, manager, health advocate, scholar and professional. Two rounds were conducted. University of Vic-­Central University of Results: In round 1, 18 competencies were discarded and nine had inconclusive re- Catalonia (UVIC-­UCC), Barcelona, Spain 4 sults. Eighteen competencies were proposed by participants. The nine competencies AFIN Research Group and Outreach Centre, Autonomous University of with inconclusive results and the 18 newly proposed competencies were considered Barcelona, Cerdanyola del Vallès, Spain 5 in round 2. In round 2, three of these 27 competencies tested were discarded, and University Hospital of Vic –­Vic Hospital Consortium (HUV-­CHV), Barcelona, Spain consensus was reached on the other 24. 6 Department of Nursing and Conclusion: Health education and the empowerment of the patient and family are Physiotherapy, Lector Serra Húnter, fundamental pillars in the practice of nurse anaesthetists in Spain, especially in University of Lleida, Lleida, Spain 7 Health Care Research Group (GRECS) pre-­anaesthetic assessment and pain care. These areas of practice can help define -­IRB Lleida, Lleida, Spain competencies in other countries where the profession of nurse anaesthetist is less 8 Society, Health, Education and Culture developed. Research Group (GESEC), University of Lleida, Lleida, Spain Impact: The lack of regulation of the competencies of nurse anaesthetists leads to great variability in training and practice. The results can help in their standardization Correspondence Paola Galbany-­Estragués, Research Group in Spain and in other countries lacking regulation. Our approach can also help policy- on Methodology, Methods, Models and makers and hospital administrators in health systems that are undergoing the process Outcomes of Health and Social Sciences (M3O), Faculty of Health Science and of regulation. The regulation of the competencies of nurse anaesthetists will allow Welfare, Centre for Health and Social Care them to contribute their expertise to the health-­illness continuum, increasing safety Research (CESS), University of Vic-­Central University of Catalonia (UVIC-­UCC), and improving the quality of care. Barcelona, Vic., Spain. Email: paola.galbany@uvic.cat KEYWORDS advance practice nursing, competencies, nurse anaesthetists This is an open access article under the terms of the Creative Commons Attribution-­NonCommercial-­NoDerivs License, which permits use and distribution in any medium, provided the original work is properly cited, the use is non-­commercial and no modifications or adaptations are made. © 2022 The Authors. Journal of Advanced Nursing published by John Wiley & Sons Ltd. 3696 |  wileyonlinelibrary.com/journal/jan J Adv Nurs. 2022;78:3696–3709. SANCLEMENTE-­DALMAU et al. | 3697 1 | I NTRO D U C TI O N has not been defined, and no specific certification is required for conducting clinical practice in this area (Ayuso Murillo et al., 2019). The training that nurse anaesthetists receive and the regulation of In the first decade of the 2000s, postgraduate training pro- their professional skills vary widely by country. Since its inception, grammes in nurse anaesthesia were established at Spanish univer- the International Federation of Nurse Anaesthetists has aimed to sities. In 2007, nursing studies in Spain were restructured from a define a conceptual framework for the practice of nurse anaesthe- three-­year university diploma to a four-­year bachelor's degree. With tists and establish guidelines for their training, in accordance with this change, the postgraduate training programmes in nurse anaes- safe practices in anaesthesia. In 1998, the International Federation thesia became master's degrees. This shift has made it possible to im- of Nurse Anaesthetists conducted a study in 96 countries in which prove the quality and extend the duration of training. Currently, there it was observed that nurse anaesthetists participated actively in 70–­ are five such master's programmes (three of which are in the region 80% of anaesthesia procedures (Merry et al., 2010). of Catalonia) offering theoretical and practical training consisting of International Federation of Nurse Anaesthetists was founded in 60 European Credit Transfer System credits. In 2021, one of them 1989 by two nurses, one from Switzerland and one from Denmark, was included in the International Federation of Nurse Anaesthetists initially bringing together 11 countries. Throughout its history, list of Approved Non-­Physician Anaesthesia Programmes/Schools at International Federation of Nurse Anaesthetists has been incorpo- the level of registration (first level of acknowledgement). rated into institutions such as the International Council of Nurses and In 2012, the Spanish Nursing Association of Anaesthesia, the World Federation of Societies of Anaesthesiologists (Meeusen Recovery and Pain Therapeutics prepared a document listing et al., 2016). It is currently made up of associations of nurse anaes- the competencies of nurse anaesthetists (Peix Sagués & Pérez thetists in 43 countries, including Spain (International Federation of Castro, 2012). Nurse anaesthetists in Spain have added more activ- Nurse Anaesthetists, 2021). ities to their clinical practice. However, their competencies remain The conceptual model of professional practice defined by the unregulated. International Federation of Nurse Anaesthetists focuses on the training of nurse anaesthetists. Nursing competencies are the set of knowledge, abilities, attitudes and complex decision-­making 2 | BAC KG RO U N D processes that make it possible for nurses to act according to the demands of the situation. To establish the competencies, the Anaesthesia first began to be used in surgical procedures at the end International Federation of Nurse Anaesthetists adapted the of the nineteenth century in the United States. It was administered CanMEDS model of the Royal College of Physicians and Surgeons. by medical students or nurses. The need to treat pain in soldiers led CanMEDS is widely used for defining of competencies in the training to the generalization of the use of anaesthesia by Catholic nurses, of physicians and is also used by other health professionals. It is based such as Catherine S. Lawrence, under the supervision of surgeons, on six cross-­cutting competencies: professional, communicator, col- given that at the time there was no medical training in anaesthe- laborator, health advocate, scholar and manager, which converge in sia. Training in anaesthesia was carried out by nurses such as Alice a single central competency: expert. To adapt the CanMEDS model, Magaw and Agatha Hodgins. In the early 1900s, training pro- the International Federation of Nurse Anaesthetists used the same grammes were established, first in hospitals and then as university set of seven competencies, centring them in the areas of care that postgraduate training (“Certified Registered Nurse Anaesthetist”). NAs nurse anaesthetists provide (Herion et al., 2019; International CRNAs have to have acquired a minimum of a master's degree fo- Federation of Nurse Anaesthetists [IFNA], 2016). This conceptual cusing on anaesthesia, have completed extensive clinical training, framework was recognized in 2021 by the International Council of and have passed the certification exam of the National Boards of Nurses, which urged countries to regulate the training and practice Certification and Recertification of Nurse Anaesthetists (NBCRNA) of nurse anaesthetists (International Council of Nurses, 2021). (Ray & Desai, 2016). Beginning in 2022, nurse anaesthesia training in In countries such as the United States, Sweden and France, nurse the United States will occur within a doctorate of nursing practice. anaesthesia is recognized as a specialized area of nursing, and the The American model of anaesthesia nursing was exported during training and practice of nurse anaesthetists is regulated. In Spain, World War II to Europe, and several countries began to train nurses however, nurse anaesthetists are not considered specialists and to administer anaesthesia. Unlike in the United States and France, their training and practice are unregulated (Meeusen et al., 2016). In where nurse anaesthetists' contribution to the health system is well 2005, seven nursing specialities were defined in Spain: obstetrics/ documented (Ray & Desai, 2016; Taland, 2017), in Spain, there is lit- gynaecology nursing, mental health nursing, occupational nursing, tle documentation of the activities carried out by nurse anaesthe- geriatric nursing, family and community nursing, paediatric nursing tists (Canet & Monedero, 2007). We know that nurses administered and medical-­surgical care nursing, the last of which include nurse an- anaesthesia during war times and that they worked with physicians aesthesia (Ministerio de la Presidencia, 2005). The General Council trained in the administration of anaesthesia until the 1980s, when of Nursing has proposed to the Spanish Ministry of Health that the medical specialities and the Resident Intern Physician (MIR) medical-­surgical care nursing be subdivided into two or three sepa- programmes were founded, including Anaesthesiology, Recovery rate areas, but the definitive training programme for this speciality and Pain Management (Tutosaus Gómez et al., 2018). Nurse 3698 | SANCLEMENTE-­DALMAU et al. anaesthetists did not disappear, but they lost autonomy and their home and at the end of life. The fact that Iranian nurse anaesthe- activities in surgical procedures became more varied. tists worked outside of hospital settings differentiates them from In 2007, Canet proposed “anaesthesia teams” that would be nurse anaesthetists in other countries. In France, the Syndicat formed by anaesthesiologists and nurse anaesthetists, based on the National des Infirmier(e)s-­Anesthesistes conducted a survey in 2018 results of a study in Catalan hospitals that highlighted the need for among nurse anaesthetists to take a snapshot of the profession the recognition and professionalization of nurse anaesthetists (Canet and identify possible areas for improvement. One finding was that & Monedero, 2007). However, this proposal has not been adopted. most nurse anaesthetists worked in anaesthesia teams. Nurse an- Since the beginning of this century, in Catalonia, the population aesthetists performed expert management in general anaesthesia over 65 years of age has increased by 19%, and this growth is expected and airway management. In most cases, extubation in the recovery to reach 22% by 2030 (Instituto de Estadística de Catalunya, 2021). room was the responsibility of the nurse anaesthetists, as was the Other factors such as the increase in life expectancy, the advance- decision to discharge to another unit, although this required the ment of surgical technology, and the availability of early detection anaesthesiologist's approval. Nurse anaesthetists were unlikely to programmes have increased the demand for anaesthesia. The con- perform as health educators, health advocates and communicators ceptual shift from “anaesthesiology” to “perioperative medicine” has because they were generally not included in pre-­anaesthesia visits. led nurse anaesthetists to work in new areas such as pre-­operative (Syndicat National des Infirmier(e)s-­Anesthestits-­es [SYNA], 2019). consultation, diagnostics/therapeutics and acute and chronic pain In Switzerland, Herion et al. (2019) highlights among nurse anaes- units. Nurse anaesthetists are present throughout the perioperative thetists the roles of expert, communicator, collaborator and pro- period, caring for the patient and his or her family while also en- fessional. In this research, the roles of health manager and health gaging in health education and promotion. Nurse anaesthetists in promotor were less prominent. In Spain, the latest research from Spain have gone from supporting the anaesthesiologist in anaesthe- Comellas Oliva (2016) and Sevilla Guerra et al. (2017) demonstrates sia procedures to playing an increasingly autonomous role inside the the existence of advanced practices among nurse anaesthetists. anaesthesia team, developing competencies that could lead them to Even so, training, competencies and professional practices remain be considered advanced practice nurses. unregulated in the country. The advanced practice nurse has been studied by a range of As seen in this section, nurse anaesthetists' competencies vary authors, such as Benner and Hamrich, since the appearance of this greatly around the world because they depend on national history, category in the 1980s in the United States (Comellas Oliva, 2016). training, regulation and legislation. Despite these differences in clin- The International Council of Nurses defines an advanced practice ical practice, broad standards based on the International Federation nurse as a generalist or specialist nurse who has acquired at least of Nurse Anaesthetists criteria should be developed to ensure the a master's degree, a base of expert knowledge, the capacity to quality of care. make complex decisions, and the clinical competencies necessary We aim to define the competencies of nurse anaesthetists in for expanded professional practice. The specific characteristics of Catalonia (Spain) to contribute to the development of the profession this nurse depend on the context in which he or she is accredited to in Spain and serve as a potential model for other countries in which practice (International Council of Nurses, 2020). there are no nurse anaesthetists or in which the field is undergoing The International Council of Nurses's 2021 Guidelines on definition and regulation, like in Spain. Advanced Practice Nursing -­ Nurse Anaesthetists (ICN, 2021) de- fine the nurse anaesthetists as an advanced practice nurse that has the training and competencies to provide care in the areas of anaes- 3 | TH E S T U DY thesia and pain during all stages of the patient's life. The guidelines, which outline the competencies and requirements of the training 3.1 | Aim programmes for nurse anaesthetists, have established a reference framework for the profession. To define the competencies of nurse anaesthetists in the hospitals of Turning to the situation of nurse anaesthetists around the world, Catalonia on the basis of their clinical practice through a consensus-­ in 2017, Hu et al. established the first educational programme in building process. China for nurse anaesthetists, based on the 2016 International Federation of Nurse Anaesthetists standards (IFNA, 2016). In this programme, clinical practice, health education and research were 3.2 | Design the core competencies that allowed nurse anaesthetists to admin- ister anaesthesia, perform airway management and practice in re- We used a modified conventional Delphi study, a valid method for covery units, always under the supervision of an anaesthesiologist, exploring a question to which there is no absolute answer. In a Delphi according to Chinese legislation (Hu et al., 2017). In Iran, Halakou study, a panel of experts arrives at a consensus (Keeney et al., 2011). et al. (2017) found that nurse anaesthetists participated in pre-­ “Consensus” has been defined in different ways. We followed von der anaesthetic assessments, care management and the treatment of Gracht (2012), using three consensus criteria for each question: 80% acute and chronic pain, not only in the hospital setting but also at of participants answered “agree” or “strongly agree”, mean > 4 ± 0.5 SANCLEMENTE-­DALMAU et al. | 3699 SD and interquartile range ≤ 1. We agreed that we would consider expert in Delphi technique (who is also one of the authors), two ex- consensus to have been met when all three criteria were fulfilled, to pert nurse anaesthetists and a nurse anaesthetist who was a mem- re-­introduce in subsequent round competencies that met one or two ber of the Catalan Association of Anaesthesia, Post-­anaesthesia and criteria, and to discard competencies that met zero criteria. Pain Management Nursing. These reviewers tested the question- naire and proposed modifications in its organization. They also sug- gested adding eight questions inside the seven domains; they did not 3.3 | Participants propose any changes to the domains. The resulting questionnaire had a first part containing socio- The selection of the panel members is the most important part of demographic data and a second part containing 142 questions the Delphi method. The panel was composed of expert nurses, as distributed across the seven competency domains defined by the defined by Benner (1987). The number of panel members was deter- International Federation of Nurse Anaesthetists (International mined by the number of hospitals that agreed to interpret. Hospitals Federation of Nurse Anesthetists, 2016): expert (pre-­anaesthetic were selected to cover a range of organizational structures and geo- assessment, anaesthetic management, risk management, moni- graphical locations. We contacted 29 hospitals in Catalonia (24 pub- toring, post-­anaesthesia, equipment management, advanced life lic and five private). Nine hospitals did not respond to our invitation. support, post-­operative care, pain management, infection control, Three answered but did not have any nurses who met the criteria. documentation), communicator, collaborator, manager, health advo- One hospital rejected the proposal, leaving 16 participating hospi- cate, scholar and professional. The answers were given on a Likert-­ tals, each of which provided a participant. The 16 participants met type scale ranging from 1 to 5 (1 “strongly disagree”, 2 “disagree”, 3 the following inclusion criteria for consideration as expert nurses “neither agree nor disagree”, 4 “agree”, 5 “strongly agree”). At the (Benner, 1987): having more than 5 years of experience as a nurse end of round 1, participants were given the opportunity to incor- anaesthetist, having postgraduate training in anaesthesia, and being porate any competencies that they believed were missing from the engaged in clinical practice at the time of the research. Hospitals questionnaire. This technique is part of the Delphi method and aims of different care levels from all of the administrative health areas to draw on participants' feedback (Keeney et al., 2011). Likewise, at of Catalonia were included. Before administering the first question- the end of the questionnaire, there was a blank space for comments naire, we met with each participant to inform him or her about the about perceptions of the organizational and legal structure of nurse research and obtain informed consent. We also explained that par- anaesthetists in Spain. A second questionnaire of 27 items was de- ticipation was voluntary and that he or she could withdraw at any veloped for round 2, based on the outcomes of round 1, as explained time. None of the participants chose to withdraw. in Results. The questionnaires were conducted in Catalan. 3.4 | Data collection 3.5 | Ethical considerations The data was collected by questionnaire in two rounds. The ques- This research received the approval of the Research Ethics tionnaires were sent via email with a link to the SurveyMonkey® Committee of the Fundació Unió Catalana d'Hospitals (CEI 18/87). platform. Participants received a reminder 10 days later. The two Following the principles of the Helsinki Declaration (World Medical rounds were held between February and June 2020, which is in line Association, 2013), all participants received information about the with the timeframes for the Delphi method (Keeney et al., 2011). research and signed the informed consent form before participat- ing in the study. Only the research team had access to participants' personal information. Data collection through SurveyMonkey® was 3.4.1 | Questionnaire design anonymous. To develop the first questionnaire, we followed the existing litera- ture on the modified Delphi method (Keeney et al., 2011). We con- 3.6 | Data analysis ducted a review of the relevant literature appearing in the PUBMED, Scopus and Google Scholar databases. We used the key words For the analysis, we used SurveyMonkey® and Excel®. The statis- “competencies” and “nurse anaesthetists” and limited our search to tics used were descriptive, including mean, median, standard devia- the previous 5 years. Of the 163 articles identified, we selected 11 tion and interquartile range. in which an assessment of the competencies in nurse anaesthesia had been made and drew on them to build the questionnaire. We also used the results of a qualitative phenomenological study about 3.7 | Validity, reliability and rigour nurse anaesthetists that we had conducted previously (Sanclemente Dalmau, 2017). Finally, the questionnaire was evaluated by a team of We developed the Delphi questionnaire for round 1 by drawing reviewers composed of an expert in advanced nursing practice, an on the recent literature about nurse anaesthetists' competencies. 3700 | SANCLEMENTE-­DALMAU et al. To translate the competencies identified to Catalan, we used the 4.2 | Round 1 document provided by the Catalan Association of Anaesthesia, Post-­anaesthesia and Pain Management Nursing, which was based In round 1, participants reached consensus in 115 of the 142 com- on the original document of the International Federation of Nurse petencies. Of the 27 competencies failing to reach consensus, those Anaesthetists. Once the questionnaire was developed, it was re- meeting none of the consensus criteria were discarded. These in- viewed by four experts who made minor suggestions, which we in- cluded 17 from the expert domain and one from the manager do- corporated. They agreed with the proposed domains and confirmed main. Nine competencies that met one or two of the consensus the validity and reliability of the questionnaire design. criteria in round 1 were retested in round 2 (Table 1). In all cases, these were competencies that failed to meet the criterion of >80% of participants reporting “agree” or “strongly agree”. Participants 4 | R E S U LT S proposed 18 new competencies. 4.1 | Description of the participants 4.3 | Round 2 The total number of participants was 16 nurse anaesthetists. 93.8% were women and 6.25% were men. The mean age was In round 2, in addition to retesting the nine competencies that had 43.12 years ± 11.06 SD. All had postgraduate training in anaesthe- an inconclusive outcome in round 1, we added the 18 competencies sia, and one had completed a doctorate. The average years of experi- proposed by the participants in round 1. Of these 27 items, consensus ence as a nurse was 21 years ± 5 SD and specifically in the field of was reached on 24 competencies in round 2 (all three criteria met). anaesthesia it was 18 years ± 8.42 SD. Most participants (81.25%) Three competencies from the expert domain met none of the three worked in more than one area in anaesthesia. Specifically, 50% par- consensus criteria and were discarded (Table 2). We did not conduct a ticipated in pre-­anaesthetic assessment, 68.75% in surgery, 84% in third round because by the end of round 2, all items had been fully ac- post-­operative care units, 56.25% in pain units and 43.75% in units cepted (three consensus criteria met) or fully rejected (zero consensus outside the surgical area. criteria met), leaving no items for further consideration. TA B L E 1 Results round 1 Competencies from Discarded (0 Retested in round 2 (1–­2 Consensus (3 Domain domain criteria met) criteria met) criteria met) Expert 96 17 4 75 Pre-­anaesthetic assessment 13 3 1 9 Preparing and administering anaesthesia 20 5 1 14 Patient safety 12 0 1 11 Monitoring 7 0 0 7 Termination of anaesthesia 5 1 0 4 Equipment 4 1 0 3 Advanced life support 6 1 0 5 Post-­operative care 12 3 1 8 Pain management 12 3 0 9 Risk prevention 3 0 0 3 Documentation 2 0 0 2 Communicator 6 0 2 4 Collaborator 7 0 0 7 Manager 7 1 1 5 Health advocate 8 0 1 7 Scholar 10 0 1 9 Professional 8 0 0 8 Totally 142 18 9 115 Note: “Discarded” refers to the competencies that met none of the three consensus criteria and were therefore eliminated from further consideration. “Retested in round 2” refers to the competencies that met one or two consensus criteria and were considered again in the second round. “Consensus” refers to the competencies that met all three consensus criteria in round 1. SANCLEMENTE-­DALMAU et al. | 3701 TA B L E 2 Results round 2 Competencies Discarded (0 Consensus (3 Domain from domain criteria met) criteria met) Expert 21 3 18 Pre-­anaesthetic assessment 7 1 6 Preparing and administering 4 1 3 anaesthesia Patient safety 2 0 2 Monitoring 3 0 3 Termination of anaesthesia 0 0 0 Equipment 2 0 2 Advanced life support 1 0 1 Post-­operative care 2 1 1 Pain management 0 0 0 Risk prevention 0 0 0 Documentation 0 0 0 Communicator 2 0 2 Collaborator 0 0 0 Manager 1 0 1 Health advocate 1 0 1 Scholar 1 0 1 Professional 1 0 1 Finally 27 3 24 Note: “Discarded” refers to the competencies that met zero of the consensus criteria in round 2. “Consensus” refers to the competencies that met all three consensus criteria in round 2. After completing the two rounds, the final set of competen- cies consisted of 139 items distributed across the seven domains corresponding to the conceptual framework of the International Federation of Nurse Anaesthetists (Figure 1). We did not have to discard any of the seven key domains because of a lack of consensus. (Table 3). 5 | DISCUSSION The competencies and skills of nurse anaesthetists in Spain are in- creasing. In the last 13 years, university postgraduate training has been consolidated, making it possible to obtain the theoretical and practical training necessary to enter the field. However, of the exist- ing programmes, only one has been included by the International Federation of Nurse Anaesthetists in its list of Approved Non-­ Physician Anaesthesia Programmes/Schools. Both the International Council of Nurses and the International Federation of Nurse Anaesthetists recommend a programme duration of at least 18–­ 24 months to allow nurse anaesthetists to develop the necessary competencies (ICN, 2021), and none of the Spanish programmes F I G U R E 1 Description of the phases of the modified Delphi have this minimum length. Perhaps the lack of adequate postgradu- method ate training opportunities is one reason why nurse anaesthetists in 3702 | SANCLEMENTE-­DALMAU et al. TA B L E 3 Competencies and percentage of participants reporting “agree” or “strongly agree” Participants reporting “agree” or Mean ± SD Domain Competency “strongly agree” (%) (1–­5) IR Expert 86.99% Pre-­anaesthetic Conduct pre-­anaesthetic interview (with anaesthesiologist) 93.75% 4.43 ± 0.62 1 assessment Conduct pre-­anaesthetic interview (alone) 93.75% 4.56 ± 0.62 1 Assess medical and surgical history 93.75% 4.5 ± 0.63 1 Assess medications 93.75% 4.43 ± 0.81 1 Assess anaesthesic risk 93.75% 4.43 ± 0.81 1 Assess predictors of difficult airway 100.00% 4.68 ± 0.47 1 Request preoperative tests 68.75% 3.87 ± 1.20 2 Assess the results of pre-­operative testsa 81.25% 4.25 ± 1.12 1 Request consultation with another department 50.00% 3.31 ± 1.2 2 Conduct diagnostic tests (electrocardiogram. Lab tests)a 93.75% 4.5 ± 1.03 1 Conduct pre-­anaesthetic appointments virtually or by phonea 100.00% 4.81 ± 0.40 0 Formulate an anaesthetic plan based on knowledge and scientific evidence 81.25% 4.06 ± 1.12 1 Provide information about the anaesthetic plan 100.00% 4.62 ± 0.5 1 Inform patients about anaesthetic risks 87.50% 4.25 ± 0.68 1 Acquire informed consent from the patient 75.00% 3.87 ± 0.95 1.5 Coordinate patient scheduling with other departmentsa 81.25% 4.0 ± 1.31 1 a Handle surgery scheduling problems 75.00% 3.93 ± 1.28 1.75 Make changes in medication according to protocolb 100.00% 4.68 ± 0.47 1 Provide pre-­anaesthesia recommendationsb 93.75% 4.62 ± 1.02 0 Preparation and Prepare anaesthetic medications according to one's knowledge, the patient's 100.00% 4.75 ± 0.44 0.75 administration history, the technique and the surgical procedure of anaesthesia Choose anaesthetic medications according to one's knowledge, the patient's 87.70% 4.25 ± 1.06 1 history, the technique and the surgical procedure Administer anaesthetic medications according to one's knowledge, the 81.25% 4.18 ± 0.91 1 patient's history, the technique and the surgical procedure Prepare anaesthetic procedures according to one's knowledge, the patient's 100.00% 4.68 ± 0.47 1 history, the technique and the surgical procedure Conduct anaesthetic procedures according to one's knowledge, the patient's 87.50% 4.31 ± 0.87 1 history, the technique and the surgical procedure Administer general anaesthesia according to protocol in different surgical 68.75% 3.75 ± 1.12 1.75 procedures Collaborate with the anaesthesiologist in the administration of general 100.00% 4.87 ± 0.34 0 anaesthesia Administer regional anaesthesia according to protocol in different surgical 31.25% 2.87 ± 1.08 2 procedures Collaborate with the anaesthesiologist in the administration of regional 93.75% 4.75 ± 0.57 0 anaesthesia Administer sedation according to protocol in different surgical procedures 100.00% 4.62 ± 0.61 1 Collaborate with the anaesthesiologist in the administration of sedation 100.00% 4.81 ± 0.40 0 Administer coadjunctive drugs to prevent complicationsb 93.75% 4.62 ± 1.02 0 Conduct ventilation support in patients 100.00% 4.68 ± 0.47 1 Insert airway maintenance devices: Nasal cannula 93.75% 4.68 ± 0.60 0.75 Insert airway maintenance devices: Simple mask and reservoir mask 100.00% 4.81 ± 0.40 0 Insert airway maintenance devices: Laryngeal mask 68.75% 3.87 ± 1.14 2 Insert airway maintenance devices: Endotracheal intubation 50.00% 3.5 ± 1.15 2.5 SANCLEMENTE-­DALMAU et al. | 3703 TA B L E 3 (Continued) Participants reporting “agree” or Mean ± SD Domain Competency “strongly agree” (%) (1–­5) IR Insert airway maintenance devices: Techniques for difficult intubation 25.00% 2.68 ± 1.01 1.75 Use ultrasound to carry out invasive techniques (airway canalisation, 81.25% 4.25 ± 1.12 1 evaluation of bladder volume)b Be present during the administration of anaesthesia 87.50% 4.56 ± 0.25 0 Be present when the patient wakes upa 87.50% 4.5 ± 1.09 0.75 Offer psychological support by using communication skills 100.00% 4.93 ± 0.25 0 a Provide information to family members about the anaesthesia procedure 75.00% 3.93 ± 0.99 1.75 Patient safety Take adequate precautions to ensure safe administration of anaesthesia 93.75% 4.75 ± 0.77 0 Review patient records 100.00% 4.93 ± 0.25 0 Prepare equipment according to standards and checklists 100.00% 4.93 ± 0.25 0 Test anaesthesia equipment (respirator, monitors, aspiration) 100.00% 4.93 ± 0.25 0 Prepare anaesthesic plans according to standards and checklists 93.75% 4.75 ± 0.57 0 Prepare anaesthesia drugs according to standards and checklists 100.00% 4.87 ± 0.34 0 Participate in the administration of the Safe Surgical Checklist 93.75% 4.75 ± 0.57 0 Lead the administration of the Safe Surgical Checklistb 100.00% 4.75 ± 0.44 0.75 Participate in courses or conferences related to the topica 93.75% 4.62 ± 1.02 0 Participate in the development of procedures/protocols for the use of 100.00% 4.56 ± 0.62 1 equipment and drugs Participate in the reporting of safety incidents 93.75% 4.68 ± 0.60 0.75 Participate in groups for safety improvement or the analysis of safety 93.75% 4.62 ± 0.61 1 incidents Participate in the prevention of risks to patients and health 93.75% 4.56 ± 0.62 1 professionals Monitoring Collaborate in set-­up for monitoring 100.00% 5±0 0 Monitor patient parameters during the anaesthesia procedure 100.00% 4.93 ± 0.25 0 Monitor patient's clinical status during the anaesthesia procedurea 93.75% 4.62 ± 1.02 0 Analyse data obtained from invasive and non-­invasive monitoring techniques 100.00% 4.81 ± 0.40 0 using critical thinking and clinical judgement. Perform interventions based on the results of invasive and non-­invasive 87.50% 4.37 ± 1.02 1 monitoring using critical thinking and clinical judgement Participate in changes to ventilation/pharmacological therapy in response to 87.50% 4.5 ± 0.89 1 unexpected situations, following scientific knowledgea Participate in changes to ventilation/pharmacological therapy in response to 100.00% 4.81 ± 0.40 0 unexpected situations, according to guides/protocolsa Record data obtained from monitoring 87.50% 4.75 ± 0.68 0 Identify patient priorities and safety parameters 100.00% 4.81 ± 0.40 0 Respond constructively to unexpected or rapidly changing situations to 87.50% 4.56 ± 0.72 1 manage the clinical situation Termination of Assess the patient's condition before transferring care to the appropriate 93.75% 4.75 ± 0.57 0 anaesthesia department End ventilatory support if applicable 81.25% 4.31 ± 0.94 1 Conduct extubation autonomously 25.00% 2.81 ± 1.26 1.75 Accompany patient during transfer 100.00% 4.93 ± 0.25 0 Transfer information to the personnel of the post-­operative care unit 93.75% 4.75 ± 0.57 0 (Continues) 3704 | SANCLEMENTE-­DALMAU et al. TA B L E 3 (Continued) Participants reporting “agree” or Mean ± SD Domain Competency “strongly agree” (%) (1–­5) IR Equipment Select appropriate equipment according to the procedure and the situation 93.75% 4.68 ± 0.60 0.75 (planned or emergency) Prepare appropriate equipment according to the procedure and the situation 100.00% 4.87 ± 0.34 0 (planned or emergency) Use appropriate equipment according to the procedure and the situation 100.00% 4.81 ± 0.40 0 (planned or emergency) Clean the appropriate equipment according to the procedure and the 68.75% 3.81 ± 1.47 3 situation (planned or emergency) Follow-­up on equipment maintenancea 100.00% 4.75 ± 0.44 0.75 a Check that equipment is functioning correctly before use 100.00% 4.87 ± 0.34 0 Advanced life Take action to maintain or stabilize the patient's condition and provide 93.75% 4.75 ± 0.77 0 support advanced life support care Provide adequate advanced life support: use of equipment and medications, 100.00% 4.87 ± 0.34 0 coordination with the rest of the team Provide knowledge about basic and advanced life support to other health 87.50% 4.56 ± 0.72 1 professionals Maintain one's accreditation as a professional/instructor of advanced life 87.50% 4.56 ± 0.72 1 support Lead life support teams in institutions 62.50% 3.87 ± 1.08 2 Keep in mind non-­technical skills (leadership, teamwork, situational 93.75% 4.56 ± 0.62 1 awareness, communication) in urgent/emergency situations Participate in simulationsa 100.00% 4.62 ± 0.61 1 Post-­operative Serve as a resource person in immediate post-­operative care 81.25% 4.31 ± 1.07 1 care Decide when to discharge the patient from the post-­anaesthesia recovery 62.50% 3.93 ± 1.12 2 unit Sign the discharge papers for a patient leaving the post-­anaesthesia 31.25% 3.06 ± 1.18 1.75 recovery unit Decide when to discharge the patient from the major outpatient surgery 75.00% 3.93 ± 1.28 1.75 unita Demonstrate advanced knowledge in pharmacology and the 93.75% 4.81 ± 0.54 0 pharmacokinetics of drugs, analgesics and anaesthetic medications Assess all of the immediate post-­operative complications in the recovery 93.75% 4.62 ± 0.61 1 room/post-­anaesthesia recovery unit: respiratory, neurological, hemodynamic, nausea, vomiting Detect post-­operative complications in all areas: respiratory, neurological, 93.75% 4.68 ± 0.60 0.75 hemodynamic, nausea, vomiting Administer appropriate drugs autonomously 62.50% 3.43 ± 1.09 1.75 Administer appropriate drugs according to protocol 100.00% 4.68 ± 0.60 0.75 Administer appropriate drugs by medical order 87.50% 4.37 ± 0.71 1 Perform drug management during weaningb 87.50% 4.31 ± 0.87 1 Develop personnel protocols in the post-­anaesthesia recovery unit 81.25% 4.12 ± 0.88 1 Participate in carrying out personnel protocols in the post-­anaesthesia 93.75% 4.62 ± 0.61 1 recovery unit SANCLEMENTE-­DALMAU et al. | 3705 TA B L E 3 (Continued) Participants reporting “agree” or Mean ± SD Domain Competency “strongly agree” (%) (1–­5) IR Pain management Form part of institutional bodies for pain management 81.25% 4.25 ± 0.93 1 Serve as a resource person for nurses in pain units 81.25% 4.31 ± 1.07 1 Supervise invasive treatments for post-­operative pain management in 93.75% 4.56 ± 0.62 1 different departments (catheter, pain pump, etc.) Inform the patient about pain treatments and their side effects 87.50% 4.5 ± 0.73 1 Educate patients about pain treatment 93.75% 4.81 ± 0.54 0 Lead control of and recording-­keeping for opioids 80.00% 4.21 ± 0.96 1 Manage rotation of opioids in chronic patients 56.25% 3.87 ± 1.02 2 Apply transcutaneous electrical nerve stimulation autonomously in chronic 56.25% 3.68 ± 1.30 2 pain units Apply iontophoresis autonomously in chronic pain units 56.25% 3.62 ± 1.25 2 Conduct follow-­up and monitoring of treatments applied in chronic pain units 93.75% 4.62 ± 0.61 1 Train other professionals in the area of pain management 87.50% 4.62 ± 0.71 0.75 Give emotional support to patients in the chronic pain unit 87.50% 4.75 ± 0.68 0 Risk management Conduct procedures according to the recommended standards, to guarantee 100.00% 4.87 ± 0.34 0 the cleaning and sterilization of equipment Stay up to date with national guidelines on the risk of infection 93.75% 4.81 ± 0.54 0 Engage in the adaptation of national standards for anaesthesia procedures 87.50% 4.5 ± 0.89 1 Documentation Record patient information completely 100.00% 4.75 ± 0.44 0.75 Facilitate comprehensive care for the patient by recording information in 100.00% 4.87 ± 0.35 0 patient records Communicator 91.67% Establish effective communication and synergies with the patient 93.75% 4.56 ± 0.72 1 b Establish effective communication and synergies with the family of the patient 93.75% 4.68 ± 0.70 0 Provide emotional support to patients 93.75% 4.75 ± 0.57 0 Provide emotional support to patients' familiesb 93.75% 4.75 ± 0.57 0 Demonstrate skills to ensure patient understanding, respect, empathy and 93.75% 4.75 ± 0.57 0 trust by maintaining confidentiality and discretion Demonstrate skills for resolving interpersonal conflicts 81.25% 4.5 ± 0.81 1 Collaborator 99.11% Collaborate with other members of the team to identify solutions to health 100.00% 4.81 ± 0.40 0 problems Implement new technologies that improve patient safety 100.00% 4.81 ± 0.40 0 Establish professional relationships with health professionals from other fields 100.00% 4.87 ± 0.34 0 Promote cooperation among the different members of the anaesthesia team 100.00% 4.87 ± 0.34 0 Respect the roles and competencies of other team members 100.00% 4.93 ± 0.25 0 Engage in constructive discourse and promote the strengths of the members 93.75% 4.75 ± 0.57 0 of the health care team Offer solutions to problems that appear inside the health care team 100.00% 4.75 ± 0.44 0.75 Manager 85.71% Make decisions in advance to organize health care staff and prepare 93.75% 4.62 ± 0.61 1 equipment and materials Use resources to design and participate in evidence-­based strategies that 87.50% 4.43 ± 0.72 1 integrate patient needs Establish plans for eco-­friendly waste management 75.00% 3.87 ± 1.08 2 Evaluate and optimize the impact of the use of products and technologies in 81.25% 4.06 ± 0.99 1 patient care Conduct quality-­of-­c are assessments 87.50% 4.62 ± 0.71 0.75 Participate in committees for the quality of patient care 81.25% 4.5 ± 0.81 1 b Participate in patient safety committees as a manager/leader 93.75% 4.62 ± 0.61 1 (Continues) 3706 | SANCLEMENTE-­DALMAU et al. TA B L E 3 (Continued) Participants reporting “agree” or Mean ± SD Domain Competency “strongly agree” (%) (1–­5) IR Health advocate 90.63% Assess patients' health state 93.75% 4.68 ± 0.60 0.75 Participate in health promotion in patients 100.00% 4.75 ± 0.44 0.75 Participate in patient health education at any time in the perioperative period 93.75% 4.68 ± 0.60 0.75 Participate in family health education at any time in the perioperative period 81.25% 4.43 ± 1.09 0.75 Participate in patient empowerment in the perioperative period 81.25% 4.43 ± 0.96 1 Ensure the patient's right to privacy and confidentiality 100.00% 4.93 ± 0.25 0 Participate in safety commissions 81.25% 4.43 ± 0.81 1 Use information & communication technologies and digital health tools in the 93.75% 4.62 ± 0.61 1 perioperative periodb Scholar 96.88% Participate in continuous professional development 100.00% 4.75 ± 0.44 0.75 Be evaluated during his/her professional career 87.50% 4.5 ± 0.73 1 Incorporate evidence-­based techniques, such as those described in updated 100.00% 4.62 ± 0.5 1 national guidelines and standards Participate in funded research and other studies 93.75% 4.75 ± 0.57 0 Incorporate research into his/her daily practice 93.75% 4.5 ± 0.81 1 Protect the rights of patients who participate in research 100.00% 4.81 ± 0.40 0 Know the standards of education and practice in the profession 100.00% 4.75 ± 0.44 0.75 Contribute to the education of professionals and students by sharing one's 100.00% 4.75 ± 0.44 0.75 experience Help other health care professional by sharing one's experience in 100.00% 4.75 ± 0.44 0.75 anaesthesia Demonstrate knowledge about national-­level professional regulationsb 93.75% 4.56 ± 0.62 1 Professional 95.31% Provide patient-­centred, evidence-­based care 93.75% 4.75 ± 0.57 0 Recognize one's responsibility in professional practice by maintaining a high 100.00% 4.93 ± 0.25 0 level of quality in knowledge, judgement and technological skills Accept and carry out responsibilities delegated by others 100.00% 4.81 ± 0.40 0 Delegate regularly to other members of the health care team 81.25% 4.06 ± 0.85 1 Identify opportunities for the continuous professional development activities 100.00% 4.87 ± 0.34 0 Participate in professional associations 93.75% 4.43 ± 0.62 1 Use criteria of quality, satisfaction and study of costs to make changes in the 100% 4.56 ± 0.62 1 practice and care of the patient Ensuring the rights of patients according to their individual, cultural, ethnic 93.75% 4.75 ± 0.57 0 and religious characteristics, giving the most appropriate care and respecting these singularities Note: Competencies in bold did not meet the threshold of 80% of participants having reported “agree” or “strongly agree” and were therefore discarded from the final set of competencies. SD: standard deviation. IR: interquartile range. a Competencies proposed by the participants in round 1 and added for consideration in round 2. b Competencies that only met one or two consensus criteria in round 1 and were therefore reconsidered in round 2. Spain do not have the same level of competencies as in other coun- anaesthetists in the administration of different types of anaes- tries. Despite this shortcoming, our research reveals that partici- thesia varies depending on the training received and on national pants recognized the seven-­domain competency framework defined legislation. In Spain, nurse prescribing is in its infancy. Nurse an- by the International Federation of Nurse Anesthetists (2016), with aesthetists can indicate, administer and authorize drugs that do all seven domains having achieved “agree” or “strongly agree” among not require a medical prescription. However, anaesthetic drugs more than 80% of respondents. do not fall into this category. In some states of the United States, The expert domain is the most variable across countries, be- there are legal regulations that permit nurse anaesthetists to ad- cause of differing legal frameworks. The participation of nurse minister anaesthetic drugs. In others, the presence of a physician, SANCLEMENTE-­DALMAU et al. | 3707 though not necessarily an anaesthesiologist, is required (Hoyem in and support for research has room for improvement, as is also the et al., 2019). In China, nurse anaesthetists are permitted to ad- case in other countries (Halakou et al., 2017; Herion et al., 2019). minister anaesthetic drugs under the supervision of an anaes- The degree of consensus for the domains collaborator and profes- thesiologist (Hu et al., 2017). In France, the training of the nurse sional are slightly higher than that of other studies. In perioperative anaesthetists is recognized as a state diploma, and French law care in Spain, teams are increasingly multidisciplinary. For example, states that only nurse anaesthetists and anaesthesiologists may nurse anaesthetists participate actively in enhanced recovery after administer aesthesis drugs (Légifrance, 2017). surgery. Teamwork and collaboration among health professionals are Also under the expert domain, the nurse anaesthetists in our noteworthy in the clinical practice of nurse anaesthetists in our study. study recognized non-­invasive airway management as an autono- mous activity (cannula, face mask) and invasive airway management as one they performed in collaboration with physicians (laryngeal 5.1 | Limitations mask, orotracheal intubation). The competencies related to monitor- ing, safety and recording information coincide with competencies The study was carried out in Catalonia, which shares responsibility signalled by the International Federation of Nurse Anaesthetists for health care with the central government of Spain. The manage- and other authors (Halakou et al., 2017; Herion et al., 2019; Syndicat ment of hospitals and teams may be different from those of other re- National des Infirmier(e)s-­Anesthestits-­es, 2019). In terms of the gions of Spain. The fact that Spain does not have legislation covering pre-­anaesthesia visit, the nurse anaesthetists conducted preanaes- nursing anaesthesia may cause professional and personal conflicts thetic assessment autonomously or collaboratively, including patient in health teams, which need to be considered in the development history assessment, pharmacological treatments, preoperative tests of a competencies model. We are currently conducting a qualitative and airway assessment (the latter of which varied depending on the analysis to tackle this issue. Legislation and regulation about nurse patient's anaesthetic risk and the complexity of the surgery). This anaesthesia vary by country, meaning that caution must be used in finding differs from the situation in France, in which nurse anaes- extrapolating our results to other contexts. thetists have an undeniable presence in surgery but not in the pre-­ anaesthesia visit (SYNA, 2019). Information about the anaesthesia process appears in the ex- 6 | CO N C LU S I O N pert domain and also in the communicator domain because com- munication with the patient and his/her family is a cross-­cutting We have shown that the competencies of nurse anaesthetists competency. For our participants, informing the patient is a nurse in Spain largely coincide with those defined by the International anaesthetist competency, but obtaining informed consent is not, Federation of Nurse Anaesthetists. In Spain, nurse anaesthetists are because, according to Spanish legislation, informed consent can an essential pillar throughout the perioperative period. Their holistic only be obtained by a physician. This practice is shared with other approach to the person offers not only nursing expertise but also in other Western countries, except for the United States, where the cross-­cutting elements such as communication skills and the inte- health professional who provides the information to the patient also gration of the family into the health-­illness continuum. At the same obtains his/her informed consent (American Association of Nurse time, the inclusion of nurse anaesthetists in pre-­anaesthesia visits Anesthesiology, 2019). and pain units allows them to carry out health education for patients The participants were in high agreement with the competencies and their families, thus contributing to the quality of care received related to management, answering affirmatively to participation in and taking part in the community. The role of nurse anaesthetists in quality and safety committees, the use of new technologies, the use our study in the pre-­anaesthesia visit and their competencies related of evidence-­based practice and the role of manager inside teams. to preparing and accompanying the patient and providing informa- This finding contrasts with those of other studies in which nurse an- tion about the anaesthesia process could serve as a model for other aesthetists are less autonomous in management but more autono- health care systems in which these roles of the nurse anaesthetist mous in the expert domain (Herion et al., 2019). are not fully developed. The results for the domain of health advocate are similar. Nursing The scope of the nurse anaesthetists' practice in Spain de- education in Spain is firmly rooted in health education, and this em- pends on the workplace and not on national regulations. This may phasis is transferred to clinical practice. Nurse anaesthetists have be why advanced practice competencies are not developed equally integrated the values of promotion, education and empowerment throughout the sample. For example, consensus was not reached of the patient and his/her family. Nurse anaesthetists participation on the administration of general anaesthesia, invasive airway man- in the pre-­anaesthesia visit and in pain units gives this competency agement, discharge from recovery units and the autonomous man- greater weight in Spain than in places such as France and Switzerland agement of opioid rotation for patients in chronic pain units. It is (Herion et al., 2019; SYNA, 2019). surprising that in a country in which nurse anaesthetists have no In terms of the scholar domain, the consensus percentage was high, recognized role in the post-­operatory process that they are carry- especially in the competencies related to continuing education and ing out pre-­anaesthetic visits with the consent of health institutions. participation in the training of other health professionals. Participation Nurse anaesthetists' theoretical and practical training should allow 3708 | SANCLEMENTE-­DALMAU et al. them to advance in these competencies, while continuing to ensure ORCID high quality patient care. To accomplish this goal, nurse anaesthetist Montse Sanclemente-­Dalmau https://orcid. university education should follow the standards published by the org/0000-0003-1518-4976 International Federation of Nurse Anaesthetists. Health care teams Paola Galbany-­Estragués https://orcid. in general and anaesthesia teams in particular should be prepared org/0000-0003-3775-1695 to incorporate the nurse anaesthetist, who has a differentiated role Xavier Palomar-­Aumatell https://orcid. that is complementary to that of the anaesthesiologist. org/0000-0001-9022-4144 The study has revealed the contribution of nurse anaesthetists to Esther Rubinat-­Arnaldo https://orcid.org/0000-0003-0232-9777 the perioperative process as a key member of the anaesthesia team. Defining nurse anaesthesia as a speciality and regulating its practice T WITTER would make it possible to expand the training available, especially Montse Sanclemente-­Dalmau @montsesancle for the competencies that were less widespread. This expansion in Paola Galbany-­Estragués @GalbanyPaola the competency framework would enable patients to receive higher Xavier Palomar-­Aumatell @XevicX quality care from anaesthesia teams, care that adheres to the high- Esther Rubinat-­Arnaldo @rubinatesther est standards of safety and quality. Policy makers, managers and the nurse anaesthetists themselves are positioned to take the next steps REFERENCES in the regulation process. American Association of Nurse Anesthesiology. (2019). Standards for The regulatory situation of nurse anaesthetists in Spain may be Nurse Anesthesia Practice. Retrieved from https://www.aana.com/ docs/defau​l t-­s ourc​e /pract​i ce-­a ana-­c om-­w eb-­d ocum​e nts-­(all)/ similar to that of other countries in which nurse anaesthesia is still profe​s sion​a l-­p ract​i ce-­m anua​l /stand​a rds-­f or-­n urse​- ­a nest​h esia​ in development. In this sense, our methodological approach and our -­pract​ice.pdf?sfvrs​n=e0004​9b1_20 results may be of help to other health systems that are in the process Ayuso Murillo, D., Cobos Serrano, J. L., & Lletget Aguilar, R. (2019). of defining the competencies of the nurse anaesthetists. Specialty of Medical Surgical Nursing, a subject still pending after 14 years. Enfermería Clínica (English Edition), 29(6), 389–­390. https:// doi.org/10.1016/J.ENFCLE.2019.09.002 AU T H O R C O N T R I B U T I O N S Benner, P. (1987). Práctica progresiva en enfermería (Grijalbo [Ed.]). All authors have agreed on the final version and meet at least one of Canet, J., & Monedero, P. (2007). Enfermería de Anestesia en Espana: the following criteria (recommended by the ICMJE*): Una verdad incómoda o la caja de los truenos ? Revista Española de Anestesiologia y Reanimación, 54(5), 265–­267. Comellas Oliva, M. (2016). La construcción de la práctica avanzada en en- 1. substantial contributions to conception and design, acquisition fermería en el contexto sanitario catalán. Avanzando en la disciplina of data or analysis and interpretation of data; enfermera. Universitat de Barcelona. Retrieved from http://www. 2. drafting the article or revising it critically for important intellec- tdx.cat/handl​e/10803/​380905 tual content. Halakou, S., Bakhsha, F., Jafari, S. Y., Yousefi, Z., & Aryaee, M. (2017). The clinical competencies of nurse anesthetists in response to commu- nity needs: A Delphi Study. Journal of Clinical and Basic Research, 1, AC K N OW L E D G E M E N T S 13–­19. We thank the experts Dr Montserrat Comellas Oliva, Daniel López Herion, C., Egger, L., Greif, R., & Violato, C. (2019). Validating interna- Torres, Lucia Cao García and Neus Pàrrega Fernández for their con- tional CanMEDS-­based standards defining education and safe practice of nurse anesthetists. International Nursing Review, 66, tribution in reviewing the questionnaire and the NAs who partici- 404–­415. https://doi.org/10.1111/inr.12503 pated in the study even during the worst moments of the COVID-­19 Hoyem, R. L., Quraishi, J. A., Jordan, L., & Wiltse Nicely, K. L. (2019). pandemic. Susan Frekko provided feedback on the manuscript and Advocacy, research, and anesthesia practice models: Key stud- translated it from Spanish to English. ies of safety and cost-­effectiveness. Policy, Politics, and Nursing Practice, 20(4), 193–­204. https://doi.org/10.1177/15271​5 4419​ 874410 F U N D I N G I N FO R M AT I O N Hu, J., Fallacaro, M. D., Jiang, L., Wu, J., Jiang, H., Shi, Z., & Ruan, H. This research received no specific grant from any funding agency in (2017). IFNA approved Chinese anaesthesia nurse education pro- the public, commercial or not-­for-­profit sectors. gram: A Delphi method. Nurse Education Today, 56(May), 6–­12. https://doi.org/10.1016/j.nedt.2017.05.017 Instituto de Estadística de Catalunya. (2021). Idescat. Indicadores an- C O N FL I C T O F I N T E R E S T uales. Población a 1 de enero. Por grupos de edad. Retrieved No conflict of interest has been declared by the author(s). October 6, 2021, from https://www.idesc​at.cat/indic​adors/​ ?id=anual​s&n=10329​&lang=es&tema=XIFPO​&col=2 International Council of Nurses. International council of nurses guidelines PEER REVIEW on advanced practice nursing 2020 (2020). Retrieved from https:// The peer review history for this article is available at https://publo​ www.icn.ch/syste​m/files/​2021-­07/ICN_APNRe​port_ES_WEB.pdf ns.com/publo​n/10.1111/jan.15348. International Council of Nurses. (2021). Directrices para las Enfermeras Anestesistas|ICN -­International Council of Nurses. Retrieved from DATA AVA I L A B I L I T Y S TAT E M E N T https://www.icn.ch/es/notic​ias/el-­conse​jo-­inter​nacio​nal-­de-­enfer​ meras​-­lanza​-­direc​trice​s-­para-­las-­enfer​meras​-­anest​esistas Author elects to not share data: Research data are not shared. SANCLEMENTE-­DALMAU et al. | 3709 International Federation of Nurse Anesthetists. (2016). Code of ethics, Sevilla Guerra, S., Miranda Salmerón, J., & Zabalegui, A. (2017). Profile standards of practice, monitoring, and education. Retrieved from of advanced nursing practice in Spain: A cross-­s ectional study. http://dev.ipsasb.org/syste​m/files/​meeti​ngs/files/​4502.pdf Nursing & Health Sciences, 20, 1–­8 . https://doi.org/10.1111/ International Federation of Nurse Anesthetists. (2021). Retrieved nhs.12391 October 6, 2021, from https://ifna.site/about​-­ifna/ Syndicat National des Infirmier(e)s-­Anesthestits-­es. (2019). Great Survey Keeney, S., Hasson, F., & McKeena, H. (2011). The Delphi tecnique in nurs- French Nurse Anesthetists 2018. Retrieved from https://ifna.site/ ing and health research. Wiley-­Blackwell. app/uploa​ds/2019/02/SNIA_Enque​te_ENG_IFNA.pdf Légifrance. Article R4311-­12 -­ Code de la santé publique. (2017). Taland, S. (2017). Publications -­ Syndicat National Des Infirmier(e)s Retrieved from https://www.legif​rance.gouv.fr/codes/​artic​le_lc/ Anesthesistes. Retrieved October 7, 2021, from https://www.snia. LEGIA​RTI00​0 0341​69206/ net/publi​c atio​ns.html Meeusen, V., Ouellette, S., & Horton, B. (2016). The global organization Tutosaus Gómez, J. D., Morán-­Barrios, J., & Pérez Iglesias, F. (2018). of nurses in anesthesia: The International Federation of Nurse Historia de la formación sanitaria especializada en España y sus Anesthetists. Trends in Anaesthesia and Critical Care, 6(2016), 20–­ claves docentes. Educación Médica, 19(4), 229–­234. https://doi. 25. https://doi.org/10.1016/j.tacc.2016.03.001 org/10.1016/J.EDUMED.2017.03.023 Merry, A. F., Cooper, J. B., Soyannwo, O., Wilson, I. H., & Eichhorn, J. von der Gracht, H. A. (2012). Consensus measurement in Delphi studies. H. (2010). International standards for a safe practice of anesthesia Review and implications for future quality assurance. Technological 2010. Canadian Journal of Anaesthesia, 57(11), 1027–­1034. https:// Forecasting and Social Change, 79(8), 1525–­1536. https://doi. doi.org/10.1007/S1263​0 -­010-­9381-­6 org/10.1016/j.techf​ore.2012.04.013 Ministerio de la Presidencia. Real Decreto 450/2005, de 22 de abril, World Medical Association. (2013). World Medical Association sobre especialidades de enfermería (2005). Retrieved from https:// Declaration of Helsinki: Ethical principles for medical research in- www.boe.es/busca​r/pdf/2005/BOE-­A-­2 005-­7354-­conso​l idado. volving human subjects. JAMA, 310(20), 2191–­2194. https://doi. pdf org/10.1001/JAMA.2013.281053 Peix Sagués, M.., & Pérez Castro, A. (2012). Competencias y Funciones de la Enfermería de Anestesia, Reanimación y Terapia del Dolor. Aseedar-­td. Retrieved from http://www.aseed​ar-­td.org/compe​ How to cite this article: Sanclemente-­Dalmau, M., Galbany-­ tencias Ray, W. T., & Desai, S. P. (2016). The history of the nurse anesthesia Estragués, P., Palomar-­Aumatell, X., & Rubinat-­Arnaldo, E. profession. Journal of Clinical Anesthesia, 30, 51–­58. https://doi. (2022). Defining competencies for nurse anaesthetists: A org/10.1016/j.jclin​ane.2015.11.005 Delphi study. Journal of Advanced Nursing, 78(11), 3696–3709. Sanclemente Dalmau, M.(2017). Anesthesia nursing in Catalonia: https://doi.org/10.1111/jan.15348 Advanced Practice Nursing Model [ Master's thesis no published]. Autonomous University of Barcelona The Journal of Advanced Nursing (JAN) is an international, peer-reviewed, scientific journal. 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